SHARE @ Advocate Health - Midwest - Scientific Day: Massive Pulmonary Embolism in Setting of Chronic PE and Lack of Medication Access
 

Affiliations

Advocate Lutheran General Hospital

Abstract

Introduction/Background:

Venous thromboembolism (VTE) is a common phenomenon in sedentary individuals with risk factors including malignancy and trauma and includes both deep venous thrombosis (DVT) and pulmonary embolism (PE). There are individuals with notable unprovoked DVTs that may embolize to the lungs, causing a PE. When there are indications of hypotension, right ventricular strain, and/or troponinemia, these are indications of a massive pulmonary embolism. Approximately 25 to 50% of thromboembolisms are unprovoked, prompting further evaluation for hypercoagulable states or malignancy. According to the American Society of Hematology (ASH), VTE may recur after 2 years in 10% of patients who were treated with anticoagulation, and up to 30% by 10 years. This case is unique in the fact that this patient had a fatal PE secondary to stopping her rivaroxaban for only 5 weeks.

Description:

We present a case of a 69-year-old female with a medical history of heart failure with preserved ejection fraction (HFpEF), pulmonary hypertension, history of DVT and PE who was unable to afford her anticoagulation, CAD, CKD, HTN, and COPD found to have lower extremity DVT which was complicated by massive pulmonary embolization and pulseless electrical activity (PEA) cardiac arrest secondary to DVT embolization to lungs while ambulating (with return of spontaneous circulation achieved). Intravascular ultrasound (IVUS) was performed, demonstrating group I and II pulmonary HTN and right segmental PE; the patient was started on a heparin drip and epoprostenol. Catheter directed thrombolysis was unable to be performed due to significant pulmonary hypertension and increased risk of bleeding, requiring transfer to higher level of care at a pulmonary hypertension center. The hospital course at an outside facility was complicated by renal failure requiring continuous renal replacement therapy, intubation, and atrial fibrillation. The patient then further decompensated and expired.

Discussion:

This case stresses the need for early treatment for pulmonary hypertension and policy changes to help improve the cost of anticoagulation and the complications that may arise from discontinuing life-saving medications based on affordability. According to The American Journal of Managed Care, it was found that 14 to 17.8% of patients with atrial fibrillation were not able to receive any oral anticoagulation after an initial rejection for apixaban. If approved, delays may take up to 2 months before approval. Other common barriers include formulary restrictions including quantity limitations, insurance limitations, high copayments, and racial disparities. This highlights the need for better access to the care needed.

Presentation Notes

Presented at Scientific Day; May 21, 2025; Park Ridge, IL.

Full Text of Presentation

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Document Type

Poster


 

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May 21st, 11:41 AM May 21st, 1:15 PM

Massive Pulmonary Embolism in Setting of Chronic PE and Lack of Medication Access

Introduction/Background:

Venous thromboembolism (VTE) is a common phenomenon in sedentary individuals with risk factors including malignancy and trauma and includes both deep venous thrombosis (DVT) and pulmonary embolism (PE). There are individuals with notable unprovoked DVTs that may embolize to the lungs, causing a PE. When there are indications of hypotension, right ventricular strain, and/or troponinemia, these are indications of a massive pulmonary embolism. Approximately 25 to 50% of thromboembolisms are unprovoked, prompting further evaluation for hypercoagulable states or malignancy. According to the American Society of Hematology (ASH), VTE may recur after 2 years in 10% of patients who were treated with anticoagulation, and up to 30% by 10 years. This case is unique in the fact that this patient had a fatal PE secondary to stopping her rivaroxaban for only 5 weeks.

Description:

We present a case of a 69-year-old female with a medical history of heart failure with preserved ejection fraction (HFpEF), pulmonary hypertension, history of DVT and PE who was unable to afford her anticoagulation, CAD, CKD, HTN, and COPD found to have lower extremity DVT which was complicated by massive pulmonary embolization and pulseless electrical activity (PEA) cardiac arrest secondary to DVT embolization to lungs while ambulating (with return of spontaneous circulation achieved). Intravascular ultrasound (IVUS) was performed, demonstrating group I and II pulmonary HTN and right segmental PE; the patient was started on a heparin drip and epoprostenol. Catheter directed thrombolysis was unable to be performed due to significant pulmonary hypertension and increased risk of bleeding, requiring transfer to higher level of care at a pulmonary hypertension center. The hospital course at an outside facility was complicated by renal failure requiring continuous renal replacement therapy, intubation, and atrial fibrillation. The patient then further decompensated and expired.

Discussion:

This case stresses the need for early treatment for pulmonary hypertension and policy changes to help improve the cost of anticoagulation and the complications that may arise from discontinuing life-saving medications based on affordability. According to The American Journal of Managed Care, it was found that 14 to 17.8% of patients with atrial fibrillation were not able to receive any oral anticoagulation after an initial rejection for apixaban. If approved, delays may take up to 2 months before approval. Other common barriers include formulary restrictions including quantity limitations, insurance limitations, high copayments, and racial disparities. This highlights the need for better access to the care needed.

 

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