New PE Guidelines From ACEP

May 31, 2018

Written by Thomas Davis

Spoon Feed
ACEP has taken a stand on some of the most contemporary issues within the diagnosis and management of venous thromboembolic disease in the emergency department.

Why does this matter?
The 2016 CHEST guidelines published a broad set of recommendations for the management of venous thromboembolic (VTE) disease.  However, some important questions in the diagnostic workup of VTE went unanswered. Here, ACEP addresses the remaining diagnostic questions. 

Summary

1. For patients who are at low risk for acute PE, use the PERC to exclude PE without further diagnostic testing. (Level B recommendation)
   • Low risk is defined either by clinical gestalt (risk < 15%) or using an objective tool (e.g. Wells < 2)
2. In patients older than 50 years deemed to be low or intermediate risk for acute PE, clinicians may use a negative age-adjusted D-dimer result to exclude the diagnosis of PE. (Level B recommendation)
   • Be careful with units. If your assay uses fibrin equivalent units (FEU), then the cutoff is age x 10 ug/L. If using D-dimer units (DDU), the cutoff is age x 5 ug/L.
   •  Age-adjusted D-dimer allows about 10% more patients to be ruled out with D-dimer testing while leading to a very small miss rate.
3. Given the lack of evidence, anticoagulation treatment decisions for patients with subsegmental PE without associated DVT should be guided by individual patient risk profiles and preferences. (Level C recommendation).
   • The CHEST guidelines issue a soft recommendation against anticoagulation in patients without proximal DVT.
4. Selected patients who are at low risk for adverse outcomes as determined by PESI, simplified PESI, or the Hestia criteria may be safely discharged from the ED on anticoagulation, with close outpatient follow-up. (Level C recommendation)
   • Since nearly 50% of patients meet low risk criteria, expect to discharge about 50% of your patients with PE.
   •  ACEP acknowledges that explicit evaluation for right ventricular dysfunction is controversial—something that is not included in the above scoring systems.  The CHEST guidelines state that there is no need to explicitly look for right heart strain but if identified incidentally (strain on CT scan or elevated troponin/BNP), patients should probably not be discharged home.
5. Selected patients with acute DVT may be treated with a non-vitamin K antagonist oral anticoagulant (Level B recommendation) and discharged from the emergency department (Level C recommendation).

Source
Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presentingto the Emergency Department With Suspected Acute Venous Thromboembolic Disease.  Ann Emerg Med. 2018 May;71(5):e59-e109. doi: 10.1016/j.annemergmed.2018.03.006.

Reviewed by Clay Smith