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

Maughan, Brandon C.; Frueh, Lisa; McDonagh, Marian; Casciere, Bryan; Kline, Jeffrey A.

doi:10.1111/acem.14108

Cited by 22 publications

(22 citation statements)

References 60 publications

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“…Consistent with prior studies, we observed that only 1.3% of patients managed as outpatients experienced return visits for bleeding 31 . This was reassuring because the outcomes achieved in clinical trials do not always translate into routine practice.…”

Section: Discussionsupporting

confidence: 88%

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Outpatient Management of Patients Following Diagnosis of Acute Pulmonary Embolism

Westafer

Shieh

Pekow

et al. 2020

Academic Emergency Medicine

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Objective While guidelines recommend outpatient management of patients with low‐risk pulmonary embolism (PE), little is known about the disposition of patients with PE diagnosed in United States emergency departments (EDs). We sought to determine disposition practices and subsequent health care utilization in patients with acute PE in U.S. EDs. Methods This was a retrospective cohort study of adult ED patients with a new diagnosis of acute PE treated at 740 U.S. acute care hospitals from July 1, 2016, through June 30, 2018. The primary outcome was the initial disposition following an ED visit for acute PE. Additional measures included hospital cost and 30‐day revisit rate to the ED. Results A total of 61,070 cases were included in the overall cohort, of which 4.1% of new cases of PE were discharged from the ED. The median hospital‐specific proportion of patients discharged was 3.1% (interquartile range = 0.8%–6.8%). The median odds ratio, representing the importance of the hospital in initial disposition decisions, was 2.21 (95% confidence interval = 2.05 to 2.37), which was greater than any patient‐level factor with the exception of concurrent ED diagnosis of hypoxemia/respiratory failure, shock, or hypotension. Within 30 days of discharge, 17.9% of discharged cases had an ED return visit to the ED only and 10.3% of patients were hospitalized. Of the 30‐day ED return visits in patients initially managed as outpatients, 1.3% had a bleeding‐associated diagnosis. Conclusion Despite guidelines promoting outpatient management, few patients are currently discharged home in the United States; however, practice varies widely across hospitals. Return visit rates were high but most did not result in hospitalization.

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Section: Discussionsupporting

confidence: 88%

“…The evidence underpinning the management of low‐risk PE in the outpatient setting is centered on two randomized controlled trials and several cohort studies 31 . Based on these data, professional societies have recommended outpatient management of PE for these select patients 11,12,32,33 .…”

Section: Discussionmentioning

confidence: 99%

Outpatient Management of Patients Following Diagnosis of Acute Pulmonary Embolism

Westafer

Shieh

Pekow

et al. 2020

Academic Emergency Medicine

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“…Several studies have previously evaluated these two triaging tools, but most of them were single-arm cohort studies precluding direct comparison of their safety, applicability, and effectiveness. 3 , 4 To our knowledge, only two studies previously compared the sPESI and the Hestia rule. The first one was retrospective, 18 and the other a single-centre observational prospective study where the investigators did not use the triaging tools for decision-making of home treatment.…”

Section: Discussionmentioning

confidence: 99%

“… 1 , 2 However, current evidence is mainly based on cohort studies using different sets of eligibility criteria. 3 , 4 Therefore, controversy persists about the optimal triaging strategy and eligibility criteria for home treatment. 3 …”

Section: Introductionmentioning

confidence: 99%

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Triaging acute pulmonary embolism for home treatment by Hestia or simplified PESI criteria: the HOME-PE randomized trial

Roy

Penaloza

Hügli

et al. 2021

European Heart Journal

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Aims The aim of this study is to compare the Hestia rule vs. the simplified Pulmonary Embolism Severity Index (sPESI) for triaging patients with acute pulmonary embolism (PE) for home treatment. Methods and results Normotensive patients with PE of 26 hospitals from France, Belgium, the Netherlands, and Switzerland were randomized to either triaging with Hestia or sPESI. They were designated for home treatment if the triaging tool was negative and if the physician-in-charge, taking into account the patient’s opinion, did not consider that hospitalization was required. The main outcomes were the 30-day composite of recurrent venous thrombo-embolism, major bleeding or all-cause death (non-inferiority analysis with 2.5% absolute risk difference as margin), and the rate of patients discharged home within 24 h after randomization (NCT02811237). From January 2017 through July 2019, 1975 patients were included. In the per-protocol population, the primary outcome occurred in 3.82% (34/891) in the Hestia arm and 3.57% (32/896) in the sPESI arm (P = 0.004 for non-inferiority). In the intention-to-treat population, 38.4% of the Hestia patients (378/984) were treated at home vs. 36.6% (361/986) of the sPESI patients (P = 0.41 for superiority), with a 30-day composite outcome rate of 1.33% (5/375) and 1.11% (4/359), respectively. No recurrent or fatal PE occurred in either home treatment arm. Conclusions For triaging PE patients, the strategy based on the Hestia rule and the strategy based on sPESI had similar safety and effectiveness. With either tool complemented by the overruling of the physician-in-charge, more than a third of patients were treated at home with a low incidence of complications.

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Acute Pulmonary Embolism

Freund

Cohen‐Aubart

Bloom

2022

JAMA

102

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ImportancePulmonary embolism (PE) is characterized by occlusion of blood flow in a pulmonary artery, typically due to a thrombus that travels from a vein in a lower limb. The incidence of PE is approximately 60 to 120 per 100 000 people per year. Approximately 60 000 to 100 000 patients die from PE each year in the US.ObservationsPE should be considered in patients presenting with acute chest pain, shortness of breath, or syncope. The diagnosis is determined by chest imaging. In patients with a systolic blood pressure of at least 90 mm Hg, the following 3 steps can be used to evaluate a patient with possible PE: assessment of the clinical probability of PE, D-dimer testing if indicated, and chest imaging if indicated. The clinical probability of PE can be assessed using a structured score or using clinical gestalt. In patients with a probability of PE that is less than 15%, the presence of 8 clinical characteristics (age &lt;50 years, heart rate &lt;100/min, an oxygen saturation level of &gt; 94%, no recent surgery or trauma, no prior venous thromboembolism event, no hemoptysis, no unilateral leg swelling, and no estrogen use) identifies patients at very low risk of PE in whom no further testing is needed. In patients with low or intermediate clinical probability, a D-dimer level of less than 500 ng/mL is associated with a posttest probability of PE less than 1.85%. In these patients, PE can be excluded without chest imaging. A further refinement of D-dimer threshold is possible in patients aged 50 years and older, and in patients with a low likelihood of PE. Patients with a high probability of PE (ie, &gt;40% probability) should undergo chest imaging, and D-dimer testing is not necessary. In patients with PE and a systolic blood pressure of 90 mm Hg or higher, compared with heparin combined with a vitamin K antagonist such as warfarin followed by warfarin alone, direct oral anticoagulants such as apixaban, edoxaban, rivaroxaban, or dabigatran, are noninferior for treating PE and have a 0.6% lower rate of bleeding. In patients with PE and systolic blood pressure lower than 90 mm Hg, systemic thrombolysis is recommended and is associated with an 1.6% absolute reduction of mortality (from 3.9% to 2.3%).Conclusions and RelevanceIn the US, PE affects approximately 370 000 patients per year and may cause approximately 60 000 to 100 000 deaths per year. First-line therapy consists of direct oral anticoagulants such as apixaban, edoxaban, rivaroxaban, or dabigatran, with thrombolysis reserved for patients with systolic blood pressure lower than 90 mm Hg.

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

Cited by 22 publications

References 60 publications

Outpatient Management of Patients Following Diagnosis of Acute Pulmonary Embolism

Outpatient Management of Patients Following Diagnosis of Acute Pulmonary Embolism

Triaging acute pulmonary embolism for home treatment by Hestia or simplified PESI criteria: the HOME-PE randomized trial

Acute Pulmonary Embolism

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