HWN Suggests

Should I Stay or Should I Go: Outpatient Treatment of Venous Thromboembolism

The care of venous thromboembolism (VTE) is currently undergoing a paradigm shift in the US with an increasingly large percentage of patients being discharged home from the Emergency Department (ED). Patients diagnosed with VTE and immediately discharged from the ED while treated with rivaroxaban had a low rate of VTE recurrence and bleeding.

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  Wells' Criteria for Pulmonary Embolism

Some advocate using the Wells’ score over clinician gestalt to predict who is low-risk and then applying the PERC rule to stop workup for PE. As with all clinical decision aids, the physician must first have a suspicion of the diagnosis before attempting to apply the Wells criteria. The original intent of this tool was to determine who was low risk enough to rule out testing with a d-dimer.

  PERC Rule for Pulmonary Embolism

In the setting of a low-risk patient who is not PERC negative, the physician should consider a d-dimer for further evaluation. If the d-dimer is negative, and clinical gestalt determines a pre-test probability is <15% then, the patient does not require further testing for PE. If the d-dimer is positive, further testing such as a CT-angiography or V/Q scan should be pursued.

  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…”

 DOACs Part 1: Use and Misuse

The first thing to know about DOAC dosing is that dosages are different for venous thromboembolism than for atrial fibrillation. Dosing for venous thromboembolism is fixed as opposed to atrial fibrillation where it is adjusted based on renal function, weight and age. Apixiban 10mg po bid for 1 week followed by 5mg po bid or Rivaroxiban 15mg po bid for 3 weeks followed by 20mg once daily.

 PERCs of the Wells Score

In order to avoid missing a PE while mitigating the risks associated with overtesting, some clinical decision tools have been created to aid in the diagnostic process. We will focus on two of these commonly used decision tools: the PERC rule and the WELLS score for PE.

 The Approach to Venous Thromboembolism

Like the approach to the DVT, you can use the Wells Score for PE to risk stratify. Consider the three-tier model and use it with the PERC. This applies to the high sensitivity d dimer assay. If using a moderately sensitive d dimer assay, consider using the two-tier model.

Articles of Interest

ED VTE Pathway

The treatment of venous thromboembolism (VTE) in the emergency department is a prime example of the benefits of value-based care. A decade ago, the majority of pulmonary embolism (PE) and deep vein thrombosis (DVT) cases required admission for anticoagulation and bridging therapy with heparin.

Pulmonary embolism: the diagnosis, risk-stratification, treatment and disposition of emergency department patients

This review will discuss the challenge of PE diagnosis, risk stratification and treatment - including the use of novel anticoagulants for the outpatient treatment of low risk PE and the creation of PE response teams to facilitate advanced treatment for high risk PE.

Resources

Geneva Score

Objectifies risk of PE, like Wells’ score.

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.

YEARS Algorithm

Helps rule out pulmonary embolism; also validated in pregnant patients.