Here’s how readers responded to a You Make the Call question about anticoagulation for a young patient with COVID-19 and pulmonary embolism.
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I would recommend treating with anticoagulation for three to six months, then reassessing. If all risk factors (including resolution of COVID-19 infection) are absent, then I would stop anticoagulation.
Due to the atypical location of the index thrombosis (subclavian vein), I would evaluate the patient for the possibility of thoracic outlet syndrome and investigate for the possibility of effort-related thrombosis (Paget-Schroetter syndrome). In addition, I would ask the patient about use of anabolic steroids or testosterone supplements, recent trauma to the area, and any family history of thrombosis at a young age.
Some patients with COVID-19 have positive antiphospholipid antibodies, but this is also seen with other viral or bacterial infections and may not persist, therefore I would not recommend performing a thrombophilia evaluation in the setting of acute thrombosis. After completing three months of anticoagulation, I would recommend repeating compression ultrasound of the upper extremity to assess for residual venous occlusion.
Data from AuriculA, the Swedish national anticoagulation registry, were retrospectively evaluated for 55 patients treated with direct oral anticoagulants (DOACs) because of upper extremity deep vein thrombosis (UEDVT) between 2012 and 2015. Patients were followed for six months, during which period there was one recurrence of DVT during treatment and two recurrences after cessation of treatment. No patients died, whereas one had clinically relevant nonmajor bleeding. The authors concluded that DOACs can be used in the treatment of patients with UEDVT with acceptable efficacy and safety. (Montiel FS, et al. Thromb J. 2017;15:26.)
Maria T. DeSancho, MD
New York, NY
I would recommend three months of anticoagulation, but no testing during apixaban treatment.
Cristina Pascual, MD
The duration of treatment should be at least three months, and could be extended to six months. No further testing is required. I would suggest thrombolysis for the subclavian DVT. The patient is young, and would benefit from a decrease in the risk of post thrombotic syndrome of the upper extremity.
Ibraheem Othman, MD, PhD
Regina, Saskatchewan, Canada
I would anticoagulate for at least six months. I would also test for thrombophilia and cancer because the main causes of DVT in the arms have been shown, so far, to be cancer and thrombophilia.
Marcia Novaretti, MD, PhD
Sao Paulo, Brazil
I would recommend six months of apixaban treatment. He should be tested for factor V and prothrombin gene mutations.
Aleksandar Mijovic, MBBS, PhD, FRCPath
I would recommend evaluating coagulopathy via D-dimer test, checking for inflammation, thrombocytosis, autoantibodies (evaluating for antiphospholipid syndrome), and keeping the patient on edoxaban for at least three months.
At that point, I would reevaluate coagulopathy (D-dimer, inflammation, platelets), antiphospholipid antibodies, and subclavian DVT by sonography, then decide on further length of anticoagulation.
Paul La Rosée, MD
I would recommend six months of anticoagulation.
David Mann, MD
Miramar Beach, FL
I would recommend checking lupus anticoagulant and other lupus markers to rule out triple positive antiphospholipid syndrome before continuing apixaban. I would suggest at least three months of anticoagulation, then follow biomarkers (e.g., D-dimer) at the end of therapy. I would also want to rule out thoracic inlet syndrome as the cause of the subclavian clot. Is the clot related to a central venous line?
Anjali Sharathkumar, MBBS, MD
Iowa City, Iowa
If the patient has no additional risk factors (including accessory ribs, etc.), I would suggest three months of anticoagulation.
Shyam Balepur, MD
Since it is a provoked first PE, three months of apixaban would be sufficient.
Giuseppe Di Lucca, MD
I would recommend three to six months of anticoagulation.
Begoña Fernández, MD
I would treat the patient for three months since this is a provoked venous thromboembolism and do a perfusion scan to evaluate his recovery before stopping apixaban. If the scan shows that his perfusion is still not good, continue anticoagulation for another three months. If initially the PE involved much of the lung vasculature, then I would anticoagulate for six months.
Shadan Lalezari, MD
I would give three months of full anticoagulation. I would perform an ultrasound at three months to look for residual thrombus and also check D-dimer levels. If residual persistent thrombus is seen or high D-dimer levels are present at three months, I would give three more months of anticoagulation.
Farooq Ahmad Wandroo, MD
West Bromwich, U.K.