Thrombolysis and use of argatroban for the treatment of massive pulmonary embolism following anticoagulation failure in a patient with COVID-19

Am J Health Syst Pharm. 2020 Nov 16;77(23):1961-1964. doi: 10.1093/ajhp/zxaa287.


Purpose: Successful use of alteplase and argatroban to treat a patient with coronavirus disease 2019 (COVID-19)-associated massive pulmonary embolism with cardiac arrest is reported.

Summary: This case report describes a 42-year-old male with COVID-19 who developed a massive pulmonary embolism resulting in cardiac arrest after suspected failure of low-molecular-weight heparin therapy for a deep venous thrombosis. Administration of two 50-mg doses of intravenous alteplase resulted in return of spontaneous circulation, and low-dose argatroban was used as follow-up anticoagulation therapy without complications. This is the first case report of use of argatroban in a patient with COVID-19 with cardiac arrest-associated massive pulmonary embolism after failure of previous anticoagulation efforts.

Conclusion: Argatroban may be used as an alternate anticoagulation strategy in COVID-19 patients who fail low-molecular weight therapy. A risk versus benefit discussion should be had regarding appropriateness of therapy as well as dosing. More data is needed to understand the unique hypercoagulable condition in COVID-19 patients as well as research that further highlights the role of argatroban and bivalirudin therapy in this patient population.

Keywords: COVID-19; anticoagulants; argatroban; heart arrest; pulmonary embolism; tissue-plasminogen activator.

Publication types

  • Case Reports

MeSH terms

  • Adult
  • Anticoagulants / therapeutic use*
  • Arginine / analogs & derivatives
  • COVID-19
  • Coronavirus Infections / complications*
  • Fibrinolytic Agents / therapeutic use*
  • Heart Arrest / etiology
  • Heart Arrest / therapy
  • Heparin, Low-Molecular-Weight / therapeutic use
  • Humans
  • Male
  • Pandemics
  • Pipecolic Acids / therapeutic use*
  • Pneumonia, Viral / complications*
  • Pulmonary Embolism / drug therapy*
  • Pulmonary Embolism / etiology*
  • Sulfonamides
  • Thrombolytic Therapy / methods*
  • Treatment Failure
  • Treatment Outcome


  • Anticoagulants
  • Fibrinolytic Agents
  • Heparin, Low-Molecular-Weight
  • Pipecolic Acids
  • Sulfonamides
  • Arginine
  • argatroban