discussing the role of NOAC in every step in PE management according to the ESC 2019 guidelines

1. NOACs in pulmonary
embolism
Haytham Soliman, MD, FSCAI
Fayoum university

2. NOAC Expansion
ACS
AF
VTE/PE

3. In pulmonary embolism
Initial
anticoagulation Maintenance
treatment Long term
treatment

5. Case
• 65 year old female
• She has a breast cancer on hormonal targeted therapy
• She had an attack of dyspnea, chest discomfort and air hunger
• She was rushed to the ER

6. • BP: 110/70 mmHg
• HR: 112 bpm
• RR: 35/min
• Temp: 36.5 c
• Mental status intact
• O2 saturation 91%
• CR CL: 50ml /min

7. • As she has high probability of PE she was rushed to do CTPA that
showed signs of RV dysfunction and
Troponin was positive

11. Bleeding
risk

14. Let’s treat
First step
First use
But when?

16. Derived mainly by recurrence of fatal PE

18. For how long ?

19. Patients without cancer

23. Patients with cancer

26. Early discharge from hospital

27. Back to our patient
• Fondaparinux 7.5 mg once daily for 3 days
• Followed by Rivaroxaban 15mg twice daily for three weeks
• then she was shifted to Rivaroxaban 20 mg once daily
• The plan is to follow her up every 3 month
• And to continue anticoagulation till the cancer is completely cured

28. Summary
• NOACS are now superior to VKAs in initial and long term anticoagulation in
VTE/PE patients
• They have also less bleeding incidence
• The dose of Rivaroxaban and Apixaban should be reduced after 6 month
• Rivaroxaban and Edoxaban can be used in extended treatment of cancer
patients except for GIT cancer
• NOAC are contraindicated in pregnancy, severe renal impairment CrCl<
15ml/min and in anti phospholipid antibody syndrome
• Risk stratification including bleeding risk is extremely important to derive
management