VTE Week | Outpatient PE Treatment in the DOAC Era

Written by Bo Stubblefield

Spoon Feed
In this systematic review, outpatient treatment of patients with pulmonary embolism (PE) deemed low-risk by a clinical decision tool demonstrated a low incidence of mortality, recurrent venous thromboembolism (VTE), or major bleeding at 90 days. There was no association between direct oral anticoagulant (DOAC) use and rates of adverse outcomes.

Why does this matter?
The majority of patients with acute PE are hemodynamically stable and have low 30-day mortality rates (1,2). The clinical decision tools PESI, sPESI, and Hestia Criteria help identify low-risk, hemodynamically stable patients who have low 30-day mortality (0.5-2.5%) (3-5). Although guidelines from professional societies (see links in Another Spoonful below) suggest outpatient management of low-risk patients with VTE, we see a large disparity in what flavor of VTE is sent home (read: PE vs. DVT). Almost half of DVTs are discharged home in the US, while only 8-10% PEs receive similar outpatient management (6,7). A Cochrane Review in 2019 provided no further insight into outpatient PE management. This systematic review expands our understanding by incorporating several prospective, high quality studies to assess outcomes based on anticoagulant class and treatment location.

There’s no place like home. There’s no place like home…
This was a systematic review evaluating adverse outcomes among patients treated for PE in the outpatient setting. Authors selected 12 prospective studies for inclusion – four randomized controlled trials (RCTs) and eight nonrandomized trials (NRTs) with a total of 3,191 patients.

The authors reported three major findings:

1. There are very few controlled studies looking at low-risk PE patients across discharge location (inpatient vs. outpatient) or anticoagulant class. Of eight studies published since DOAC treatment became available in US, only two used a RCT design. Of the NRTs included in review, none had a control group.

2. There were very low rates of major adverse outcomes. Pooled 90-day all-cause mortality was 0.7% in the studies deemed high-quality (10/12 studies). The clinical decision tools PESI, sPESI, and Hestia Criteria all appear to select patients at low risk of short-term mortality. The majority of studies reported no episodes of recurrent VTE or major bleeding (ISTH definition). Studies with these adverse outcomes reported rates of 1.4%. This is similar to rates of complications reported by other clinical decision tools (HEART Score, ABCD2*, CURB-65) which categorize emergency department patients as low-risk and suitable for outpatient management.

3. Similar to findings of prior RCTs, there was no significant association between anticoagulant treatment class and rates of major adverse events. Observed rates of bleeding were similar across treatment class of anticoagulation.

Another Spoonful
Senior author insight:
“We will see several large multicenter studies in coming months that report on the safety and efficacy of home treatment of pulmonary embolism. At the same time, other work will show a slow rate of adoption.” – Jeff Kline, MD (from Bo’s conversation with the guru of all things PE – yeah, the guy who gave us PERC)

Professional Guidelines for Management of PE:

• American College of Emergency Physicians

• American College of Chest Physicians

• European Society of Cardiology

FOAMed link: Oldie but a goodie (2015) on Outpatient VTE Tx from SGEM

Source
Outpatient Treatment of Low-Risk Pulmonary Embolism in the Era of Direct Oral Anticoagulants: A Systematic Review [published online ahead of print, 2020 Aug 11]. Acad Emerg Med. 2020;10.1111/acem.14108. doi:10.1111/acem.14108

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Works Cited

1. Jimenez D, Bikdeli B, Barrios D, et al. Epidemiology, patterns of care and mortality for patients with hemodynamically unstable acute symptomatic pulmonary embolism. Int J Cardiol 2018;269:327-33.

2. Lin BW, Schreiber DH, Liu G, et al. Therapy and outcomes in massive pulmonary embolism from the Emergency Medicine Pulmonary Embolism in the Real World Registry. Am J Emerg Med 2012;30:1774-81.

3. Aujesky D, Obrosky DS, Stone RA, et al. Derivation and validation of a prognostic model for pulmonary embolism. American journal of respiratory and critical care medicine 2005;172:1041-6.

4. Jimenez D, Aujesky D, Moores L, et al. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med 2010;170:1383-9.

5. Zondag W, Mos IC, Creemers-Schild D, et al. Outpatient treatment in patients with acute pulmonary embolism: the Hestia Study. Journal of thrombosis and haemostasis : JTH 2011;9:1500-7.

6. Weeda ER, Butt S. Systematic Review of Real-World Studies Evaluating Characteristics Associated With or Programs Designed to Facilitate Outpatient Management of Deep Vein Thrombosis. Clin Appl Thromb Hemost 2018;24:301S-13S.

7. Singer AJ, Thode HC, Jr., Peacock WFt. Admission rates for emergency department patients with venous thromboembolism and estimation of the proportion of low risk pulmonary embolism patients: a US perspective. Clin Exp Emerg Med 2016;3:126-31.

*Reviewed by Clay Smith – Not that we are recommending ABCD2 be used as a tool to decide which patients are safe for outpatient management…