Response to the letter concerning the article “Acute pulmonary embolism treatment with rivaroxaban results in a shorter duration of hospitalisation compared to standard therapy: an academic centre experience”

published in “Kardiologia Polska” 2016; 74, 7: 650–656

Michał Ciurzyński, Marzanna Paczyńska, Piotr Sobieraj, Piotr Pruszczyk

Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland

We have read with great interest the Letter to the Editor by Prof. Anetta Undas with comments to our study [1]. Non-vitamin K oral anticoagulants (NOACs) are free from many of the limitations of vitamin K antagonists (VKA) and represent a valuable alternative for the treatment of patients with acute pulmonary embolism (APE). According to the recent European Society of Cardiology guidelines on the diagnosis and management of APE, rivaroxaban and apixaban alone and dabigatran as well as edoxaban, after short-term parenteral anticoagulant, achieved class I level of evidence B recommendation in acute phase treatment and rivaroxaban, dabigatran, apixaban, class IIa, level B for extended anticoagulation [2]. Numerous favourable factors associated with the use of NOAC and increasingly affordable price result in increasing use of these drugs in a population of patients with APE. The aim of our study was to evaluate the frequency and characteristics of patients with APE treated with rivaroxaban in an academic referral centre and to assess the possibility of shortening hospitalisation time of patients treated with NOAC compared with those treated with VKA. We included 215 consecutive APE patients: 110 female, 105 male, median age 65.0 (range 19.5–91.9) years. High-risk APE was diagnosed in seven (3.3%) patients, intermediate in 157 (73%), and low risk in 51 (24%). At discharge 30.5% of patients received VKA, 39.0% of subjects were prescribed rivaroxaban, while in the remaining 30.5% of patients low molecular weight heparin (LMWH) was used. An interesting finding of our analysis was the fact that patients who were treated and discharged with rivaroxaban were hospitalised for significantly shorter periods of time than were patients who received VKA (6 [2–22] vs. 8 [2–17] days, p = 0.0005).

We stratified the severity of APE in normotensive patients according to simplified pulmonary embolism severity index (sPESI) score, and we found that those patients with sPESI = 0 points and also in subjects with sPESI ≥ 1 points, who were treated with rivaroxaban, were hospitalised for significantly shorter periods of time than were others, treated with VKA [1]. We did not find any differences in age between patients treated with rivaroxaban vs. VKA and rivaroxaban vs. LMWH (63.7 [19.8–90.6] vs. 63.2 [19.5–90.5] and 63.7 [19.8–90.6] vs. 67.0 [26.6–91.9], respectively, p = NS) and also in mean glomerular filtration rate (GFR) values (78.8 ± 27.2 vs. 79.0 ± 33.4 and 78.8 ± 27.2 vs. 72.1 ± 29.9 mL/min/1.73 m2, respectively, p = NS). However, we noticed that in the rivaroxaban group median sPESI score was significantly lower than in LMWH patients (0 vs. 1 point, p = 0.002). Similarly, median sPESI score was significantly lower in the VKA group than in the LMWH group (0 vs. 1 point, p = 0,002). The reason was probably the fact that patients treated with LMWH had higher levels of active cancer than those in the rivaroxaban or VKA groups (39% vs. 1.2%, p < 0.001; 39% vs. 3.1%, p < 0.001, respectively).

We would like to emphasise that we proposed rivaroxaban as a long-term phase therapy for all normotensive APE patients without contraindications for this drug. However, for some patients (e.g. those with eGFR < 30 mL/min/1.73 m2 or with active cancer) first-choice drugs were VKA or LMWH. As we have mentioned above, 82 (39%) of all our patients were discharged home on rivaroxaban. However, about 60% of “rivaroxaban eligible patients” received this medication. It seems to us that the frequency of use of NOAC for patients with APE will steadily increase due to the numerous advantages of this class of drugs. Definitively, for our patients, the economic factor was the most important argument for VKA selection in the “rivaroxaban-eligible group”. We analysed our two years’ experience with rivaroxaban in APE patients. As expected, in the beginning of this period, due to our limited experience, we were more careful while using rivaroxaban; however, after only a few months NOAC was much more frequently prescribed. We believe that significant shortening of the hospitalisation period in the rivaroxaban group, independently of the sPESI value, is an argument to start discussion on the optimal organisation of healthcare systems.

Conflict of interest: none declared

References

1. 1. Paczyńska M, Kurnicka K, Lichodziejewska B et al. Acute pulmonary embolism treatment with rivaroxaban results in a shorter duration of hospitalisation compared to standard therapy: an academic centre experience. Kardiol Pol, 2016; 74: 650–656. doi: 10.5603/KP.a2015.0253.
2. 2. Konstantinides SV, Torbicki A, Agnelli G et al. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J, 2014; 35: 3033–3069, 69a–69k. doi: 10.1093/eurheartj/ehu283.