Is it safe to manage pulmonary embolism in Primary Care? Roopen Arya King s College Hospital

A few definitions Safe Avoid death, recurrent thrombosis, bleeding Manage Diagnosis + treatment Pulmonary embolism Majority of cases of PE Primary Care At home from outset outpatient treatment Managed by GP / secondary care

Home treatment of PE DVT = PE = VTE Better diagnostic pathways PTP, D-dimer, CTPA Anticoagulation is straightforward with availability of LMWH and newer agents in future Risk stratification approaches are available

Home treatment of PE Analogous to DVT Px, >90% as outpatients Health economics favorable Patient preference Peer practice

Natural history of PE 10% PE are rapidly fatal and another 5% cause death later, despite diagnosis and Px 5-10% patients with PE present with shock 50% of diagnosed PEs associated with RV dysfunction, which is associated with 5-fold increase in in-hospital mortality Barritt and Jordan: 26% mortality when untreated

Home treatment of PE DVT = PE = VTE Better diagnostic pathways PTP, D-dimer, CTPA, V/Q Spect Anticoagulation is straightforward with availability of LMWH and newer agents in future Risk stratification approaches are available

? Acute PE PTP Normal CXR Abnormal d-dimer d-dimer Normal Low PTP Abnormal V/Q Intermediate prob Abnormal CTPA Normal Low PTP High prob Low prob/normal Equivocal Positive Neg No PE Treat LMWH STOP Pulmonary angiogram Lower limb Doppler Treat LMWH No PE

Outpatient Treatment of Pulmonary Embolism (OTPE) trial 344 patient in 19 centres over 3 years; 30% initial cohort potentially suitable Low risk (PESI risk class I or II); mean LOS was 0.5 vs 3.9 days Non-inferiority for recurrent events (1/171 outpts vs 0/168 inpts) 1 patient in each group died within 90 days 3 outpatients vs 0 inpatients had major bleeding Duration of LMWH: 11.5 vs 8.9 days Aujesky et al, Lancet 2011; 378: 41

Outpatient treatment in patients with acute pulmonary embolism (Hestia Study) Prospective cohort study, 12 hospitals in Netherlands, 2008-2010; n=297 Clinical outcome No. Percentage (95% CI) Total recurrences 6 2.0 (0.75 4.3) Fatal recurrent PE 0 0 (0 1.2) Non-fatal recurrent PE 5 1.7 (0.55 3.9) Non-fatal recurrent DVT 1 0.34 (0.0082 1.9) Major bleeding complications 2 0.67 (0.082 2.4) Fatal bleeding 1 0.34 (0.0082 1.9) Non-fatal major bleeding 1 0.34 (0.0082 1.9) Clinically relevant non-major bleeding 15 5.1 (2.9 8.2) All-cause mortality 3 1.0 (0.21 2.9) Zondag et al, JTH 2011; 9:1500

Cardiac biomarkers: Risk stratification cardiac troponin I (ctni) Brain natriuretic peptide (BNP) Heart-type fatty acid binding protein (H-FABP) Highly sensitive cardiac troponin T (hstnt) Thrombus burden: D-dimer complete lower limb U/S testing RV dysfunction on imaging Echocardiography CT

Clinical prognostic models Pulmonary embolism severity index (PESI) Variable Points Age Years Male sex +10 History of cancer +30 History of heart failure +10 History of chronic lung disease +10 Pulse>110 bpm +20 Systolic blood pressure < 100 mm Hg +30 Respiratory rate > 30 breaths / min +20 Temperature < 36 0 C +20 Altered mental status +60 Arterial oxyhemoglobin saturation (SaO 2 ),90% +20

Jiminez et al; British Journal of Haematology Volume 151, Issue 5, pages 415-424, 19 OCT 2010 Risk stratification of normotensive patients with acute symptomatic PE

Home treatment of PE Analogous to DVT Px, >90% as outpatients Health economics favorable Patient centred care Peer practice & guidelines

Patient-centred care Safety Aetiology of VTE Symptomatic support Anticoagulation support Aftercare

Home treatment of PE Analogous to DVT Px, >90% as outpatients Health economics favorable Patient centred care Peer practice & guidelines

Guidelines American College of Chest Physicians (ACCP) 2012 National Institute for Health and Clinical Excellence (NICE) 2012 American Heart Association (AHA) 2011 European Society of Cardiology (ESC) 2008 British Thoracic Society (BTS) 2003 None recommend home treatment of PE

Is it safe to manage pulmonary embolism in Primary Care? PE is associated with a higher mortality than DVT Insufficient evidence supporting home treatment in the majority of patients Available risk stratification schemes are complex and cumbersome Can we ensure holistic /seamless care? Not supported by peer practice / guidelines Resources are limited