Early discharge of patients with pulmonary embolism in daily clinical practice: A prospective observational study comparing clinical gestalt and clinical rules

Vanni, Simone; Becattini, Cecilia; Nazerian, Peiman; Bova, Carlo; Stefanone, Valerio Teodoro; Cimini, Ludovica Anna; Viviani, Gabriele; Caviglioli, Cosimo; Sanna, Michela; Pepe, Giuseppe; Grifoni, Stefano

doi:10.1016/j.thromres.2018.05.008

Cited by 17 publications

(24 citation statements)

References 28 publications

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“…Of those, 12 articles were eligible for inclusion in the study analysis, and the reasons for excluding the other 190 articles are given in Figure 1. Table 1 lists the 12 eligible studies, which included four RCTs 30,38–40 and eight NRTs 7,25,41–46 that enrolled a total of 3191 patients. Six studies included use of DOACs, and only three used DOACs exclusively.…”

Section: Resultsmentioning

confidence: 99%

“…However, both studies excluded patients with high‐risk features such as active bleeding, recent stroke, renal failure, thrombocytopenia, hypotension, or hypoxia on room air. The single observational study in our review examined “daily clinical practice” in which decisions regarding patient disposition were made by the treating physician rather than by a study protocol; no consistent approach was used to identify patients who were considered safe for outpatient treatment 45 . This study had the highest reported rates of all‐cause mortality, PE‐related mortality, and recurrent VTE (Table 2).…”

Section: Resultsmentioning

confidence: 99%

“…Eight studies defined outpatient treatment as discharge from the hospital within 24 hours. Two studies required that eligible patients were treated entirely as outpatients (either evaluated initially in an outpatient clinic 40 or discharged directly from the ED without additional observation 44 ), and two studies allowed up to 48 hours of care before discharge 42,45 . Despite these concrete time limits, studies varied substantially in how these times were measured; two studies assessed this “discharge time” in relation to the time of the patient's initial presentation to the ED, 30,42 while other studies used the time at which PE was diagnosed, 7,39 the time at which the patient was enrolled in the study, 38 or the time at which the patient was admitted to the hospital or observation unit 41,43,46 .…”

Section: Resultsmentioning

confidence: 99%

“…Despite these concrete time limits, studies varied substantially in how these times were measured; two studies assessed this “discharge time” in relation to the time of the patient's initial presentation to the ED, 30,42 while other studies used the time at which PE was diagnosed, 7,39 the time at which the patient was enrolled in the study, 38 or the time at which the patient was admitted to the hospital or observation unit 41,43,46 . All four RCTs and five NRTs specified the type of anticoagulation treatment that enrolled patients would receive, while three NRTs deferred choice of anticoagulant to the treating physician 43–45 …”

Section: Resultsmentioning

confidence: 99%

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Outpatient Treatment of Low‐risk Pulmonary Embolism in the Era of Direct Oral Anticoagulants: A Systematic Review

Maughan

Frueh

McDonagh

et al. 2020

Academic Emergency Medicine

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Background Clinical guidelines have supported outpatient treatment of low‐risk pulmonary embolism (PE) since 2014, but adoption of this practice has been slow. Direct oral anticoagulant (DOAC) therapy for venous thromboembolism (VTE) is now as common as vitamin K antagonist treatment, but data are sparse regarding outcomes for patients with low‐risk PE treated with DOACs as outpatients. We conducted a systematic review of literature on outcomes of outpatient management for PE, including comparisons to inpatient treatment and differences by anticoagulant class. Methods We searched Medline, Embase, PubMed, CENTRAL, clinicaltrials.gov, and ICTRN for studies published from January 1980 through February 2019 using a predefined strategy developed with a medical librarian. We included English‐language randomized controlled trials (RCTs) and prospective nonrandomized trials (NRTs) of adult patients diagnosed with acute, symptomatic PE, and discharged from the emergency department or within 48 hours. Our primary outcome included four major adverse outcomes (all‐cause mortality, PE‐related mortality, recurrent VTE, and major bleeding) within 30 and 90 days. A preplanned subanalysis of high‐quality studies assessed outcomes associated with different anticoagulation treatment classes. Results Our initial search identified 6,818 records, of which 12 studies (four RCT, eight NRT) with a total of 3,191 patients were included in the review. All RCTs and six NRTs were determined to have low to moderate risk of bias and were classified as high quality. Outpatients in these studies (n = 1,814) had rates of 90‐day major adverse outcomes below 1%, including all‐cause mortality (0.7%, 95% confidence interval [CI] = 0.4% to 1.2%), PE‐related mortality (0.06%, 95% CI = 0.01% to 0.3%), recurrent VTE (0.8%, 95% CI = 0.5% to 1.4%), and major bleeding (0.8%, 95% CI = 0.5% to 1.4%). Exploratory analysis revealed no association between anticoagulant treatment class and rates of major adverse outcomes. Conclusion Among patients with low‐risk PE treated as outpatients, few patients experienced major adverse outcomes such as mortality, recurrent VTE, or major bleeding within 90 days.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

See 2 more Smart Citations

Outpatient Treatment of Low‐risk Pulmonary Embolism in the Era of Direct Oral Anticoagulants: A Systematic Review

Maughan

Frueh

McDonagh

et al. 2020

Academic Emergency Medicine

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“…The majority of patients with acute PE are nowadays still treated in hospital. 2,[5][6][7][8][9][10] According to the 2019 ESC guidelines, hospitalization is recommended for all patients with intermediate-risk PE. 1 In the Hestia and Vesta studies, RV function evaluation (which is critical to the risk stratification as recommended by the ESC) was not part of standard baseline assessment.…”

Section: Discussionmentioning

confidence: 99%

Reasons for Hospitalization of Patients with Acute Pulmonary Embolism Based on the Hestia Decision Rule

et al. 2020

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Background The Hestia criteria can be used to select pulmonary embolism (PE) patients for outpatient treatment. The subjective Hestia criterion “medical/social reason for admission” allows the treating physician to consider any patient-specific circumstances in the final management decision. It is unknown how often and why this criterion is scored. Methods This is a patient-level post hoc analysis of the combined Hestia and Vesta studies. The main outcomes were the frequency of all scored Hestia items in hospitalized patients and the explicit reason for scoring the subjective criterion. Hemodynamic parameters and computed tomography-assessed right ventricular (RV)/left ventricular (LV) ratio of those only awarded with the subjective criterion were compared with patients treated at home. Results From the 1,166 patients screened, data were available for all 600 who were hospitalized. Most were hospitalized to receive oxygen therapy (45%); 227 (38%) were only awarded with the subjective criterion, of whom 51 because of “intermediate to intermediate-high risk PE.” Compared with patients with intermediate risk PE (RV/LV ratio > 1.0) treated at home (179/566, 32%), hospitalized patients with only the subjective criterion had a higher mean RV/LV ratio (mean difference +0.30, 95% confidence interval [CI] 0.19–0.41) and a higher heart rate (+18/min, 95% CI 10–25). No relevant differences were observed for other hemodynamic parameters. Conclusion The most frequent reason for hospital admission was oxygen therapy. In the decision to award the subjective criterion as sole argument for admission, the severity of the RV overload and resulting hemodynamic response of the patient was taken into account rather than just abnormal RV/LV ratio.

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Management and Outcomes of Adults Diagnosed with Acute Pulmonary Embolism in Primary Care: Community-Based Retrospective Cohort Study

et al. 2022

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Early discharge of patients with pulmonary embolism in daily clinical practice: A prospective observational study comparing clinical gestalt and clinical rules

Cited by 17 publications

References 28 publications

Outpatient Treatment of Low‐risk Pulmonary Embolism in the Era of Direct Oral Anticoagulants: A Systematic Review

Outpatient Treatment of Low‐risk Pulmonary Embolism in the Era of Direct Oral Anticoagulants: A Systematic Review

Reasons for Hospitalization of Patients with Acute Pulmonary Embolism Based on the Hestia Decision Rule

Management and Outcomes of Adults Diagnosed with Acute Pulmonary Embolism in Primary Care: Community-Based Retrospective Cohort Study

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