Ryan Walsh, MD Department of Emergency Medicine Madigan Army Medical Center

Ryan Walsh, MD Department of Emergency Medicine Madigan Army Medical Center

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

142,000 ED visits a year for PE 2006: 5% treated as outpatient 2010: 6% treated as outpatient

January 2015 study Retrospective cohort of 175 Kaiser Permanente patients with pulmonary embolism 32% were sent home in <24hours

Risk of recurrence is greatest in first 2 weeks 2% at 2 weeks 6% at 3 months

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%

PESI spesi Echocardiography CT Angiography BNP/NT-proBNP Troponin Clinical Judgment

Age >80 History of cancer History of chronic cardiopulmonary disease Heart rate >110 Systolic BP <100 mm Hg O 2 Saturation <90%

SCORE 30-DAY MORTALITY 0 1% 1 10.9%

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%)

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 =3.8 2013 Systematic Review of 2288 Normotensive PE pts RVD on CT was associated with increased risk of mortality (OR = 1.8) -LR = 0.71 +LR = 1.27

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

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

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

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

In Outpatient Treatment Cohort 13 VTE recurrences 3 Major Bleeding events 0 PE related deaths

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%

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 7.98 90 day mortality: RR 0.98, 95% CI 0.06 to 15.58 Small sample size Couldn t verify publication bias

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

In patients with low risk PE and whose home circumstances are adequate, we suggest early discharge over standard discharge (Grade 2B)

Outpatient anticoagulation is safe and effective in select patients...

Outpatient management of PE appears to be safe Determining who can safely be discharged is controversial

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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