Outpatient<i>versus</i>inpatient treatment in patients with pulmonary embolism: a meta-analysis

Zondag, Wendy; Kooiman, Judith; Klok, Frederikus A.; Dekkers, Olaf M.; Huisman, Menno V.

doi:10.1183/09031936.00093712

Cited by 156 publications

(96 citation statements)

References 32 publications

(55 reference statements)

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“…However the quality of the included studies was low and subsequent and recent larger observational studies and randomized control trials were not included [8,11,16,17]. More recently, two additional systematic reviews of the outpatient management of acute symptomatic PE were published [18,19]. However the first review did not include studies of patients with acute PE managed with early discharge and did not perform a meta-analysis [18].…”

Section: Introductionmentioning

confidence: 99%

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

Piran

Gal

Wells

et al. 2013

Thrombosis Research

136

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Background: Patients with acute deep vein thrombus (DVT) can safely be treated as outpatients. However the role of outpatient treatment in patients diagnosed with a pulmonary embolism (PE) is controversial. We sought to determine the safety of outpatient management of patients with acute symptomatic PE. Materials and Methods: A systematic literature search strategy was conducted using MEDLINE, EMBASE, the Cochrane Register of Controlled Trials and all EBM Reviews. Pooled proportions for the different outcomes were calculated. Results: A total of 1258 patients were included in the systematic review. The rate of recurrent venous thromboembolism (VTE) in patients with PE managed as outpatients was 1.47% (95% CI: 0.47 to 3.0%; I 2 : 65.4%) during the 3 month follow-up period. The rate of fatal PE was 0.47% (95% CI: 0.16 to 1.0%; I 2 : 0%). The rates of major bleeding and fatal intracranial hemorrhage were 0.81% (95% CI: 0.37 to 1.42%; I 2 : 0%) and 0.29% (95% CI: 0.06 to 0.68%; I 2 : 0%), respectively. The overall 3 month mortality rate was 1.58% (95% CI: 0.71 to 2.80%; I 2 : 45%). The event rates were similar if employing risk stratification models versus using clinical gestalt to select appropriate patients for outpatient management. Conclusions: Independent of the risk stratification methods used, the rate of adverse events associated with outpatient PE treatment seems low. Based on our systematic review and pooled meta-analysis, low-risk patients with acute PE can safely be treated as outpatients if home circumstances are adequate.

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Section: Introductionmentioning

confidence: 99%

“…However the first review did not include studies of patients with acute PE managed with early discharge and did not perform a meta-analysis [18]. The last review included both retrospective and prospective studies which lower the overall quality of evidence from which the event rates are derived [7,19].…”

Section: Introductionmentioning

confidence: 99%

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

Piran

Gal

Wells

et al. 2013

Thrombosis Research

136

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“…On the other hand, in low-risk patients thrombolytic therapy is contraindicated, and anticoagulant therapy can be administered in hospital wards only. Furthermore, according to recent studies, some low-risk PE patients could be treated as outpatients (25,26). Since the availability of a cardiac ultrasound on a round-the-clock basis can be a significant problem in some hospitals, and for some patients an echocardiographic exam can be difficult to perform in emergency settings, cTnTs could play an important role in the early clinical triage of PE patients.…”

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confidence: 99%

Timing of troponin T measurements in triage of pulmonary embolism patients

Bulj

Potočnjak²,

Sharma³

et al. 2013

Croat Med J

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Aim To determine the appropriate timing of cardiac troponin T (cTnT) measurement for the early triage of pulmonary embolism (PE) patients. MethodsIn this single-center prospective study, PE was confirmed in all patients using computed tomography. 104 consecutive patients were divided into three groups (high-risk, intermediate, and low-risk) based on their hemodynamic status and echocardiographic signs of right ventricular dysfunction. cTnT levels were measured on admission and then after 6, 24, 48, and 72 hours with threshold values greater than 0.1 ng/mL. ResultsIntermediate-risk PE patients had higher cTnT levels than low-risk patients already in the first measurement (P = 0.037). Elevated cTnT levels significantly correlated with disease severity after 6 hours (intermediate vs low risk patients, P = 0.016, all three groups, P = 0.009). ConclusionIn hemodynamically stable patients, increased cTnT level on admission differentiated intermediate from low-risk patients and could be used as an important element for the appropriate triage of patients. Timing of troponin T measurements in triage of pulmonary embolism patients CLINICAL SCIENCE Croat Med J. 2013;54:561-8 doi: 10.3325/cmj.2013.54.561 CLINICAL SCIENCE 562 Nikola Bulj1Croat Med J. 2013;54:561-8 www.cmj.hrPulmonary embolism (PE) still remains one of the most frequent causes of death among patients in emergency settings. Early identification of high-risk patients and optimal treatment administration is often difficult due to the clinical variability of the disease. Several risk-stratification tools have been recently proposed based on echocardiography, biomarkers (troponins and natriuretic peptides), and computed tomography (1). Right ventricular dysfunction (RVD) is a central hemodynamic event in PE patients, and represents an independent prognostic factor of adverse events. Multiple clinical studies have convincingly shown that RVD in hypotensive and normotensive PE patients directly affects early mortality (2). A meta-analysis by ten Wolde et al clearly indicates that RVD is associated with a two times higher risk of PE related mortality (3). According to the current European Society of Cardiology (ESC) guidelines, therapy should be tailored to the estimated risk of death due to acute pulmonary embolism (4). The guidelines divide PE patients into three groups: high-risk (PE related mortality risk >15%), intermediate (PE related mortality risk 3%-15%), and low-risk patients (PE related mortality risk <1%) based on the presence of right ventricular dysfunction (measured by echocardiography, computed tomography, and natriuretic peptides) or injury (troponins). Higher risk patients should be treated with thrombolytic therapy in an intensive care unit (ICU), while non-high-risk patients should be additionally stratified and treated either in an ICU (intermediate-risk) or clinical ward (low-risk patients).Laboratory evaluations of acute right ventricular injury in PE patients have been extensively performed over the past few years, with a special emph...

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“…Many of these low-risk patients are eligible for outpatient management (2,3). Among the several prognostic tools used to identify a low-risk population, the PE Severity Index is the most extensively studied and is recommended by professional societies internationally (1,(4)(5)(6)(7).…”

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confidence: 99%

“…Two single-center retrospective case series tested the PE Severity Index in this capacity but failed to account for relative contraindications to outpatient care (9,10). Contraindications, however, are commonly used in various combinations throughout the prospective outpatient PE literature as well as in outpatient management protocols (2,3,11,12).…”

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confidence: 99%

Impact of Relative Contraindications to Home Management in Emergency Department Patients with Low-Risk Pulmonary Embolism

et al. 2015

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Rationale: Studies of adults presenting to the emergency department (ED) with acute pulmonary embolism (PE) suggest that those who are low risk on the PE Severity Index (classes I and II) can be managed safely without hospitalization. However, the impact of relative contraindications to home management on outcomes has not been described.Objectives: To compare 5-day and 30-day adverse event rates among low-risk ED patients with acute PE without and with outpatient ineligibility criteria. Methods:We conducted a retrospective multicenter cohort study of adults presenting to the ED with acute low-risk PE between 2010 and 2012. We evaluated the association between outpatient treatment eligibility criteria based on a comprehensive list of relative contraindications and 5-day adverse events and 30-day outcomes, including major hemorrhage, recurrent venous thromboembolism, and all-cause mortality.Measurements and Main Results: Of 423 adults with acute lowrisk PE, 271 (64.1%) had no relative contraindications to outpatient treatment (outpatient eligible), whereas 152 (35.9%) had at least one contraindication (outpatient ineligible). Relative contraindications were categorized as PE-related factors (n = 112; 26.5%), comorbid illness (n = 42; 9.9%), and psychosocial barriers (n = 19; 4.5%). There were no 5-day events in the outpatient-eligible group (95% upper confidence limit, 1.7%) and two events (1.3%; 95% confidence interval [CI], 0.1-5.0%) in the outpatient-ineligible group (P = 0.13). At 30 days, there were five events (two recurrent venous thromboemboli and three major bleeding events) in the outpatient-eligible group (1.8%; 95% CI, 0.7-4.4%) compared with nine in the ineligible group (5.9%; 95% CI, 2.7-10.9%; P , 0.05). This difference remained significant when controlling for PE severity class.Conclusions: Nearly two-thirds of adults presenting to the ED with low-risk PE were potentially eligible for outpatient therapy. Relative contraindications to outpatient management were associated with an increased frequency of adverse events at 30 days among adults with low-risk PE.

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Outpatientversusinpatient treatment in patients with pulmonary embolism: a meta-analysis

Cited by 156 publications

References 32 publications

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

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

Timing of troponin T measurements in triage of pulmonary embolism patients

Impact of Relative Contraindications to Home Management in Emergency Department Patients with Low-Risk Pulmonary Embolism

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