Introduction Pulmonary embolism (PE) is a common complication of malignancy. NICE guidance for the treatment of venous thromboembolism (VTE) issued in June 2012 recommended that those with active cancer and confirmed PE be treated with low molecular weight heparin (LMWH) rather than alternative anticoagulants.¹ We assessed whether this guidance is being adhered to in our Trust.

Methods A retrospective review of electronic discharge summaries was undertaken on those who were discharged from the two acute hospitals in our Trust (population 600,000) with a diagnosis of PE between July 2012 and June 2013, the 12 months following the publication of the NICE guidance. In addition, an anonymised, internet-based survey was undertaken of the 62 consultant physicians within the Trust, to determine which anticoagulant they would routinely prescribe for PE in active malignancy.

Results Within the 12 month period of this study, 298 patients (173 women, 125 men) survived to discharge, having had PE confirmed on imaging. Forty six of these were known to have malignancy and a further 13 were found to have cancer at the time of diagnosis or very shortly afterwards. Two thirds of these (69.5%) were discharged on LMWH but the remainder (30.5%) were discharged on warfarin. Perhaps unsurprisingly, a similar percentage of the consultant physicians who completed the internet-based survey said they would prescribe LMWH, although a sizeable proportion continue to prescribe warfarin.

Conclusion NICE guidance is largely being adhered to but a proportion of clinicians continue to prescribe warfarin despite there being good evidence that LMWH is associated with a reduced risk of VTE recurrence in this group.² Further investigation is needed to determine whether this pattern of prescribing is prevalent throughout the UK, and why the guidance is being ignored in our Trust.

References

1. National Institute for Health and Care Excellence (2012). Venous thromboembolic diseases: the management of venous thromboembolic diseases and the role of thrombophilia testing [CG144]. London: National Institute for Health and Care Excellence.

2. Lee AY et al. Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer. N Engl J Med 2003;349:146–153.