Apixaban or Rivaroxaban Versus Warfarin for Treatment of Submassive Pulmonary Embolism After Catheter-Directed Thrombolysis

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Submassive pulmonary embolism after catheter-directed thrombolysis (n=62). Intervention: Direct oral anticoagulant (apixaban or rivaroxaban) transition after parenteral anticoagulation vs. Warfarin bridged with parenteral anticoagulation (UFH or LMWH). Primary outcome: Hospital length of stay (days) (β -2.1, 95% CI -3.5 to -0.7, p=0.002).

Q: What does this research mean for the field?

Initiation of a DOAC (apixaban or rivaroxaban) after catheter-directed thrombolysis for submassive pulmonary embolism significantly reduces hospital length of stay compared to parenterally bridged warfarin. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.NEUTRAL.

Lara Groetzinger; Taylor Miller; Ryan Rivosecchi; Roy E. Smith; Mark T. Gladwin; Belinda Rivera‐Lebron

doi:10.1177/1076029618755311

February 18, 2018Clinical and Applied Thrombosis/HemostasisOpen Access

Apixaban or Rivaroxaban Versus Warfarin for Treatment of Submassive Pulmonary Embolism After Catheter-Directed Thrombolysis

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Key result

DOACs after catheter-directed thrombolysis for submassive PE linked to ~2-day shorter hospital stay vs. warfarin.

β -2.1
95% CI -3.5 to -0.7
P=0.002
n=62

Figures

Why the study?

Does transitioning to apixaban or rivaroxaban decrease hospital length of stay compared to parenterally bridged warfarin in patients with submassive pulmonary embolism after catheter-directed thrombolysis?

Key Points

To determine whether transitioning from parenteral anticoagulation to direct oral anticoagulants rather than warfarin reduces hospital length of stay for patients with submassive pulmonary embolism following catheter-directed thrombolysis.
Retrospective review of 62 patients with submassive pulmonary embolism who underwent catheter-directed thrombolysis between January 1, 2012, and February 28, 2017.
Evaluated 26 patients prescribed a direct oral anticoagulant (19 rivaroxaban, 7 apixaban) versus 36 patients treated with parenterally bridged warfarin.
Measured hospital and intensive care unit length of stay, alongside in-hospital and 90-day bleeding and clotting events.
Patients receiving rivaroxaban or apixaban had a significantly shorter median hospital length of stay compared to warfarin (4.0 vs 6.1 days, P = .002), whereas median ICU length of stay was identical (2.7 vs 2.7 days, P = .68).
Multivariate regression analysis identified DOAC administration as an independent predictor of decreased hospital stay (β: −2.1, 95% CI −3.5 to −0.7, P = .004).
No major bleeding events occurred in either group; minor bleeding occurred in 3 patients (8%) in the warfarin group versus 0 in the DOAC group, with 1 recurrent pulmonary embolism in the warfarin group by 90 days.

Study Design

Type

Cohort (n=62)

Multicenter

No

Structured PICO

Does transitioning to apixaban or rivaroxaban decrease hospital length of stay compared to parenterally bridged warfarin in patients with submassive pulmonary embolism after catheter-directed thrombolysis?

P

Population

62 adults (median age 59 years, 53% female) with submassive pulmonary embolism who underwent catheter-directed thrombolysis at a single academic center, followed for 90 days.

E

Exposure

Transition from parenteral anticoagulation (UFH, LMWH, or argatroban) to a direct oral anticoagulant (DOAC) factor Xa inhibitor—specifically rivaroxaban (n=19) or apixaban (n=7)—initiated at a median of 2.3 days after hospital admission.

C

Comparator

Transition from parenteral anticoagulation (UFH or LMWH) bridged to warfarin (n=36), initiated at a median of 2.9 days after hospital admission.

O

Outcome

Hospital length of stay (LOS), defined as the number of days from arrival at the institution until discharge.

Main Result

Effect estimate: β -2.1 (95% CI -3.5 to -0.7)

Absolute Event Rate: 4% vs 6.1%

p-value: p=0.002

Transitioning patients with submassive PE to apixaban or rivaroxaban following catheter-directed thrombolysis reduces median hospital length of stay by approximately 2 days compared to bridged warfarin without increasing 90-day bleeding or thrombotic events.

Limitations

Retrospective nature
Nonrandomized, single-center design
Did not evaluate matched cohorts, so confounding variables may have been missed
90-day outcomes were derived from physician progress notes within a single health system network, potentially missing outside events
Results only reflect apixaban and rivaroxaban and cannot be applied to edoxaban or dabigatran
Unmatched cohorts with potential unmeasured confounding variables
90-day outcomes restricted to records within the health system's network
Results limited to apixaban and rivaroxaban and cannot be extrapolated to edoxaban or dabigatran

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Implication

May shorten hospital stay after CDT for submassive PE; leaves open confirmation in randomized trials.

Abstract

BACKGROUND: Little data exist on the use of direct oral anticoagulant (DOAC) factor Xa inhibitors for submassive pulmonary embolism (PE) after catheter-directed thrombolysis (CDT). The objective of this evaluation was to determine whether the transition from parenteral anticoagulation to DOACs for submassive PE after CDT would decrease hospital length of stay (LOS) compared to warfarin. METHODS: A retrospective review of patients diagnosed with submassive PE who underwent CDT was conducted from January 1, 2012, to February 28, 2017. Hospital LOS and major and minor bleeding events were recorded during hospitalization and at 90 days. RESULTS: Sixty-two patients met the inclusion criteria, 36 in warfarin group and 26 in the DOAC group. Overall, patients receiving rivaroxaban or apixaban had a shorter median hospital LOS compared to warfarin (4.0 vs 6.1 days, P = .002). In the multivariate regression analysis, administration of DOAC was an independent predictor of decreased hospital LOS, β: -2.1, 95% confidence interval (-3.5 to -0.7). CONCLUSION: Among patients with submassive PE, initiation of a DOAC shortly after CDT may result in a decreased hospital LOS compared to parenterally bridged warfarin.

Discussion

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Cite This Study

Groetzinger et al. (2018) conducted a cohort in Submassive pulmonary embolism after catheter-directed thrombolysis (n=62). Direct oral anticoagulant (apixaban or rivaroxaban) transition after parenteral anticoagulation vs. Warfarin bridged with parenteral anticoagulation (UFH or LMWH) was evaluated on Hospital length of stay (days) (β -2.1, 95% CI -3.5 to -0.7, p=0.002). Apixaban or rivaroxaban initiation after catheter-directed thrombolysis for submassive PE reduced median hospital length of stay compared to warfarin.

synapsesocial.com/papers/6a86feaac7caab105a15509b https://doi.org/10.1177/1076029618755311

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Apixaban or Rivaroxaban Versus Warfarin for Treatment of Submassive Pulmonary Embolism After Catheter-Directed Thrombolysis

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Apixaban or Rivaroxaban Versus Warfarin for Treatment of Submassive Pulmonary Embolism After Catheter-Directed Thrombolysis

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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