Home at last? Early discharge for acute pulmonary embolism

Antithrombotic treatment for acute deep vein thrombosis (DVT) or pulmonary embolism (PE) should consist of a therapeutic dose of low molecular weight heparin (LMWH) for ≥5 days, followed by a vitamin K antagonist for ≥3 months. LMWH has simplified the initial management of DVT because it is at least as effective and safe as unfractionated heparin and can be administered in fixed subcutaneous doses without laboratory monitoring 1. These advantages over standard, unfractionated heparin allow the majority of patients with DVT to be treated at home without being admitted to hospital, improve the quality of life and reduce healthcare costs 2, 3. While a recent meta-analysis concluded that LMWH is at least as effective and safe as unfractionated heparin for the initial treatment of nonmassive PE 4, the question of starting treatment for PE in the outpatient setting has been less satisfactorily addressed. While DVT and PE are clearly manifestations of one pathophysiological process, it cannot be assumed that they can always be treated the same. Patients treated for PE appear to be almost four times as likely (1.5 versus 0.4%) to die of recurrent venous thromboembolism (VTE) in the following year than patients treated for DVT 5. While outpatient PE therapy for carefully selected patients may already be the standard of care 6, for certain experienced physicians, many practitioners are less secure with this approach. Based on data from Davies et al. 7 in the current issue of the European Respiratory Journal , one may move closer to a comfort level. Previous trials have suggested the feasibility of early discharge or entire outpatient therapy for acute PE, but have had limitations including study size, retrospective data collection and/or lack of randomisation 8–14. Certain large randomised outpatient DVT trials have included PE patients, …