Written by Clay Smith
A protocol in select ED patients with low PESI, no RV dysfunction on echo, and no proximal DVT was safe for treating PE as an outpatient.
Why does this matter?
Reducing admission for low risk PE patients would reduce cost, hospital crowding, and may even be safer. But we need more evidence to make sure we can pull this off without harming people. Here’s some now.
LoPE on off to the house…
LoPE was a prospective study of 200 patients with confirmed PE who were treated on an outpatient basis. To be eligible, they had to have PESI <86, no RV dysfunction on echo, and negative leg ultrasound for DVT proximal to the popliteal vein. They were also excluded for, “hypoxia, hypotension, hepatic or renal failure, contraindication to therapeutic anticoagulation, or another condition requiring hospital admission.” Most (85%) were started on rivaroxaban or apixaban. The 90-day composite outcome of all-cause mortality, recurrent symptomatic VTE, and major bleeding occurred in 0.5% (1/200) and was a major bleed. They obtained follow up on 100%. Patients seemed to like it; 91% were highly satisfied with this care. All patients were observed for 12-24 hours (median, 13.5h) in the ED or hospital.
Here is more evidence that in the right patient, this is safe. The problem is finding the right patient. They have to be able to get the medication, afford it, understand how to take it, and have follow up, not to mention all the exclusion criteria. It’s not easy.
Management of Low-Risk Pulmonary Embolism Patients Without Hospitalization: The Low-Risk Pulmonary Embolism Prospective Management Study. Chest. 2018 Aug;154(2):249-256. doi: 10.1016/j.chest.2018.01.035. Epub 2018 Feb 2.
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