Outpatient or inpatient treatment for acute pulmonary embolism: a retrospective cohort study of 439 consecutive patients

Abstract

Current guidelines consider outpatient treatment as an option for low-risk pulmonary embolism (PE), and risk assessment tools such as the HESTIA criteria can be used to identify PE patients who could feasibly be treated in an outpatient setting. Little is known about what proportion of patients in daily care this would comprise, and, in these patients, outcome data outside of clinical trials are scarce. To assess the proportion of PE patients receiving outpatient early discharge or in-hospital therapy, evaluate differences in patient characteristics between these subgroups and to assess clinical outcomes at 6 months. Monocentric, retrospective cohort study in 439 consecutive patients undergoing outpatient, early-discharge or in-hospital treatment for PE. Outcome data on recurrent VTE, pulmonary hypertension or death were collected from routine follow-up visits 6 months after VTE diagnosis. PE patients were treated as outpatient (OP; n = 49; 11.2 %); early-discharge (ED; n = 62; 14.1 %) or in-hospital (IH; n = 328; 74.7 %). Median duration of hospital stay in the ED and IH groups were 1 (IQR: 1) day and 9 (IQR: 7) days, respectively. Outcome event rates at 6 months were 3.9 % for recurrent VTE (95 % CI 2.3-6.1, similar between groups), 5.2 % for pulmonary hypertension (95 % CI 3.3-7.8, similar between groups) and 10.7 % for mortality (95 % CI 8.0-14.0). Mortality was significantly higher in IH patients (14.0 %; 95 % CI 10.5-18.3) compared to OP (0 %; 95 % CI 0.0-7.3) or ED (1.6 %; 95 % CI 0.0-8.7) patients. Mortality risk factors were high-risk ESC category (OR: 5.7), paraneoplastic VTE (OR: 3.0), need for oxygen supplementation (OR: 5.2), diabetes (OR: 2.5), age (OR per additional year: 1.1) and elevated INR (OR per 0.1 point increase: 1.5). No difference in the treatment groups for pulmonary hypertension during follow-up was found. Independent risk factors were thrombophilia (OR: 8.43), signs of right ventricular strain in baseline ECG (OR: 6.64) or echocardiography (RVESP > 40 mmHg OR: 2.99). 32 % of the OP or ED patients had at least one criterion of the HESTIA score that would have excluded them from outpatient treatment. In daily care, treating PE in an almost exclusively outpatient setting seems feasible and safe for up to 25 % of all PE patients. The HESTIA criteria seem to exclude up to 30 % of patients for whom outpatient or early-discharge treatment seems feasible and safe.

Three-month follow-up of pulmonary embolism in patients with COVID-19

“…The low rate for recurrent VTE (1.7%) that we found was similar to that reported following 6 month follow-up (3.9%) of unselected PE (n = 439) [10] The high prevalence (30%) of residual thrombus was unexpected in those undergoing repeat imaging. Two prior studies investigated residual thrombosis in unselected PE populations; the ELOPE study reported residual thrombus in 12.2% at 12 months with no relationship to functional impairment [11].…”

External Validation of the Hestia Criteria for Identifying Acute Pulmonary Embolism Patients at Low Risk of Early Mortality

“…Additionally, the Hestia criteria derivation study's methods (ie, predefined inclusion/exclusion criteria and need for informed consent) may have also contributed to the selection of a healthier, less generalizable study population. 5 Interestingly, a recent study by Werth and colleagues 11 which risk stratified 439 patients with acute PE with the Hestia criteria found 148 (33.7%) had score of 0, representing a low-risk population estimate more in line with our own. These studies taken together may suggest that retrospective scoring of Hestia may result in the classification of smaller proportions of patients as low risk (despite missing laboratory values being assumed to be within normal limits).…”

Cardiovascular Involvement in COVID-19: What Sequelae Should We Expect?

“…This highlights that thrombotic risk in the pulmonary vasculature may persist after hospital discharge. In a small cohort of COVID-19 patients and PE observed at 3-month follow-up, recurrent VTE was reported in only 1.6% of cases, similar to that reported for the general VTE population at short term [ 83 , 84 ]. Moreover, a high prevalence (30%) of residual thrombosis at computed tomography pulmonary angiogram was found, albeit in the absence of chronic thromboembolic pulmonary hypertension.…”