Ryan Walsh, MD Department of Emergency Medicine Madigan Army Medical Center
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1 Ryan Walsh, MD Department of Emergency Medicine Madigan Army Medical Center
2 The opinions expressed herein are solely those of the author and do not represent the official views of the Department of Defense or Army Medical Department No financial disclosures
3
4 142,000 ED visits a year for PE 2006: 5% treated as outpatient 2010: 6% treated as outpatient
5 January 2015 study Retrospective cohort of 175 Kaiser Permanente patients with pulmonary embolism 32% were sent home in <24hours
6 Risk of recurrence is greatest in first 2 weeks 2% at 2 weeks 6% at 3 months
7 ICOPER registry: 14-day mortality >20% RIETE registry: 3 month mortality Overall = 8.65% Fatal PE = 1.68% EMPEROR registry: 30 day mortality Overall = 5.4%
8
9 PESI spesi Echocardiography CT Angiography BNP/NT-proBNP Troponin Clinical Judgment
10
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12 Age >80 History of cancer History of chronic cardiopulmonary disease Heart rate >110 Systolic BP <100 mm Hg O 2 Saturation <90%
13 SCORE 30-DAY MORTALITY 0 1% %
14
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16 RV dysfunction due to PE = increased mortality RV dysfunction in hemodynamically stable patients does not consistently predict death 2004 Meta-analysis 3395 hypotensive and normotensive patients Subgroup analysis of normotensive patients with RV dysfunction correlated poorly with death (PPV 4-5%)
17 2011 prospective multicenter cohort study of 457 patients RVD is independent predictor for an adverse inhospital outcome Overall Population: HR =3.5 Hemodynamically Stable: HR = Systematic Review of 2288 Normotensive PE pts RVD on CT was associated with increased risk of mortality (OR = 1.8) -LR = LR = 1.27
18 Elevated levels have consistently been associated with an increased risk of death In hemodynamically stable patients; poor markers of death Normal or low levels consistently identify a benign clinical course
19 2007 Meta-Analysis of 1,985 patients Elevated troponin I or T in ~50% of patients with acute PE Elevated troponin concentration were associated with high mortality OR 9.44 in unselected patients OR 5.90 in hemodynamically stable patients Other studies say there is limited prognostic value to elevated troponin in normotensive patients NPV for early mortality is high when Troponin is negative
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22 473 patients Admit if: SBP <100 SP02 <92% Contraindication to LMWH Other significant comorbidities 639 patients Admit if: Hemodynamically unstable Require oxygen Need IV opiods Are high risk for bleeding
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25 92% of outpatients and 95% of inpatients were satisfied with treatment 14% of outpatients would have preferred longer in hospital treatment 29% of inpatients would have preferred outpatient treatment No difference between readmission rates, ED visits, PCM visits
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27 In Outpatient Treatment Cohort 13 VTE recurrences 3 Major Bleeding events 0 PE related deaths
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29 Recurrent 90 day VTE Outpatients (1657 pts) 1.7% 1.2% Inpatients (383 pts) Major Bleeding 0.97% 1.0% Mortality 1.9% 0.74%
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32 2014: Review on this topic performed Conclusions: Very low quality evidence Not blinding the outcome assessors Small number of events with wide CI 30 day mortality: RR 0.33, 95% CI 0.01 to day mortality: RR 0.98, 95% CI 0.06 to Small sample size Couldn t verify publication bias
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34 132 patients randomly assigned Short term mortality (within 10 days) Early vs late discharge: 2.8% vs 0% 63YOF died of UGIB 5 days after discharge (d/c on day 3) 28YOF died of cardiac arrest 5 days after discharge (d/c on day 5) Found to have right atrial thrombus on autopsy Both fell into the low risk categories
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36 In patients with low risk PE and whose home circumstances are adequate, we suggest early discharge over standard discharge (Grade 2B)
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38 Outpatient anticoagulation is safe and effective in select patients...
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40 Outpatient management of PE appears to be safe Determining who can safely be discharged is controversial
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42 Outpatient management of PE appears to be safe Determining who can safely be discharged is controversial Our literature and many societies support outpatient management There are clinical pathways in use right now
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44 Kearon et al. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141(2) Yoo et al. Outpatient versus inpatient treatment for acute pulmonary embolism. The Cochrane Collaboration Baglin T. Fifty per cent of patients with pulmonary embolism can be treated as outpatients. J Thromb Haemost 2010; 8: Erkens PMG, Gandara E, Wells P, Shen AY-H, Bose G, Le Gal G, Rodger M, Prins MH, Carrier M. Safety of outpatient treatment in acute pulmonary embolism. J Thromb Haemost 2010; 8: Kovacs MJ, Hawel JD, Rekman JF, Lazo-Langner A. Ambulatory management of pulmonary embolism: a pragmatic evaluation. J Thromb Haemost 2010; 8: Zondag et al. Hestia criteria can discriminate high- from low-risk patients with pulmonary embolism. Eur Respir J 2013; 41: Jimenez et al. Prognostic models for selecting patients with acute pulmonary embolism for initial outpatient therapy. CHEST 2007; 132: Pernot N. Pulmonary embolism management-adult-ambulatory emergency department clinical practice guideline cover sheet. Univ of Wisc Health
45 Squizzato et al. Outpatient treatment and early discharge of symptomatic pulmonary embolism: a systematic review. Eur Respir J 2009; 33: Vinson et al. Timing of discharge follow-up for acute pulmonary embolism: retrospective cohort study. WestJEM. 2015;16: Egan M, Rowland K. Treating pulmonary embolism at home? J Fam Pract. 2012;61: Tapson V. Overview of the treatment, prognosis and follow-up of acute pulmonary embolism in adult patients. UpToDate. Mar Zondag et al. Outpatient versus inpatient treatment in patients with pulmonary embolism: a meta-analysis. Eur Respir J 2013; 42: Zondag et al. Outpatient treatment in patients with acute pulmonary embolism: the Hestia study. Journal of Thrombosis and Haemostasis, 9: Zhou et al. The prognostic value of pulmonary embolism severity index in acute pulmonary embolism: a meta-analysis. Respiratory Research 2012, 13:111.
46 Fesmire et al. Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Suspected Pulmonary Embolism. Ann Emerg Med. 2011;57: Sanchez et al. Echocardiography and pulmonary embolism severity index have independent roles in pulmonary embolism. Eur Respir J 2013; 42: Aujesky et al. Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open label, randomised, non-inferiority trial. Lancet 2011; 378: Jimenez et al. Prognostic significance of multidetector CT in normotensive patients with pulmonary embolism: results of the protect study. Thorax 2014;69: Konstantinides et al ESC Guidelines on the diagnosis and management of acute pulmonary embolism. European Heart Journal (2014) 35, McNamara D. Outpatient treatment for pulmonary embolism, blood clots. March 25, Otero et al. Home treatment in pulmonary embolism. Thrombosis Research 126 (2010) e1 e5. Wolde et al. Prognostic value of echocardiographically assessed right ventricular dysfunction in patients with pulmonary embolism. Arch Intern Med. 2004;164:
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