What are the guidelines for hospital admission in a patient with their first pulmonary embolism?

Hospital Admission Guidelines for First Pulmonary Embolism in a 32-Year-Old Male

A 32-year-old male with first pulmonary embolism should be considered for outpatient management if he meets low-risk criteria (PESI class I/II, sPESI 0, or Hestia criteria) and has no clinical or social exclusion criteria that would necessitate hospital admission. 1

Risk Stratification Framework

The decision for hospital admission versus outpatient management must begin with validated clinical risk scoring:

Primary Risk Assessment Tools

• Use PESI (Pulmonary Embolism Severity Index) or simplified PESI (sPESI) to stratify 30-day mortality risk 1
• PESI class I/II or sPESI score of 0 identifies low-risk patients suitable for outpatient care 1
• Alternatively, apply Hestia clinical exclusion criteria to identify patients appropriate for ambulatory management 1

The sPESI may be easier to use in practice while maintaining equivalent predictive power to the full PESI score 1. For a 32-year-old patient, age alone contributes minimally to these scores, making other clinical factors more determinative.

Mandatory Exclusion Criteria for Outpatient Management

Even if risk scores indicate low risk, the following exclusion criteria mandate hospital admission: 1

• Active bleeding or high risk of major bleeding (recent GI bleed, recent surgery, previous intracranial bleeding, uncontrolled hypertension) 1
• Already on full-dose anticoagulation at the time of PE diagnosis 1
• Severe pain requiring opiates 1
• Other medical comorbidities requiring hospital admission 1
• Chronic kidney disease stage 4 or 5 (eGFR <30 mL/min) or severe liver disease 1
• History of heparin-induced thrombocytopenia (HIT) within the last year where heparin must be repeated 1
• Social factors: inability to return home, inadequate home care, lack of telephone communication, concerns about medication compliance 1

Hemodynamic Status Assessment

Patients with hemodynamic instability require immediate ICU admission and consideration for reperfusion therapy: 1

• Cardiac arrest, syncope, or shock mandates transfer to intensive care units in centers equipped for thrombectomy 1
• Right ventricular enlargement on echocardiography in unstable patients requires ICU-level care 1
• Stable patients with suspected PE can be transferred to emergency departments or chest pain units 1

Additional Risk Markers

While not required for initial triage decisions, the following may identify very low-risk patients or guide monitoring intensity:

• Normal cardiac biomarkers (BNP, NT-proBNP, troponin) in combination with low clinical risk scores identify patients at very low risk (0-1% complication rate) 1
• Right ventricular dysfunction on imaging does not automatically exclude outpatient management if clinical scores are low and biomarkers are normal 1
• However, RV dysfunction with elevated biomarkers should prompt consideration for inpatient monitoring 1

Outpatient Management Requirements

If outpatient management is selected, the following infrastructure must be in place: 1

• Formal review (telephone or face-to-face) at least once during the first week after discharge 1
• 24-hour emergency contact number and written instructions for readmission if specific symptoms develop 1
• Written and verbal information on signs of recurrence, major bleeding, and complications 1
• Local protocols for follow-up including assessment of ongoing symptoms and anticoagulation duration 1

The British Thoracic Society data show that outpatient protocols with telephone follow-up at days 2 and 4, plus clinical review at day 10, resulted in no deaths, major bleeding, or recurrence in the first 10 days among appropriately selected patients 1.

Common Pitfalls to Avoid

Do not discharge patients based solely on imaging findings. The absence of RV dysfunction on CT or echocardiography does not predict lower risk beyond what clinical scores already provide 1. Conversely, isolated subsegmental PE findings may represent false positives and warrant radiologist consultation before committing to anticoagulation 1.

Do not use point-of-care D-dimer, troponin, or BNP tests for pre-hospital risk stratification as these are not recommended 1. Laboratory-based cardiac biomarkers may have a role in hospital settings for further risk refinement 1.

Anticoagulation Initiation

Begin anticoagulation immediately upon diagnosis or strong suspicion of PE unless absolute contraindications exist 1. For outpatient management, direct oral anticoagulants (DOACs) are preferred over warfarin as they eliminate the need for INR monitoring and facilitate early discharge 1.