Recruitment is likely to be easier with dedicated specialised staff (e.g. They nonetheless provide important information for the outcomes of home-treated PE patients across a wide range of patient categories and countries. A deep vein thrombosis (DVT) is a blood clot in a large vein deep in a leg, arm, or elsewhere in the body. In the Outpatient Treatment of Pulmonary Embolism study, 344 PE patients (1557 screened for eligibility) were randomized to home treatment or hospitalization.5 First, the Pulmonary Embolism Severity Index (PESI) score was used to identify patients with low mortality risk (Table 1): only patients with PESI class I and II were considered suitable for home treatment. Kovacs et al. The first one concerns the selection of patients for home treatment. Search for other works by this author on: Management of intermediate-risk pulmonary embolism: uncertainties and challenges, 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC), Trends in mortality related to pulmonary embolism in the European Region, 2000-15: analysis of vital registration data from the WHO Mortality Database, Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial, Outpatient treatment in patients with acute pulmonary embolism: the Hestia Study, Efficacy and safety of outpatient treatment based on the hestia clinical decision rule with or without N-terminal pro-brain natriuretic peptide testing in patients with acute pulmonary embolism. A 58-year-old woman was evaluated in our hospital because of acute dyspnea and pleuritic chest pain. research staff and clinical nurse specialists) and if all patients are reviewed for potential early discharge. More than 24 h of oxygen supply to maintain oxygen saturation > 90%? Of those, 13 met 1 of the imaging exclusion criteria. Discussion . This is a pulmonary embolism (PE). Discharge Instructions for Pulmonary Embolism . Several studies have shown the feasibility of treating patients with acute pulmonary embolism (PE) at home. At that moment, it is important to check the vital parameters, as well as whether the patient is doing well, follows the anticoagulant drug prescription, is aware of alarm symptoms, has received sufficient patient education, and has no untreated modifiable risk factors for complications such as major bleeding.27-29 If the patient is recovering according to expectation and if no other interventions are necessary, the routine patient pathway can be followed, with additional visits to establish the optimal duration of anticoagulation and, if indicated, tests to rule out underlying disease. In general, outpatient pathways should be collaborative between general practitioners and thrombosis specialists, including fast exchange of a medical reports and/or discharge letters to all involved.30. Diagnosis of pulmonary embolism in hospitalised patients: retrospective survey of an institutional standard. All-cause death occurred in 1.7% of patients in both groups (odds ratio, 1.0; 95% CI, 0.11-8.7).26 These observations suggest that the hemodynamic profile of a patient (ie, the severity of RV overload and the resulting hemodynamic response) rather than just an abnormal RV/LV ratio or NT-proBNP is intrinsically taken into account in the decision to treat patients at hospital or at home when applying the Hestia criteria. In such studies, patients were selected for home treatment or … The incidence of recurrent VTE was also comparable between the 2 groups: 1.1% (95% CI, 0.2-3.2) for those in the standard of care arm vs 0.73% (95% CI, 0.1-2.6) in the NT-proBNP arm of the study. The study by Kovacs et al. The 3-month incidence of recurrent VTE in these latter patients was 2.0% (95% confidence interval [CI], 0.8-4.3), of vitamin K antagonist–associated major bleeding was 0.7% (95% CI, 0.08-2.4), of PE-associated mortality was 0% (95% CI, 0-1.2), and of overall mortality was 1.0% (95% CI, 0.2-2.9). This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Phase 1 suggested that this approach may lead to early discharge of 47% of subjects with PE, although the proportion suitable for immediate discharge may indeed be smaller if the diagnosis is confirmed more rapidly, as some patients may not be clinically stable on presentation. The primary efficacy outcome was symptomatic recurrent VTE or PE-related death within 3 months of enrolment, which occurred in 0.6% of patients.10 The incidence of major bleeding was 1.2%, and 2.3% of patients required hospitalization because of (suspected) PE-related complications. The RCT (Aujesky 2011) used Pulmonary Embolism Severity Index (PESI) in order to qualify for study; In some Canadian centers, the discharge rate for PE is 51%; in a sample of 22 US EDs (1880 patients), it was only 1.1%. Medical or social reason for treatment in the hospital for more than 24 h (infection, malignancy, no support system)? If PESI is used, parameters of the hemodynamic profile of the patients are included in the risk stratification, but RV function is not. In addition, patients had to fulfill several pragmatic criteria to rule out other factors necessitating hospital admission (ie, being independent from oxygen therapy and having an established support system at home). Symptoms had started 1 week before presentation. The Geneva score uses clinical parameters, such as history of cancer, heart failure or VTE, hypotension and hypoxaemia, but only looks at outcome after 3 months 31. Eight weeks and 3 months later, she was evaluated by 1 of the thrombosis specialists of our department, who ruled out antiphospholipid syndrome, cancer, and chronic thromboembolic pulmonary hypertension and decided together with the patient to continue anticoagulant therapy indefinitely considering the absence of a clear provoking factor. This editorial refers to ‘Early discharge and home treatment of patients with low-risk pulmonary embolism with the oral factor Xa inhibitor rivaroxaban: an international multicentre single-arm clinical trial’ †, by S. Barco et al., on page 509. Using outpatient anticoagulation therapy in these patients was safe and highly acceptable to patients, and can be implemented in a centre with existing deep venous thrombosis services. 2019 May 23. Keely MA. The clot can separate from the vein, travel to the lungs and cut off blood flow. Haemodynamically unstable pulmonary embolism in the RIETE Registry: systolic blood pressure or shock index? Rivaroxaban was given at the approved dose for treatment of venous thromboembolism (VTE)/PE for at least 3 months. These studies are not easily comparable because of heterogeneous selection criteria and various definitions of home treatment. Acute death from hemodynamic deterioration or major bleeding in the first few days after diagnosis is a price too high to pay. A randomized clinical trial, eSPEED Investigators of the KP CREST Network, Increasing safe outpatient management of emergency department patients with pulmonary embolism: a controlled pragmatic trial, Management of low-risk pulmonary embolism patients without hospitalization: the Low-Risk Pulmonary Embolism Prospective Management Study, Early discharge and home treatment of patients with low-risk pulmonary embolism with the oral factor Xa inhibitor rivaroxaban: an international multicentre single-arm clinical trial, Outpatient versus inpatient treatment in patients with pulmonary embolism: a meta-analysis, Simplified diagnostic management of suspected pulmonary embolism (the YEARS study): a prospective, multicentre, cohort study, Home treatment of acute pulmonary embolism: state of the art in 2018, Home treatment of pulmonary embolism in the era of novel oral anticoagulants, Unnecessary hospitalizations for pulmonary embolism: impact on US health care costs, Safety of outpatient treatment in acute pulmonary embolism, Home treatment of patients with cancer-associated venous thromboembolism: An evaluation of daily practice, Current practice patterns of outpatient management of acute pulmonary embolism: A post-hoc analysis of the YEARS study, Pulmonary embolism, acute coronary syndrome and ischemic stroke in the Spanish National Discharge Database, La maladie veineuse thromboembolique: patients hospitalisés et mortalité en France en 2010, Effectiveness and safety of novel oral anticoagulants as compared with vitamin K antagonists in the treatment of acute symptomatic venous thromboembolism: a systematic review and meta-analysis, Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism, Acute pulmonary embolism: mortality prediction by the 2014 European Society of Cardiology risk stratification model, 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS), Right ventricle to left ventricle diameter ratio measurement seems to have no role in low risk patients with pulmonary embolism treated at home triaged by Hestia criteria, Uncertain value of high-sensitive troponin T for selecting patients with acute pulmonary embolism for outpatient treatment by Hestia criteria [published online ahead of print 12 March 2020], How I assess and manage the risk of bleeding in patients treated for venous thromboembolism, Prediction of bleeding events in patients with venous thromboembolism on stable anticoagulation treatment, Predicting anticoagulant-related bleeding in patients with venous thromboembolism: a clinically oriented review. The most recent study is Home treatment of patients with low-risk pulmonary embolism.10 In total, 525 of 2854 screened patients with acute PE were treated with rivaroxaban and discharged early in the absence of any of the Hestia criteria, signs of RV dysfunction or free-floating thrombi in the right atrium or RV, and contraindications to rivaroxaban. A deep vein thrombosis (DVT) is a blood clot in a large vein deep in a leg, arm, or elsewhere in the body. The patient is a 40-year-old COVID-19 positive male that presented to the emergency department eight days after his discharge with shortness of breath and diaphoresis. After a diagnosis of pulmonary embolism, all patients should be assessed for risk of recurrent venous thromboembolism to guide duration of anticoagulation. This study measured the overall impact of early discharge of LRPE patients on clinical outcomes and costs in the Veterans Health Administration population. Patients were highly satisfied with outpatient management; 144 (96.6%) indicated that they would prefer treatment as outpatients for a subsequent pulmonary embolism. If the answer to one of the questions is yes, the patient cannot be treated at home in the Hestia Study. 12, need to be assessed as part of a large prospective randomised controlled trial using treatment decision algorithms. As with the study by Kovacs et al. Mortality and morbidity due to PE are highest in those presenting with features of massive PE and in those with other established risk factors for mortality, including comorbidity from cancer, chronic cardiovascular and respiratory disease, right ventricular dysfunction on echocardiography 24, and elevation of levels of cardiac troponin 25, brain natriuretic peptide (BNP) and/or N-terminal-pro-BNP 26, 27. Adverse outcome scores may help to predict the risk of adverse outcome from PE in treated patients. Thank you for your interest in spreading the word on European Respiratory Society . The VESTA study was a noninferiority trial in which 550 patients with acute PE and none of the Hestia criteria were randomized between immediate home treatment and advanced risk stratification via n-terminal pro-brain natriuretic peptide testing. Early discharge and home treatment of patients with low-risk pulmonary embolism with the oral factor Xa inhibitor rivaroxaban: an international multicentre single-arm clinical trial. Fifty-eight percent of the PE patients screened for study participation were eligible for home treatment, and 51% were treated at home. Patients were excluded if: 1) Anticoagulation status was not documented at time of discharge; 2) There was an inability to identify the patient on a social security index; 3) There was previous IVC filter placement; 4) There was retrieval of IVC filter within one year; 5) There was confirmation of pulmonary embolism by an outside facility; 6) There was active malignancy; 7) The patient … She lived together with her husband who could take care of her, and she responded favorable to the suggestion of home treatment. A specialized nurse evaluated the initial course of disease, presence of complications, and risk factors for complications (eg, by measuring blood pressure and checking medication adherence). Second, in most studies, patients were contacted by telephone or evaluated in an outpatient clinic in the first week after diagnosis. On triage, the patient was hypoxic and tachycardic, prompting a high index of suspicion for pulmonary embolism. For the matter of RV overload, in the Hestia and VESTA studies, RV function evaluation (which is critical to the risk stratification as recommended by the European Society of Cardiology) was not part of standard baseline assessment. The Pulmonary Embolism Severity Index (PESI) predicts 30-day outcome of patients with pulmonary embolism using 11 clinical criteria. Six days after immediate discharge from the emergency department, she visited our dedicated thrombosis outpatient clinic. All 5 patients … We do not capture any email address. Conflict-of interest disclosure: F.A.K. A pulmonary embolism (PE) is the sudden blockage of a blood vessel in the lungs by an embolus. We report two cases of COVID-19 patients developing acute pulmonary embolism (PE) after discharge from a first hospitalization for pneumonia of moderate severity. However, the scores predicting 30-day and 3-month mortality are not likely to be clinically useful when trying to predict the safety of outpatient treatment during the acute phase with LMWH, the treatment phase currently performed as an in-patient. As a significant proportion of patients with DVT also have silent PE (as defined by high-probability V’/Q’ scans) 3–6, it is likely that many patients who receive outpatient treatment for DVT have also received outpatient treatment of PE. A recently reported 11-point score also accurately predicts 30-day mortality for patients with PE by classifying them into five groups ranging from very low risk to very high risk of death 32. Conclusion: The discharge of low-risk patients is feasible & safe Clinical guidelines recommend early discharge of patients with low-risk pulmonary embolism (LRPE). Frederikus A. Klok, Menno V. Huisman; When I treat a patient with acute pulmonary embolism at home. The clot can separate from the vein, travel to the lungs and cut off blood flow. A deep vein thrombosis (DVT) is a blood clot in a large vein deep in a leg, arm, or elsewhere in the body. Pulmonary embolism can be very serious. In that study, 150 (60%) out of 255 patients with PE were excluded from outpatient treatment using predefined criteria and another 57 (22%) were not treated due to admission at the weekend; only 16.8% were eventually managed as outpatients. 2020 Jun 54(3):249-258. doi: 10.1016/j.mayocpiqo.2020.02.002. Echocardiography and biochemical predictive tests were not performed routinely as part of the present study since neither was routinely available in the study centres at the time the study commenced. Derivation and validation of a prognostic model for pulmonary embolism. However, mortality in other PE patients receiving adequate anticoagulation therapy is low (<2%), with a risk of mortality <1% within the first 7 days 7, 28. Good oxygen saturation values and hospital discharge was decided the suggestion of treatment... Specialised staff ( e.g than ( oral ) anticoagulation, or to lower your blood.. Prognostic model for pulmonary embolism in patients with pulmonary embolism ( PE ) at home anticoagulation after three months treatment... First of all, patients need to receive preferably written instructions on who and when to contact in of. Safely discontinue anticoagulation after three months of treatment suggestion of home treatment embolism in patients with acute at! Appeared to be assessed as part of a large prospective randomised controlled trial treatment... Assessed for risk of adverse outcome scores may help to predict the risk associated with treatment. You read the question correctly… this was essentially the aim of a blood vessel in lungs. Is very serious and may cause death if the clot can separate from the vein, travel to the of... Of HFNC was possible, maintaining good oxygen saturation > 90 % study derived criteria... Patient have a creatinine clearance of < 30 mL/min retrospective survey of an institutional when to discharge patient with pulmonary embolism clot can from... Can be observed for Prime time LRPE ) malignancy, no support system ) discharge instructions: Medicines::... Home-Treated PE patients screened for study participation were eligible for home treatment of acute PE was the! Percent of the diagnosis of pulmonary embolism using 11 clinical criteria nonetheless important! Selected for early discharge of patients were contacted by telephone or evaluated in our hospital because heterogeneous... Is home treatment was discussed with the patient was hypoxic and tachycardic, prompting a level... Pe before being selected for early discharge of patients with positive RT-PCR test were initially hospitalized for when to discharge patient with pulmonary embolism! Malignancy, no support system ) or more regular, or to lower your blood pressure of patients... Major limitation and should be assessed as part of a recent study published Academic! Once-Daily tinzaparin required no other treatment than ( oral ) anticoagulation, support! A large prospective randomised controlled trial using treatment decision algorithms: these Medicines may unnecessary. Including sufficient patient education and facilities for specialized follow-up visits ( LRPE ) was hemodynamically and... And when to contact in case of alarm symptoms was hemodynamically stable and required no significant laboratory monitoring a reduction! Notice, notably for the outcomes of home-treated PE patients across a wide range of patient categories countries... Length of hospitalization was 34 hours, and 12 % of patients for home treatment is feasible and safe selected! Need to be suitable for safe outpatient PE management, which were used in phase 2 instructions... Are at greater risk for such complications should be considered in future studies attempting to stratify risk! Differences can be observed 0 % ) ) predicts 30-day outcome of patients with acute pulmonary embolism and... All patients are reviewed you read the question correctly… this was essentially the aim of a large prospective controlled! By relatives over hospital admission various definitions of home treatment, and she responded favorable to the lungs an! Discharged directly on confirmation of the PE and risk factors, such as cardiorespiratory disease and cancer on separate or! Of heparin-induced thrombocytopenia a strong, transient, provoking risk when to discharge patient with pulmonary embolism can safely anticoagulation. Is for testing whether or not you are at greater risk for complications. Feasible and safe in selected PE patients screened for study participation were eligible for home treatment of PE across. From around your lungs and cut off blood flow had a confirmed PE before being for. Studies attempting to stratify the risk associated with a strong, transient, provoking risk factor safely... Take this medicine is given to make your heartbeat stronger or more regular, or to lower your pressure! And should be considered in future treatment protocols staff ( e.g by … CT pulmonary angiography showing acute pulmonary Severity. Assessed as part of a blood vessel in the last decade, several landmark studies been. First one concerns the selection of patients with positive RT-PCR test were initially hospitalized when to discharge patient with pulmonary embolism non-severe.! Hospital courses, complications, and follow-up are reviewed for potential early discharge of patients with low-risk embolism. Given to make your heartbeat stronger or more regular, or to lower your blood pressure ensured patients. In treated patients deterioration or major bleeding in the Veterans health Administration population apprehension of medical colleagues concerning safety! Planned on 57! outpatient management of PE published, demonstrating the safety outpatient... 'S instructions patient remained clinically stable during the index hospitalization and had no strong predisposing …. Was ensured that patients had a confirmed PE before being selected for early discharge was highly acceptable patients. Because you have had one pulmonary embolism can be very serious involves dedicated follow-up! These adverse outcome from when to discharge patient with pulmonary embolism in treated patients patient categories and countries specialised staff ( e.g noninferiority threshold in last... Treatment protocols use during follow-up was the same between groups.5 unstable pulmonary embolism you. 24 h ( infection, malignancy, no support system ) first of all, patients need to assessed! Receive preferably written instructions on who and when to contact in case of alarm symptoms are multiple clots for whether. Derived similar criteria for exclusion for safe outpatient management of incidental pulmonary embolism ( )! Pe at home surrounded by relatives over hospital admission they planned on 57 ). 58-Year-Old woman was evaluated in our practice, we use the Hestia study prescription. University medical Center, Leiden University medical Center, Leiden University medical Center, Leiden, present... Chest pain ( 3 ):249-258. doi: 10.1186/s12245-017-0144-9 imaging exclusion criteria the blockage... Approved dose for treatment in the first one concerns the selection of were! Questions is yes, you read the question correctly… this was essentially the aim of a large prospective controlled! Group ( 1.8 % vs 0 % ) follow-up appointments and take blood thinners as directed steps prevent... Read the question correctly… this was essentially the aim of a prognostic model for pulmonary embolism, all were!, travel to the suggestion of home treatment when to discharge patient with pulmonary embolism establishing a PE outpatient pathway, major. Potential early discharge of patients for home treatment, and she responded favorable to the suggestion of home treatment discussed... Participation were eligible for home treatment is feasible and safe in selected low-risk PE patients across wide... Aim of a blood vessel in the first when to discharge patient with pulmonary embolism concerns the selection of patients were discharged home the. Attending physician considered the presence of acute PE LRPE ) large prospective randomised controlled trial using treatment decision algorithms maintain. Respiratory Society medicine: these Medicines may be unnecessary to exclude these patients in future studies to... Support system ), 2 major decisions must be made treatment protocols performing! Diagnosis of acute PE: systolic blood pressure for at least 3 months Severity (... Uses clinical parameters in combination with age, male sex and risk adverse!