Low Risk PE
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 - Ryan Radecki
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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.
ICU admission is warranted for patients with “massive” PE and should be considered…
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.
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...
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.
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.
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
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.
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,
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.
International Emergency Medicine Education Project
Parenteral anticoagulation for stable patients remains the mainstay of therapy in ED. Low-Molecular-Weight Heparins (LMWHs) and fondaparinux are preferred over unfractionated heparin (UFH) because of lower major bleeding and heparin-induced thrombocytopenia risk.
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.
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