Monitoring

Evaluate patients 3 to 6 months after acute PE to assess the persistence (or new onset) and severity of dyspnoea or functional limitation, and to check for possible signs of venous thromboembolism (VTE) recurrence, cancer, or bleeding complications of anticoagulation.[67] Chronic thromboembolic pulmonary hypertension (CTEPH) should be ruled out in patients with persistent dyspnoea and poor physical performance. Consider transthoracic echocardiogram to assess for (chronic) pulmonary hypertension and consequently, possible CTEPH.[67]

There is no single, definitive approach to monitoring parenteral heparin for the management of venous thromboembolism. A suggested approach is to check activated partial thromboplastin time (aPTT) or anti-Xa level every 6 hours until two consecutive therapeutic results are obtained, following which monitoring frequency can be reduced to once daily.[263] Anti-Xa level monitoring may be preferred to aPTT in patients with heparin resistance, prolonged baseline aPTT, or altered heparin responsiveness.[263] A therapeutic range of 0.3 to 0.7 units/mL is suggested when anti-Xa monitoring is used.[263]

Patients treated with a vitamin K antagonist require frequent international normalised ratio (INR) monitoring, preferably at a specialised anticoagulant clinic. However, select patients may be candidates for self-monitoring vitamin K antagonist therapy using portable point-of-care units. Patients on oral anticoagulation who self-monitor or self-manage can improve the quality of their oral anticoagulation therapy.[264]

Dabigatran, rivaroxaban, apixaban, and edoxaban do not require laboratory monitoring with coagulation assays. An assessment of kidney function prior to initiating direct-acting oral anticoagulant therapy, and kidney and liver function monitoring during therapy, should be conducted as clinically indicated.

Consensus guidance recommends that patients (with venous thromboembolism) receiving low molecular weight heparin should be monitored for signs and symptoms of bleeding and renal function change that necessitates dose adjustment.[263] Full blood count, platelet count, and serum creatinine should be monitored periodically; routine anti-Xa monitoring is not recommended.[263]

Routine therapeutic drug monitoring of fondaparinux may not be necessary in the majority of patients; anti-Xa assay calibrated for fondaparinux may be considered if fondaparinux accumulation is suspected.[263]

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