Treatment of acute pulmonary embolism as outpatients or following early discharge

Summary

The purpose of this systematic review is to test the hypothesis that carefully selected low-risk patients with acute pulmonary embolism (PE) can safely be treated entirely as outpatients or after early hospital discharge.Included articles were required to describe inclusion or exclusion criteria and outcome of patients treated for PE.Early hospital discharge was defined as an average hospital stay ≤3 days.Six investigations included patients with PE who were treated entirely as outpatients; two investigations included patients with PE who were treated after early discharge. All investigations included only low-risk patients or patients with small or medium sized PE. Outcome after 3-46 months in patients treated entirely as outpatients showed recurrent PE in 0% to 6.2% of patients, major bleeding in 0% to 2.8% with one death from an intracerebral bleed. Definite death from PE did not occur, but there was one possible death from PE. Outcome in three months in patients treated after early discharge showed no instances of recurrent PE. Major bleeding occurred in 0% to 3.7% of patients.There were no deaths from PE, but there was one death from bleeding. In conclusion, outpatient therapy of acute PE is probably safe in low-risk,carefully selected compliant patients who have access to outpatient care if necessary. Such outpatient treatment would be cost-effective.

Keywords

Pulmonary embolism - deep venous thrombosis - outpatient treatment

• References

• 1 Koopman MM, Prandoni P, Piovella F. et al. Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcutaneous low-Molecular-weight heparin administered at home. The Tasman Study Group. N Engl J Med 1996; 334: 682-687.
• 2 Levine M, Gent M, Hirsh J. et al. A comparison of low-molecular-weight heparin administered primarily at home with unfractionated heparin administered in the hospital for proximal deep-vein thrombosis. N Engl J Med 1996; 334: 677-681.
• 3 Pearson SD, Blair R, Halpert A. et al. An outpatient program to treat deep venous thrombosis with low-molecular-weight heparin. Eff Clin Pract 1999; 02: 210-217.
• 4 Grau E, Tenias JM, Real E. et al. Home treatment of deep venous thrombosis with low molecular weight heparin: Long-term incidence of recurrent venous thromboembolism. Am J Hematol 2001; 67: 10-14.
• 5 Vinson DR, Berman DA. Outpatient treatment of deep venous thrombosis: a clinical care pathway managed by the emergency department. Ann Emerg Med 2001; 37: 251-258.
• 6 Spyropoulos AC, Hurley JS, Ciesla GN. et al. Management of acute proximal deep vein thrombosis: pharmacoeconomic evaluation of outpatient treatment with enoxaparin vs inpatient treatment with unfractionated heparin. Chest 2002; 122: 108-114.
• 7 Rymes NL, Lester W, Connor C. et al. Outpatient management of DVT using low molecular weight heparin and a hospital outreach service. Clin Lab Haematol 2002; 24: 165-170.
• 8 Chong BH, Brighton TA, Baker RI. et al. ASTH DVT Study Group. Once-daily enoxaparin in the outpatient setting versus unfractionated heparin in hospital for the treatment of symptomatic deep vein thrombosis. J Thromb Thrombolysis 2005; 19: 173-181.
• 9 Belcaro G, Nicolaides AN, Cesarone MR. et al. Comparison of low-molecular-weight heparin, administered primarily at home, with unfractionated heparin, administered in hospital, and subcutaneous heparin, administered at home for deep-vein thrombosis. Angiology 1999; 50: 781-787.
• 10 Hull RD. Treatment of pulmonary embolism: The use of low-molecular-weight heparin in the inpatient and outpatient settings. Thromb Haemost 2008; 99: 502-510.
• 11 Douketis JD, Kearon C, Bates S. et al. Risk of fatal pulmonary embolism in patients with treated venous thromboembolism. J Am Med Assoc 1998; 279: 458-462.
• 12 Ageno W, Steidl L, Marchesi C. et al. Selecting patients for home treatment of deep vein thrombosis: the problem of cancer. Haematologica 2002; 87: 286-291.
• 13 British Thoracic Society Standards of Care Committee Pulmonary Embolism Guideline Development Group. Thorax 2003; 58: 470-483.
• 14 Kearon C, Kahn SR, Agnelli G. et al. Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133 (Suppl. 06) 454S-545S.
• 15 Bossuyt PM, Reitsma JB, Bruns DE. et al. The STARD statement for reporting studies of diagnostic accuracy: explanation and elaboration. Ann Intern Med 2003; 138: W1-W12.
• 16 Lijmer JG, Mol BW, Heisterkamp S. et al. Empirical evidence of design-related bias in studies of diagnostic tests. J Am Med Assoc 1999; 282: 1061-1066.
• 17 Cook DJ, Mulrow CD, Haynes RB. Systematic reviews: synthesis of best evidence for clinical decisions. Ann Intern Med 1997; 126: 376-380.
• 18 Lui B, Tran A, Montalto M. Treatment of patients with pulmonary embolism entirely in Hospital in the Home. Aust Fam Physician 2007; 36: 381-384.
• 19 Beer JH, Burger M, Greterner S. et al. Outpatient treatment of pulmonary embolism is feasible and safe in a substantial proportion of patients. Thromb Haemost 2003; 01: 186-187.
• 20 Davies CW, Wimperis J, Green ES. et al. Early discharge of patients with pulmonary embolism: a two-phase observational study. Eur Respir J 2007; 30: 708-714.
• 21 Olsson CG, Bitzen U, Olsson B. et al. Outpatient tinzaparin therapy in pulmonary embolism quantified with ventilation/perfusion scintigraphy. Med Sci Monit 2006; 12: I9-13.
• 22 Kovacs MJ, Anderson D, Morrow B. et al. Outpatient treatment of pulmonary embolism with dalteparin. Thromb Haemost 2000; 83: 209-211.
• 23 Siragusa S, Arcara C, Malato A. et al. Home therapy for Deep vein thrombosis and pulmonary embolism in cancer patients. Ann Oncol 2005; (Suppl. 04) 136-139.
• 24 Wells PS, Anderson DR, Rodger MA. et al. A randomized trial comparing 2 low-molecular-weight heparins for the outpatient treatment of deep vein thrombosis and pulmonary embolism. Arch Intern Med 2005; 165: 733-738.
• 25 Ong BS, Karr MA, Chan DK. et al. Management of pulmonary embolism in the home. Med J Aust 2005; 183: 239-242.
• 26 Stein PD, Hull RD, Patel KC. et al. Venous thromboembolic disease: comparison of the diagnostic process in blacks and whites. Arch Intern Med 2003; 163: 1843-1848.
• 27 Aujesky D, Stone RA, Kim S. et al. Length of hospital stay and postdischarge mortality in patients with pulmonary embolism: a statewide perspective. Arch Intern Med 2008; 168: 706-712.
• 28 Lim AY, Parr DG, Stableforth DE. et al. Early discharge and home supervision of patients with pulmonary embolism treated with low-molecular weight heparin. Eur J Intern Med 2003; 14: 89-93.
• 29 Aujesky D, Obrosky DS, Stone RA. et al. A prediction rule to identify low-risk patients with pulmonary embolism. Arch Intern Med 2006; 166: 169-175.
• 30 Aujesky D, Perrier A, Roy P-M. et al. Validation of a clinical prognostic model to identity low-risk patients with pulmonary embolism. J Intern Med 2007; 261: 597-604.
• 31 Wicki J, Perrier A, Perneger TV. et al. Predicting adverse outcome in patients with acute pulmonary embolism: a risk score. Thromb Haemost 2000; 84: 548-552.
• 32 Kucher N, Goldhaber SZ. Risk stratification of acute pulmonary embolism. Semin Thromb Hemost 2006; 32: 838-847.