Should a patient with bilateral pulmonary embolism (PE) without right heart strain be admitted to the hospital or placed under observation?

From the Guidelines

A patient with bilateral pulmonary embolism (PE) without right heart strain should generally be admitted to the hospital rather than placed under observation, as this allows for proper initiation of anticoagulation therapy, close monitoring for clinical deterioration, and evaluation for underlying causes.

Key Considerations

• Hospital admission is crucial for patients with bilateral PE, even without right heart strain, due to the significant clot burden and risk of hemodynamic compromise, respiratory deterioration, or extension of thrombosis.
• Treatment typically begins with parenteral anticoagulation such as low molecular weight heparin (enoxaparin 1 mg/kg twice daily or 1.5 mg/kg once daily) or unfractionated heparin, followed by transition to oral anticoagulants like direct oral anticoagulants (DOACs) including apixaban (10 mg twice daily for 7 days, then 5 mg twice daily), rivaroxaban (15 mg twice daily for 21 days, then 20 mg daily), or warfarin (target INR 2-3) 1.
• Some carefully selected low-risk patients may be candidates for early discharge after 24-48 hours of observation and stable anticoagulation, but this decision should be individualized based on risk factors, home support, and follow-up capabilities, as suggested by the American Society of Hematology 2020 guidelines for management of venous thromboembolism 1.
• Clinical decision rules such as the Pulmonary Embolism Severity Index can help identify low-risk patients suitable for treatment at home, but the presence of right ventricular dysfunction or increased cardiac biomarker levels should discourage treatment out of the hospital 1.

Evidence Summary

• The American Society of Hematology 2020 guidelines suggest offering home treatment over hospital treatment for patients with pulmonary embolism with a low risk for complications, but this recommendation is based on very low certainty in the evidence of effects 1.
• A meta-analysis by Zondag et al found that major bleeding events and recurrent VTE rates were low in patients treated as outpatients, but the study had significant challenges due to differing methods for categorizing a low-risk population and defining outpatient treatment 1.
• The antithrombotic therapy for VTE disease guideline update suggests that home treatment is more convenient and less expensive than hospital treatment and is preferred by most patients, but recommends against treatment out of the hospital in the presence of right ventricular dysfunction or increased cardiac biomarker levels 1.

From the Research

Patient Management

• A patient with bilateral pulmonary embolism (PE) without right heart strain can be considered for observation or admission, depending on their individual risk factors and clinical presentation 2.
• The Pulmonary Embolism Severity Index (PESI) score can be used to assess the risk of mortality in patients with PE, with a score of < 86 indicating low risk 2.
• Patients with low-risk PE can be safely managed without hospitalization, with a 90-day composite rate of recurrent symptomatic VTE, major bleeding events, and all-cause mortality of 0.5% 2.

Treatment Options

• Anticoagulation is the primary treatment for patients with PE, with options including low-molecular-weight heparin, direct oral anticoagulants (DOACs), and unfractionated heparin 3, 4, 5.
• DOACs are becoming the agents of first choice for initial treatment of PE due to their simplicity and efficacy 4.
• The decision on the duration of anticoagulation should consider both the individual risk of PE recurrence and the individual risk of bleeding 5.

Clinical Considerations

• Patients with PE should be assessed for clinical characteristics such as age, heart rate, oxygen saturation, and recent surgery or trauma to determine their risk of PE 3.
• The presence of right heart strain is a significant factor in determining the management of patients with PE, with patients without right heart strain potentially being candidates for observation or outpatient management 6, 2.
• Patient satisfaction is an important consideration in the management of patients with PE, with patients indicating a high level of satisfaction with outpatient management 2.