Outpatient versus inpatient treatment for acute pulmonary embolism

Yoo, Hugo HB; Nunes-Nogueira, Vania Santos; Bôas, Paulo José Fortes Villas; Broderick, Cathryn

doi:10.1002/14651858.cd010019.pub3

Cited by 18 publications

(20 citation statements)

References 53 publications

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“…Sub-segmental PEs are an area of uncertainty and further research into short-and long-term outcomes is needed before a clear recommendation can be made. 18,102 Conclusion Presentation of an aPE is shown to have a substantial morbidity and mortality rate in both the short and long term. The development of CPS to assist diagnostic decision-making and prognostic stratification is facilitating safer admission and discharge decisions, but ultimately this decision still relies on radiology and other biochemical markers.…”

Section: Sub-segmental Pulmonary Embolimentioning

confidence: 99%

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Acute pulmonary embolism: a concise review of diagnosis and management

Hepburn-Brown

Darvall

Hammerschlag

2019

Internal Medicine Journal

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An acute pulmonary embolism (aPE) is characterised by occlusion of one or more pulmonary arteries. Physiological disturbance may be minimal, but often cardiac output decreases as the right ventricle attempts to overcome increased afterload. Additionally, ventilation‐perfusion mismatches can develop in affected vascular beds, reducing systemic oxygenation. Incidence is reported at 50–75 per 100 000 in Australia and New Zealand, with 30‐day mortality rates ranging from 0.5% to over 20%. Incidence is likely to increase with the ageing population, increased survival of patients with comorbidities that are considered risk factors and improving sensitivity of imaging techniques. Use of clinical prediction scores, such as the Wells score, has assisted in clinical decision‐making and decreased unnecessary radiological investigations. However, imaging (i.e. computed tomography pulmonary angiography or ventilation‐perfusion scans) is still necessary for objective diagnosis. Anti‐coagulation remains the foundation of PE management. Haemodynamically unstable patients require thrombolysis unless absolutely contraindicated, while stable patients with right ventricular dysfunction or ischaemia should be aggressively anti‐coagulated. Stable patients with no right ventricular dysfunction can be discharged home early with anti‐coagulation and review. However, treatment should be case dependent with full consideration of the patient’s clinical state. Direct oral anti‐coagulants have become an alternative to vitamin K antagonists and are facilitating shorter hospital admissions. Additionally, duration of anti‐coagulation must be decided by considering any provoking factors, bleeding risk and comorbid state. Patients with truly unprovoked or idiopathic PE often require indefinite treatment, while in provoked cases it is typically 3 months with some patients requiring longer periods of 6–12 months.

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Section: Sub-segmental Pulmonary Embolimentioning

confidence: 99%

“…Regardless, these patients should be followed closely to monitor for any new symptoms. Sub‐segmental PEs are an area of uncertainty and further research into short‐ and long‐term outcomes is needed before a clear recommendation can be made …”

Section: Sub‐segmental Pulmonary Embolimentioning

confidence: 99%

Acute pulmonary embolism: a concise review of diagnosis and management

Hepburn-Brown

Darvall

Hammerschlag

2019

Internal Medicine Journal

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“…This is likely due to the small sample size in the study and the low event rate of these outcomes among patients treated with DOACs. Safety and efficacy are likely greater in DOACs compared with VKA and LMWH 13,31 suggesting that including more studies with patients on DOACs will likely show an increased benefit in home treatment of VTE.…”

Section: Strengths and Limitations Of Studymentioning

confidence: 99%

Home vs hospital treatment of low-risk venous thromboembolism: a systematic review and meta-analysis

Khatib,

Ross,

Kennedy

et al. 2020

Blood Advances

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Increasing evidence supports the safety and effectiveness of managing low-risk deep vein thrombosis (DVT) or pulmonary embolism (PE) in outpatient settings. We performed a systematic review to assess safety and effectiveness of managing patients with DVT or PE at home compared with the hospital. Medline, Embase, and Cochrane databases were searched up to July 2019 for relevant randomized clinical trials (RCTs), and prospective cohort studies. Two investigators independently screened titles and abstracts of identified citations and extracted data from relevant full-text papers. Risk ratios (RRs) were calculated, and certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). Seven RCTs (1922 patients) were included in metaanalyses on managing patients with DVT. Pooled estimates indicated decreased risk of PE (RR 5 0.64; 95% confidence interval [CI], 0.44-0.93) and recurrent DVT (RR 5 0.61; 95% CI, 0.42-0.90) for home management, both with moderate certainty of the evidence. Reductions in mortality and major bleeding were not significant, both with low certainty of the evidence. Two RCTs (445 patients) were included in meta-analyses on home management of low-risk patients with PE. Pooled estimates indicated no significant difference in all-cause mortality, recurrent PE, and major bleeding, all with low certainty of the evidence. Results of pooled estimates from 3 prospective cohort studies (234 patients) on home management of PE showed similar results. Our findings indicate that low-risk DVT patients had similar or lower risk of patient-important outcomes with home treatment compared with hospital treatment. In patients with low-risk PE, there was important uncertainty about a difference between home and hospital treatment.

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“…The proportion of low risk patients admitted was 81% in 2013 and decreased to 73.4% in 2018. Clinical practice guidelines have recommended outpatient management of patients with DVT and low risk of complications since 2012 [6]. In 2016, these guidelines were updated to also include outpatient management of patients with PE and low risk of complications [6,7].…”

Section: Discussionmentioning

confidence: 99%

Outpatient management of patients presenting with venous thromboembolism: Retrospective cohort study at 11 community hospitals

Khatib

Nitti

McDowell

et al. 2020

J Thromb Thrombolysis

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A gap exists between clinical practice guidelines and real-world practice. We aim to investigate hospital admissions among patients presenting to emergency departments of 11 hospitals with venous thromboembolism (VTE). Eligible patients’ first emergency department VTE visit were retrospectively collected between 2013 and 2018 from electronic medical records (EMR). Patients were categorized at low risk of VTE complications if they were diagnosed with deep vein thrombosis (DVT) of the leg or if they were diagnosed with pulmonary embolism (PE) and had a PE score index < 85. Multivariable logistic regression models were constructed to measure the adjusted odds ratios (OR) and 95% confidence intervals (CI) of hospital admissions before and after clinical practice guidelines were updated to recommend outpatient management of DVT and PE with low risk of complications. A total of 13,677 patients were included in the analysis, of which 55% were diagnosed with DVT. Mean age was 65 ± 17 years, 54% were females, and 62% were Caucasian. Overall, 9281 patients were categorized at low risk VTE complications, of whom 77% were admitted for in-hospital management. The rate of in-hospital management declined from 81% in 2013 to 73% in 2018. Patients visiting emergency departments between 2016 and 2018 (post-guidelines) were equally likely to be admitted compared to patients visiting the emergency departments between 2013 and 2015 (pre-guidelines; OR = 0.99; 95% CI: 0.88, 1.11). Results from this real-world study indicate that most low-risk VTE patients are admitted for in-hospital management, despite recommendations in clinical practice guidelines.

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Outpatient versus inpatient treatment for acute pulmonary embolism

Cited by 18 publications

References 53 publications

Acute pulmonary embolism: a concise review of diagnosis and management

Acute pulmonary embolism: a concise review of diagnosis and management

Home vs hospital treatment of low-risk venous thromboembolism: a systematic review and meta-analysis

Outpatient management of patients presenting with venous thromboembolism: Retrospective cohort study at 11 community hospitals

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