Outpatient Management of Acute Pulmonary Embolism

This month, JC will be looking at evidence regarding the outpatient management of select patients with an ED diagnosis of pulmonary embolism. Does this mean that we are going to have our shortest JC ever, since a straw poll of most ED clinicians would suggest that no one should go home? Maybe not. One of the problems with the diagnosis of PE is the problem of over diagnosis. Too many D-dimers and CTA’s, and not enough adherence to broadly validated decision rules such as PERC & Wells. Interestingly, since the advent of high resolution CT angiography, the incidence of PE has gone up 80%. A study by Weiner et al. suggests that the “combination of large increase in incidence, reduced case fatality (in-hospital deaths among people with a diagnosis of pulmonary embolism), and a minimal decrease in mortality (deaths from pulmonary embolism in the population) suggests that many of the extra emboli being detected are not clinically important.” We will review articles that consider the question of outpatient management of PE and review the Pulmonary Embolism Severity Index (PESI) and the Hestia study criteria for ED discharge of patients with PE. Should make for an interesting discussion. 

Treatment of pulmonary embolism with rivaroxaban: outcomes by simplified Pulmonary Embolism Severity Index score from a post hoc analysis of the EINSTEIN PE study. Acad Emerg Med. 2015 Mar;22(3):299-307 Article Appraisal

 Outpatient treatment in patients with acute pulmonary embolism: the Hestia Study, J Thromb, 2011; 9(8):1500-1507. Article Appraisal

Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label randomised, non-inferiority trial, Lancet 2011; 378 (9785): 41-48. Article Appraisal