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Low-Risk Acute PE – What Influences Admission Decision?

May 29, 2023

Written by Chris Thom

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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.

Source
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

Works Cited

  1. 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.
  2. Fang MC, Fan D, Sung SH, et al. Outcomes in adults with acute pulmonary embolism who are discharged from emergency departments: the Cardiovascular Research Network Venous Thromboembolism study. JAMA Intern Med 2015;175:1060-2.
  3. Vinson DR, Ballard DW, Huang J, et al. Outpatient Management of Emergency Department Patients With Acute Pulmonary Embolism: Variation, Patient Characteristics, and Outcomes. Annals of emergency medicine 2018;72:62-72 e3.
  4. Westafer LM, Shieh MS, Pekow PS, Stefan MS, Lindenauer PK. Outpatient Management of Patients Following Diagnosis of Acute Pulmonary Embolism. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine 2020.
  5. 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.
  6. 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.
  7. Elias A, Mallett S, Daoud-Elias M, Poggi JN, Clarke M. Prognostic models in acute pulmonary embolism: a systematic review and meta-analysis. BMJ Open 2016;6:e010324.
  8. Donzé J, Le Gal G, Fine MJ, et al. Prospective validation of the Pulmonary Embolism Severity Index. A clinical prognostic model for pulmonary embolism. Thrombosis and haemostasis 2008;100:943-8.
  9. Aujesky D, Roy PM, Verschuren F, et al. Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial. Lancet 2011;378:41-8.
  10. Jiménez 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.
  11. Aujesky D, Perrier A, Roy PM, et al. Validation of a clinical prognostic model to identify low-risk patients with pulmonary embolism. J Intern Med 2007;261:597-604.
  12. 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.

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