Best Clinical Practice: Controversies in Outpatient Management of Acute Pulmonary Embolism

Publication date: Available online 19 December 2016
Source:The Journal of Emergency Medicine
Author(s): Brit Long, Alex Koyfman
BackgroundPulmonary embolism (PE) is a common condition managed in the emergency department (ED), with a wide range of morbidity and mortality. Patients are classically admitted for treatment and monitoring of anticoagulation.ObjectiveWe sought to evaluate the controversy concerning outpatient therapy for patients with acute PE and investigate the feasibility, safety, and efficacy of outpatient management.DiscussionPatients with venous thromboembolism have historically been admitted for treatment and monitoring for concern of worsening disease or side effects of anticoagulation (bleeding). More than 90% of EDs admit patients with PE in the United States. However, close to 50% of patients may be appropriate for discharge and outpatient therapy. The published literature suggests that outpatient treatment is safe, feasible, and efficacious, with similar rates of recurrent venous thromboembolism and all-cause mortality, especially with novel oral anticoagulants. Multiple scoring criteria can be used, including the Pulmonary Embolism Severity Index (PESI), simplified PESI, Hestia criteria, Geneva Prognostic Score, European Society of Cardiology guidelines, Global Registry of Acute Coronary Events, and Aujesky score. Simplified PESI and the European Society of Cardiology guidelines have high-quality evidence, sufficient sensitivity, and ease of use for the ED. Patients considered for outpatient therapy should possess low hemorrhage risk, adequate social situation, negative biomarkers, ability to comply, and no alternate need for admission.ConclusionsPatients with acute PE are often admitted in the United States, but a significant proportion may be appropriate for discharge. Patients with low risk for adverse events according to clinical scoring criteria, adequate follow-up, ability to comply, and no other need for admission can be discharged with novel oral anticoagulant therapy.



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