Written by Chris Thom
In a retrospective cohort of patients with acute pulmonary embolism (PE) and a low pulmonary embolism severity index (PESI) score, increased heart rate and bilateral PE were factors associated with physicians’ decision for hospitalization.
Why does this matter?
In the US, approximately half of DVTs are discharged from the emergency department (ED), while less than 10% of PEs receive outpatient management.1-4 Although high-risk PE is associated with considerable mortality, the majority of patients with acute PE are hemodynamically stable and have low 30-day mortality rates.5,6 It is estimated that approximately 30-50% of low-risk PEs may be safe for discharge.1,7-10 The pulmonary embolism severity index (PESI) is a clinical decision rule that seeks to aid in identifying individuals with low risk PE.11,12 Despite the growing body of clinical trial and real-world evidence to suggest outpatient treatment of low-risk PE is both safe and efficacious, many of these patients are still admitted.
A decision on hospitalization is often more than the PESI score….
This was a retrospective cohort of patients from 21 community EDs in California from January 2019 to February 2020. The authors previously performed a pragmatic trial of clinical decision support (CDS) embedded in the electronic health record to provide physicians with risk-based recommendations on PE management. In the current study, the authors performed a retrospective analysis four years following the CDS intervention. They evaluated low-risk patients with acute PE (PESI ≤ 85) for factors associated with the disposition decision.
461 low-risk patients were identified, 265 were admitted and 196 discharged. Heart rate > 110 had an odds ratio (OR) for admission of 3.11 (95%CI 1.07 to 9.57) and heart rate 90-109 had an OR of 2.03 (95%CI 1.18 to 3.50). Presence of bilateral PEs (as opposed to unilateral PE) had an OR of 1.92 for hospitalization (95%CI 1.13 to 3.27). The authors noted that 90% (37/41) of patients with RV dilatation by CT criteria were hospitalized.
In short, heart rate ≥90 and bilateral PEs had the biggest influence on the decision to admit patients who otherwise had low-risk PE based on PESI score.
Bilateral Emboli and Highest Heart Rate Predict Hospitalization of Emergency Department Patients With Acute, Low-Risk Pulmonary Embolism [published online ahead of print, 2023 Apr 5]. Ann Emerg Med. 2023;S0196-0644(23)00123-3.
Peer reviewed and edited by Bo Stubblefield
Editor’s note: Right ventricular dysfunction (RVD) has been closely linked with short term mortality in patients with acute PE; however, the impact of thrombus burden and the anatomic location of thrombus is unclear. ~Bo Stubblefield
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