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. 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