HWN Suggests

Can you Discharge a Pulmonary Embolism

There are almost 1,000,000 pulmonary embolisms per year. Do all of them need to be admitted? From a dispo standpoint, it can be easier when you’re at larger academic centers to admit or obs them all but the reality is that some of them can be discharged... The idea of discharging PE’s started in the 2000’s... When considering discharge, there is a lot to keep in mind so let’s go through it... Start them on a DOAC if you can. Compared to warfarin, they are faster, have fewer drug and food interactions, and have a fixed dose. You probably see a patient on a DOAC almost every shift, they are common! For a medication that is frequently used, we should feel comfortable with them.

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  Outpatient Management

Rivaroxaban (Xarelto)15 mg bid x 21 days, followed by 20 mg once daily for at least 3 months 0r Apixaban (Eliquis) 10 mg bid x 7 days, followed by 5 mg bid. Note that 5 days of therapeutic LMWH should be administered prior to the initiation of Dabigatran (Pradaxa) when this anticoagulant is used...

 Outpatient Treatment of Pulmonary Embolism

Outpatient treatment of acute PE is still in its early stages. There is no certainty that it is definitely better than inpatient treatment but many promising studies show non-inferiority of both the outpatient setting and the medications prescribed to patients within this subset. If properly applied, CDRs can help stratify low-risk patients who may benefit from outpatient management. Choice of anticoagulant should be guided by cost, social circumstances, and appropriateness based on the patient’s co-morbidities (e.g., renal function).

Articles of Interest

Pulmonary Embolus

In the past, most patients with PE were admitted to the hospital for anticoagulation. Now, patients are risk stratified to determine eligibility for outpatient anticoagulation vs need for inpatient treatment. Two commonly used clinical decision tools are the Simplified Pulmonary Embolism Severity Index (SPESI), and the Hestia Criteria. Low-molecular weight heparin, rivaroxaban and apixaban are all options for outpatient anticoagulation therapy. Patients who are being considered for outpatient therapy should be able to reliably fill their prescriptions and have reliable access to outpatient follow-up.

Anticoagulation Given for Acute Venous Thromboembolism (Deep Venous Thrombosis and Pulmonary Embolism)

In Summary, for those who got the anticoagulation: None were helped (life saved, preventing pulmonary embolism). 1 in 50-111 were harmed (major bleeding event) •1 in >50 were harmed (death from bleeding even

Computer Says: Discharge that Pulmonary Embolism!

We’ve learned a couple important things about pulmonary emboli for the past five or so years. First, we diagnose too many of them. Second, all pulmonary emboli do not need to be hospitalized. Knowing, as they say, is half the battle. That’s a start – but it’s not enough.

Is Home Treatment Safe for Patients with Acute Pulmonary Embolism?

The advantages of home treatment for selected patients with low-risk PE are obvious. Given the low risk for serious adverse events shown in this analysis, I believe that clinicians should strongly consider home treatment for such patients — assuming an appropriate level of social support and an ability to fill the anticoagulation prescription immediately. Patients should be advised to communicate with their clinicians if they experience bleeding or worsening symptoms and to seek immediate medical attention if symptoms are severe.

Management of Pulmonary Embolism

New oral anticoagulant agents are effective and safe alternatives to standard anticoagulation regimens. Recent trial data do not support insertion of cava filters in patients who can receive anticoagulant treatments.

Outpatient Management of Patients with PE – U.S. Practice Patterns

Let us repeat the mantra together: “Low-risk PEs may be discharged. Low-risk PEs may be discharged. Low-risk PEs may be discharged…”

Outpatient Management of Pulmonary Embolism

In the age of DOACs, the benefits of hospitalization for a substantial fraction of patients with low-risk PE are minimal or nonexistent.

Outpatient Treatment for Pulmonary Embolism

In patients with low-risk PE, we recommend outpatient treatment over hospitalization provided access to medications, ability to access outpatient care, and home circumstances are adequate (strong recommendation, low-certainty evidence).

Outpatient treatment of pulmonary embolism

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).

PE risk stratification: which tool is best?

Your patient with a newly diagnosed PE hates hospitals. He or she agrees to defer to your judgement about admission versus discharge home, but makes it clear they would prefer to go home if it is safe. Which tool should you use to help you decide? Up until recently, there were no prospective studies comparing sPESI (simplified pulmonary embolism severity index) and Hestia, the leading risk stratification tools for PE. Finally, in August 2018 (see reference below), a single center, prospective cohort study including 488 patients newly diagnosed with PE was published that compared the two scores head to head.

Pulmonary embolism diagnosis & treatment of low-risk PE

A HESTIA score of zero is generally regarded as the primary tool to determine if outpatient management is reasonable. Of course, this must be combined with clinical judgement. Appropriately selected patients may be discharged home on an oral Xa inhibitor (e.g., apixaban, rivaroxaban).

Pulmonary embolism, ambulatory care and the goddess of the hunt

Why are we talking about this? Well, PE lends itself very well to the topic of ambulatory care. It is a potentially serious condition with significant morbidity and mortality, and it often presents insidiously. So we think about it. And we look hard for it. And this is good. But our increasing vigilance in tandem with better scanners, keener radiologists and patient awareness has resulted in a dilute pretest probability of around 5%. So we need to think carefully about how we balance resource use and time.

Safety of treating acute pulmonary embolism at home: an individual patient data meta-analysis

The incidence of adverse events in home-treated PE patients, selected by a validated triage tool, was very low. Patients with cancer had a three- to five-fold higher incidence of adverse events and death. Patients with increased troponin or (NT-pro)BNP had a three-fold higher risk of adverse events, driven by recurrent venous thromboembolism and bleeding.

The “Don’t Anticoagulate Pulmonary Embolism” Guideline

This new guideline states patients with subsegmental PE, without another identifiable VTE source, and at low risk for recurrent VTE, have the option of watchful waiting. They cite no new groundbreaking evidence, but generally recognize the low rates of recurrent VTE in retrospective and observational studies. They also recognize a diagnosis of subsegmental PE is quite likely to be a false-positive,

Triaging acute pulmonary embolism for home treatment by Hestia or simplified PESI criteria: the HOME-PE randomized trial

For triaging PE patients, the strategy based on the Hestia rule and the strategy based on sPESI had similar safety and effectiveness. With either tool complemented by the overruling of the physician-in-charge, more than a third of patients were treated at home with a low incidence of complications.

Two triaging strategies equally safe for facilitating outpatient care of acute PE

HOME-PE is the first prospective, randomized trial to compare the sPESI and Hestia triaging strategies for outpatient treatment of patients with acute PE. The trial was conducted from 2017 to 2019 at 26 hospitals in Belgium, France, Switzerland and the Netherlands that, prior to study initiation, had set up a thrombosis team for outpatient PE care.

When I treat a patient with acute pulmonary embolism at home

Home treatment is feasible and safe in selected patients with acute pulmonary embolism (PE) and is associated with a considerable reduction in health care costs. When establishing a PE outpatient pathway, 2 major decisions must be made. The first one concerns the selection of patients for home treatment. The second one involves dedicated outpatient follow-up including sufficient patient education and facilities for specialized follow-up visits. Current evidence points toward the use of either the Hestia criteria or Pulmonary Embolism Severity Index with/without assessment of the right ventricular function to select patients for home treatment, depending on local preferences.

Resources

Hestia Criteria

Identifies low-risk PE patients safe for outpatient treatment.

Simplified PESI (Pulmonary Embolism Severity Index)

Predicts 30-day outcome of patients with PE, with fewer criteria than the original PESI.

International Emergency Medicine Education Project

Once PE is confirmed accordingly, prognostic assessment is the next step. Clinical parameters and right ventricular function via imaging and biomarkers help the EP to predict prognosis. The mostly studied prognostic prediction rules are Pulmonary Embolism Severity Index (PESI) – link. and its simplified version (sPESI)

Clerkship Directors in Emergency Medicine

... with the introduction of DOACs (Direct Oral Anti-coagulants) including rivaroxaban (Xarelto), apixaban (Eliquis) and dabigatran (Pradaxa), alternate strategies to warfarin anticoagulation are now widely prescribed. Most commonly used are rivaroxaban and apixaban.