Ambulatory management of pulmonary embolism: a pragmatic evaluation

Abstract

Summary. Background:Patients diagnosed with pulmonary embolism should be considered for treatment on an outpatient basis; however, this practise is not accepted in many centers. Objectives: Review the safety and efficacy of ambulatory management of patients with pulmonary embolism at our institution. Patients/Methods: This was a retrospective single center cohort study of consecutive patients diagnosed with idiopathic or secondary pulmonary embolism between January 2003 and January 2008 at the London Health Sciences Centre in London, Ontario, Canada. Patients were eligible for outpatient management of pulmonary embolism if they were hemodynamically stable, did not require oxygen therapy, did not require parenteral narcotics for pain management, and were not felt to be high risk for a major hemorrhage. Patients were assessed at 3 months for thrombosis recurrence and major bleeding episodes. Results: Six hundred and thirty-nine patients were included in the study, of which 314 (49.1%; 95% CI 45.2, 53.1) were managed as outpatients; among these there were three (0.95%; 95% CI, 0.25, 3) thrombotic recurrences and three hemorrhagic events. There were nine deaths (2.9%; 95% CI, 1.4, 5.6), all due to underlying cancer and all occurring after the first 7 days of treatment. Conclusions: Outpatient management of uncomplicated pulmonary embolism seems safe and effective in the absence of other indications for hospital admission.

Hestia criteria can discriminate high- from low-risk patients with pulmonary embolism

“…The other retrospective study by KOVACS et al [5] did not give information on the clinical outcomes of patients treated in the hospital. The rates of adverse clinical outcome in the outpatient group are comparable with the rates in the Hestia study: none of the patients treated at home died of fatal PE.…”

“…In 2010, two retrospective studies on outpatient treatment of PE were published [4,5]. The Hestia study is an important prospective validation of these retrospective studies.…”

“…These reviews concluded that although the evidence is not of high quality, it indicates that certain subgroups of patients with PE could be eligible for outpatient treatment. In 2010, two large retrospective studies on outpatient treatment of PE patients were published [4,5]. In these studies, low rates of adverse clinical outcome were reported, suggesting safety of outpatient treatment in PE; in both articles, prospective validation of the results is recommended.…”

Outpatient treatment of symptomatic pulmonary embolism: A systematic review and meta-analysis

“…Several studies have reported that outpatient management or early discharge of patients with acute PE is safe and effective [8][9][10][11][12][13]. Two systematic reviews suggested that patients with acute PE treated as outpatients had low incidences of major bleeding, recurrent venous thromboembolism (VTE), and mortality [14,15].…”

Physicians’ management approach to an incidental pulmonary embolism: an international survey

“…Three recent cohort studies have demonstrated that selecting PE patients for outpatient treatment solely on a clinical basis, primarily focusing on hemodynamic stable PE patients who do not require an oxygen supply, yields safe results in terms of low risks of recurrent VTE and mortality [9][10][11]. Given that patients with an asymptomatic PE are clearly able to compensate for the hemodynamic and respiratory consequences of the PE and unlikely to have decreased right ventricular function, these patients may be deemed good candidates for outpatient management, in particular if a PE is detected on elective CT scans in an outpatient setting.…”