Outpatient Management of Acute Pulmonary Embolism
There are a handful of missed ED diagnoses that will always be considered a nemesis to the EP and acute pulmonary embolism, without question, is among that group of diagnoses. The diagnosis of pulmonary emboli has more than doubled since the widespread adoption of CTA in 1998. Interestingly, although the detection of pulmonary embolism in adults has nearly doubled, changes in mortality, improvement in outcomes, and the number of central and fatal pulmonary embolisms has remained unchanged. Some argue that high resolution CTA has led to overdiagnosis of PE and in a substantial number of cases misdiagnosis, which predisposes patients to harm. Data regarding foregoing treatment of “inconsequential” isolated subsegmental PE’s is inconclusive and in lieu of definitive evidence, most ED clinicians will initiate treatment and admit these patients. There has been a host of published data however, that use validated risk stratification tools such as the PESI score and Hestia criteria that can assist in identifying patients who may be candidates for outpatient management of PE. The results of the long awaited but underpowered Mercury-PE (enrolled 114 of a planned 300) RCT demonstrated no difference in negative outcome in select patients and we are awaiting results of the larger HoT-PE trial.
We will be focusing on a systematic review on outpatient management of PE as well as two recent prospective studies that may provide additional data regarding whetherthe outpatient management of PE in select patients is ready for prime-time.
Vinson et al, Increasing Safe Outpatient Management of Emergency Department Patients With Pulmonary Embolism: A Controlled Pragmatic Trial. Ann Intern Med. 2018 Dec 18;169(12):855-865. Critical Appraisal
Bledsoe et al,Management of Low-Risk Pulmonary Embolism Patients Without Hospitalization: The Low-Risk Pulmonary Embolism Prospective Management Study. Chest. 2018 Aug;154(2):249-256. Critical Appraisal