Outpatient treatment of pulmonary embolism

Q: What is the clinical evidence from this study?

Study design: Review. Population: Pulmonary embolism (PE). Intervention: Outpatient anticoagulation management (primarily non-vitamin K oral anticoagulants [NOACs], or LMWH/fondaparinux/VKA) vs. Inpatient hospital management. Primary outcome: 30-day mortality, VTE recurrence, and major bleeding.

Q: What does this research mean for the field?

Outpatient management of low-risk pulmonary embolism identified via risk stratification tools like PESI, sPESI, and Hestia criteria is safe and effective. Novelty: ClaimNovelty.SYNTHESIS. Consensus alignment: ConsensusAlignment.SUPPORTS_CONSENSUS.

Elena Bellou; Elli Keramida; Ioannis Karampinis; Evaggelos Dimakakos; Panagiotis Misthos; Panagiotis Demertzis; Georgia Hardavella

doi:10.1183/20734735.0069-2020

September 1, 2020BreatheOpen Access

Outpatient treatment of pulmonary embolism

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Key result

Outpatient NOAC management for risk-stratified low-risk PE proves safe and effective at 3 months.

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Why the study?

Evidence has been increasing to support managing pulmonary embolism in the outpatient setting rather than during hospital admission.

Does outpatient anticoagulation management using clinical risk stratification (PESI, sPESI, Hestia criteria) safely prevent mortality, recurrent VTE, and major bleeding compared to inpatient management in patients with low-risk pulmonary embolism?

Key Points

To review the current status of outpatient management in confirmed pulmonary embolism and outline pragmatic risk-stratification pathways for clinical practice.
Review of clinical risk stratification scores, specifically the Pulmonary Embolism Severity Index (PESI), simplified PESI (sPESI), and Hestia criteria.
Evaluation of clinical trial and cohort validation data assessing safe discharge criteria, anticoagulation delivery, and outpatient feasibility.
Low-risk classification using PESI class I (<65 points) and class II (66–85 points) corresponds to 30-day mortality risks of 1.1% and 3.1%, respectively, whereas an sPESI score of 0 corresponds to a 1.1% 30-day mortality risk.
A negative Hestia assessment predicts 0% mortality and 2% venous thromboembolism recurrence, successfully identifying 25% of patients categorized as high risk by sPESI who can still be treated safely as outpatients.

Structured PICO

Does outpatient anticoagulation management using clinical risk stratification (PESI, sPESI, Hestia criteria) safely prevent mortality, recurrent VTE, and major bleeding compared to inpatient management in patients with low-risk pulmonary embolism?

P

Population

Patients with confirmed low-risk pulmonary embolism (identified via PESI class I/II, sPESI 0, or negative Hestia criteria) without serious comorbidities who are eligible for early discharge and outpatient anticoagulation management.

I

Intervention

Outpatient management with immediate anticoagulation therapy for a minimum of 3 months, primarily using non-vitamin K oral anticoagulants (NOACs: apixaban 10 mg twice daily for 7 days then 5 mg twice daily; rivaroxaban 15 mg twice daily for 21 days then 20 mg once daily; dabigatran 150 mg twice daily following 5-10 days of parenteral anticoagulation; or edoxaban 60 mg once daily following at least 5 days of heparin), or alternatively subcutaneous LMWH, fondaparinux, or vitamin K antagonists (with parenteral bridging for >=5 days until INR 2-3).

C

Comparator

Traditional inpatient hospital admission and management.

O

Outcome

30-day mortality, venous thromboembolism (VTE) recurrence, and major bleeding.hard clinical

Combining clinical risk stratification tools (PESI/sPESI and Hestia criteria) with bleeding risk assessment and direct oral anticoagulants enables safe, cost-effective outpatient treatment for appropriately selected patients with low-risk pulmonary embolism.

Limitations

PESI validation studies excluded high-risk patients such as those with terminal illness or renal failure, requiring clinical judgement over scores in pragmatic settings.
PESI and sPESI do not exclude pregnant women or patients with medical/social reasons for hospital admission, whereas sPESI excludes all patients with active cancer.
To the authors' knowledge, there is no clear evidence relating PESI or sPESI scores with specific anticoagulation therapy.
PESI validation excluded patients with terminal illness or renal failure, requiring clinical judgement over scoring tools in these populations.
Clinician confusion exists regarding whether to prefer PESI/sPESI or Hestia criteria, as PESI/sPESI does not exclude pregnant women or medical/social admission reasons, while sPESI excludes all active cancer patients.
Lack of clear evidence directly linking PESI or sPESI scores with specific anticoagulation regimens.
Delivering outpatient anticoagulation monitoring within secondary care faces challenges with frail patients of limited mobility, uninsured patients, and wide geography.

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Implication

Supports outpatient low-risk PE management with NOACs after stratification; leaves open randomized trials for confirmation.

Abstract

Over the past decade there has been an increasing trend to manage many conditions traditionally treated during a hospital admission as outpatients. Evidence is increasing to support this approach in patients with pulmonary embolism (PE). In this article, we review the current status of outpatient management of confirmed PE and present a pragmatic approach for clinical healthcare settings.

Discussion

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Cite This Study

Bellou et al. (2020) conducted a review in Pulmonary embolism (PE). Outpatient anticoagulation management (primarily non-vitamin K oral anticoagulants [NOACs], or LMWH/fondaparinux/VKA) vs. Inpatient hospital management was evaluated on 30-day mortality, VTE recurrence, and major bleeding. Outpatient management of low-risk pulmonary embolism using PESI, sPESI (91% sensitivity, 100% NPV), and Hestia criteria (82% sensitivity, 99% NPV) with NOACs is safe and effective for at least 3 months.

synapsesocial.com/papers/6a7b8c6d0449e558d7c2854e https://doi.org/10.1183/20734735.0069-2020

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Outpatient treatment of pulmonary embolism

Figures

Key Points

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Outpatient treatment of pulmonary embolism

Figures

Key Points

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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