From the Guidelines
Pulmonary embolism can be safely managed as an outpatient in carefully selected low-risk patients, as evidenced by recent studies such as 1 and 1. The management of pulmonary embolism (PE) as an outpatient is a viable option for patients who are deemed low-risk, according to the most recent and highest quality study published in 2021 1.
Key Considerations for Outpatient Management
- Patients should be evaluated using validated risk stratification tools such as the Pulmonary Embolism Severity Index (PESI) or simplified PESI.
- Those with hemodynamic stability, no significant comorbidities, good social support, and reliable follow-up may qualify for outpatient treatment.
- The presence of right ventricular dysfunction or increased cardiac biomarker levels should discourage treatment out of the hospital, as noted in 1.
Treatment Options
- Direct oral anticoagulants (DOACs) such as rivaroxaban (15 mg twice daily for 21 days, then 20 mg once daily), apixaban (10 mg twice daily for 7 days, then 5 mg twice daily), or edoxaban (60 mg once daily after 5-10 days of parenteral anticoagulation) are suitable options.
- Low molecular weight heparin (LMWH) such as enoxaparin (1 mg/kg twice daily) with transition to warfarin (target INR 2-3) is another option, as discussed in 1.
Essential Components of Outpatient Care
- Patients require clear discharge instructions.
- A follow-up appointment within 1-2 weeks is necessary.
- Education about warning signs requiring immediate medical attention is crucial.
- Confirmation of medication access is also essential, as highlighted in 1. This approach is safe and effective for appropriate candidates because it reduces hospitalization risks while maintaining treatment efficacy, and studies show comparable outcomes to inpatient management for low-risk PE patients, as demonstrated in 1.
From the Research
Overview of Pulmonary Embolism Management
Pulmonary embolism (PE) is a potentially fatal condition that requires prompt management. Traditionally, patients with PE have been hospitalized for treatment and monitoring. However, recent studies suggest that outpatient management may be a viable option for certain patients.
Eligibility Criteria for Outpatient Management
Several studies have identified eligibility criteria for outpatient management of PE, including:
- The HESTIA rule, which is based on a list of pragmatic criteria 2
- The Pulmonary Embolism Severity Criteria (PESI) or simplified PESI, which take into account the risk of death 2
- Clinical gestalt, which involves a physician's overall assessment of the patient's condition 3
Safety and Efficacy of Outpatient Management
Numerous studies have demonstrated the safety and efficacy of outpatient management for low-risk PE patients, including:
- A systematic review and meta-analysis of 13 studies, which found that the pooled incidence of recurrent venous thromboembolism was 1.7% in outpatients, compared to 1.2% in inpatients 4
- A retrospective cohort study of 439 consecutive patients, which found that outcome event rates at 6 months were similar between outpatient, early-discharge, and in-hospital treatment groups 5
- A narrative systematic review of 23 studies, which found that the overall early complication rate was low, with <2% for thromboembolic recurrences or major bleedings and <3% for deaths 2
Key Findings
Key findings from the studies include:
- Outpatient management appears to be feasible and safe for many patients with PE, particularly those who are hemodynamically stable 2, 6
- The rate of adverse events associated with outpatient PE treatment seems low, with rates of recurrent venous thromboembolism, major bleeding, and mortality comparable to those of inpatient treatment 3, 4
- Independent risk factors for mortality and pulmonary hypertension have been identified, including high-risk ESC category, paraneoplastic VTE, and thrombophilia 5
Outpatient Management Approach
Outpatient management of PE typically involves: