Why So Much UFH for Acute PE? Can We Just Stop…

August 1, 2024

Written by Jason Lesnick

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This retrospective study found increased use of unfractionated heparin (UFH) relative to low-molecular weight heparin (LMWH) and direct oral anticoagulants (DOACs) over time, despite guidelines recommending LMWH or DOACs as first-line treatment for most patients with acute pulmonary embolism (PE).

UFH appears to be having ‘a moment’ in acute PE…and it needs to just not
This retrospective study examined nearly 300,000 cases of PE using ICD codes from 1,045 hospitals in the Premier Healthcare Database (~20% of all US hospitalizations) from 2011 to 2020. The primary outcome was initial anticoagulant received.

In 2011, most patients hospitalized with PE were initially treated with LMWH (58.1%) over UFH (41.9%). By 2020, UFH had become the more common initial anticoagulant (56.3% UFH, 37.3% LMWH, and 6.4% DOACs) (See Figure from the article below). Notably, rates of cases admitted to the ICU, treated with mechanical ventilation or vasopressors, and inpatient mortality were stable over time.

Factors associated with receiving UFH were: ICU admission (OR 6.90, 95%CI 6.31 to 7.54), receiving thrombolysis (OR 4.25, 95%CI 3.09 to 5.84), step-down admission (OR 2.30, 95%CI 2.16 to 2.45), vasopressors (OR 1.83, 95%CI 1.32 to 2.54), and chronic kidney disease (OR 1.67, 95%CI 1.54 to 1.81).

How will this change my practice?
The authors hypothesize that in anticipation of procedural interventions or thrombolysis for more severe PEs, clinicians may choose UFH. I have done this in the past; however, after reading this paper (and being inspired to look at safety outcomes comparing LMWH against UFH in PE patients receiving the above treatments) I will be more likely to choose LMWH in the future.

Editors’ notes:

1. Practice appears to be quite variable across the U.S. Together, we can improve guideline-directed anticoagulation in acute PE. Keep an eye out for a qualitative study looking at barriers and facilitators to LMWH use. ~Bo Stubblefield
2. I learned something new. Thrombolysis and catheter-directed therapies can still be used with LMWH. Unless a patient has significant renal dysfunction, I will be using LMWH, even in patients with higher risk PE. ~Clay Smith

Reviewed by Bo Stubblefield

Source
Trends in Initial Anticoagulation Among US Patients Hospitalized With Acute Pulmonary Embolism 2011-2020. Ann Emerg Med. 2024 Jun 18:S0196-0644(24)00277-4. doi: 10.1016/j.annemergmed.2024.05.009. PMID: 38888528.