I would say- not for a while!!
They generally have a PE for a reason.... likely malignancy or post surgery. If malignancy this will involve multiple procedures both surgical and diagnostic. If post operative they have an acute surgical problem. NOACs are a pain and are difficult to manage bleeding effects etc- this LMWH and warfarin- tried and tested!! and reversible!!
Leave the NOACs for the long term stable patients with a diagnosis!!
!! Sorry auto correct on my tablet!
A person with a PE typically has an underlying condition/s that predisposed them to the pro thrombotic state. The very modest benefit (convenience!) of A NOAC that cannot be easily reversed must be weighted against the likely hood of needing ongoing invasive testing (malignancy etc) which is much safer to manage with old fashioned heparinoids and warfarin.
In the long term noan issue... but in the short term I believe it is still ill advised!
From esc 2014 Acute Pulmonary Embolism guideline "At present, NOACs can be viewed as an alternative to standard treatment." It is only alternative, not first line therapy instead VKA?
Acute: PE heparin immediately
Days: Stabilize on LMWH over days allows time for Ix etc. Typically 2-3 days.
Medium (weeks months): VKA or NOAC considering renal/hepatic function and bleeding risk etc. There is no rule! This is the art of medicine!
I am yet to be convinced of any good data to suggest superiority of NOACs. Hence I prefer in general to use the well understood and known drugs.... remember these patients will not be managed by you when they leave hospital the GP must be familiar with the drugs too! As for convenience of not testing NOACs... regular contact with this group of patients in the short term is NOT a bad thing!!
I have been increasingly using NOACs as first-line treatment for acute VTE in patients with normal (or near-normal) renal function who are not at high risk for bleeding and believe the safety and efficacy data support that approach. The biggest concern I would have about starting them immediately post-thrombolysis would be the possibility that the patient might have occult bleeding from the thrombolysis that becomes apparent after an initial dose of a (relatively irreversible) anticoagulant. Given the short half-life of tPA, heparin can be started immediately following the tPA infusion (particularly if the aPTT is < 2x the upper limit of normal), and it might be most prudent to use unfractionated heparin until you are sure that the patient is not bleeding, and then initiate the NOAC once you are confident that there was not bleeding from the thrombolytic infusion.
for these patients with renal dysfunction combine pulmonary embolism or venous thrombosis embolism ,the conidtion is complicated ,the mild,moderate or severe level,the diferent level determine the option between UFH or LMWH NOAC, determine the dosage and the risk of beeding,every specific case is need discuss
The standard therapy following thrombolysis is UFH or LMWH. So, I suggest starting NOAC after 2-3 days of UFH of LMWH in these patients.
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