Lara Groetzinger, BCCCP, PharmD
Unit Based Clinical Pharmacist
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania
Disclosure information not submitted.
Ian Barbash, MD
Physician
University of Pittsburgh Medical Center, United States
Disclosure information not submitted.
Phillip Lamberty, MD
Physician
University of Pittsburgh Medical Center, United States
Disclosure information not submitted.
Michael Donahoe, MD
Physician
University of Pittsburgh Medical Center, United States
Disclosure information not submitted.
Roy Smith, MD
Physician
University of Pittsburgh Medical Center, United States
Disclosure information not submitted.
Belinda Rivera-Lebron, MD
Physician
University of Pittsburgh Medical Center, United States
Disclosure information not submitted.
Title:
Early enoxaparin versus unfractionated heparin for submassive pulmonary embolism
Introduction/Hypothesis: Timely therapeutic anticoagulation is important for the treatment of submassive pulmonary embolism (PE) by decreasing the risk of recurrent thromboembolic events. Guidelines recommend low molecular weight heparin, but a hesitancy remains due to fear of bleeding complications should an intervention become necessary. Unfractionated heparin (UFH) may take longer to get therapeutic and prolong intensive care unit (ICU) length of stay (LOS). To better align with guideline recommendations, an enoxaparin for submassive PE protocol was implemented in our medical ICU (MICU). We hypothesized that early enoxaparin would decrease time to therapeutic anticoagulation and MICU LOS.
Methods: A retrospective review of patients admitted to the MICU who were diagnosed with a submassive PE was conducted from July 1st, 2017 to May 31st, 2021. Patients were divided into two groups: early enoxaparin (initial anticoagulant or within 12 hours of ICU admission) or UFH. Patients were evaluated for therapeutic anticoagulation during their MICU LOS. Groups were compared using Fisher’s exact and Mann-Whitney U tests.
Results: Ninety-nine patients were included in the analysis, 24 in the early enoxaparin group and 75 in the UFH group. There were no differences in baseline demographics such as age, gender, or pulmonary embolism severity index (PESI) score between the two groups. Patients in the enoxaparin group has a faster time to therapeutic anticoagulation 4.4 (IQR: 2.9 to 10) vs. 15 (IQR: 7.2 to 21.4) hours, p < 0.001. Enoxaparin patients also had a higher percentage of time in therapeutic range (100% vs. 65%, p< 0.001). Patients in the early enoxaparin group had a statistically significant decreased MICU LOS, 41 (IQR: 29 to 60) vs. 64 (IQR: 48 to 76) hours, and hospital LOS, 4.2 (IQR: 2.9 to 5.8) vs. 5 (IQR 3.7 to 8.8) days; p = 0.006 and p = 0.032, respectively.
Conclusion: Implementation of an early enoxaparin protocol for submassive PE decreased time to initial therapeutic anticoagulation while improving overall time in therapeutic range. Early enoxaparin was also associated with decrease MICU and hospital LOS compared to UFH. Future studies should evaluate bleeding and recurrent thrombotic events with enoxaparin.