Diagnosis: PE

Is he discharged yet?

Written by Dr. Ferrari, Edited by Dr. deSouza

Case: 44 year-old man with PMH of PE 5 years ago presents with shortness of breath and chest pain x 2 days. It started the day after returning from California by plane. It is worse with exertion. Previous PE was unprovoked, and treatment with warfarin was completed. Vitals are WNL. Patient is in no respiratory distress. He is able to ambulate to and from restroom without dyspnea.

Lets review some literature:

Can Selected Patients With Newly Diagnosed Pulmonary Embolism Be Safely Treated Without Hospitalization? A Systematic Review, Vinson 2012

• Data Collection
  

  • 8 studies: 7 observational (all prospective) and 1 RCT
    

  • 777 total patients
    

  • Evidence quality: very low x 7, moderate x 1
    

• Characteristics of Studies
  

  • <24 hrs in ED
    

  • Treatment with LMWH and warfarin; follow up in 7-10 days or daily home visits
    

• Outcomes
  

  • No VTE or bleeding-related deaths within 90 days (standard treatment length) in 7 of the studies

  • 2 deaths from VTE or bleeding-related deaths within study reporting 180-day outcomes. When pooled with the 90-day studies, this was 0.26%
    

  • Non-fatal VTE 0-6.2% & non-fatal hemorrhage 0-1.2% at 90 days
    

• Discussion
  

  • The highest rate of complications was in cancer patients
    

  • There is the possibility of publication bias: studies with poor outcomes may not be published
    

  • The RCT (Aujesky 2011) used Pulmonary Embolism Severity Index (PESI) in order to qualify for study
    

  • In some Canadian centers, the discharge rate for PE is 51%; in a sample of 22 US EDs (1880 patients), it was only 1.1%.
    

• Conclusion: The discharge of low-risk patients is feasible & safe

Immediate Discharge and Home Treatment With Rivaroxaban of Low-risk Venous Thromboembolism Diagnosed in Two US Emergency Departments: a One-year Preplanned Analysis, Beam 2015

• Prospective observational study with 106 patients
  

  • Included either DVT or PE
    

  • 27% of patients diagnosed with PE were treated with protocol
    

  • 51% of patients diagnosed with DVT were treated with protocol
    

• Protocol
  

  • Meet Modified Hestia Criteria (SBP<100, no contraindications to LMWH or warfarin, no other reason for hospitalization, INR<1.7, platelet >50,000, not pregnant, not incarcerated)
    

  • CBC, BMP
    

  • 15mg Rivaroxaban in ED +/- 1mg/kg enoxaparin
    

  • 15mg Rivaroxaban BID x 1 month followed by 20mg QD for duration of treatment
    

  • Two day follow-up call and appointment for re-evaluation within 3 weeks
    

• Outcomes
  

  • There was no mortality secondary to VTE
    

  • There were no recurrent VTE while on therapy (there were 3 recurrent VTE after completion of therapy)
    

  • There were no major bleeding events (defined as >2g/dl drop in Hb or >2 units of pRBCs transfused)
    

  • 2 deaths were reported from other causes (cancer and end-stage liver disease)
    

  • Minor bleeding was reported: menorrhagia in 2 patients, jaw swelling after dental procedure in 1 patient
    

• Limitations: The study combined PE and DVT with significantly smaller number of PE patients
  

• Conclusion: Data supports initial outpatient management of VTE with a new oral anticoagulant (NOAC)
  

Antithrombotic Therapy for VTE Disease: Chest Guidelines and Expert Panel Report, 10^th Edition February 2016

#20 – In patients with low-risk PE and whose home circumstances are adequate, we suggest treatment at home or early discharge over standard discharge

• This can be done with NOAC which do not require initial heparin – rivaroxaban and apixaban
  

• Criteria to qualify:
  

  • Clinically stable with good cardiopulmonary reserve
    

  • No contraindications to anticoagulation (recent bleeding, severe renal/liver disease, thrombocytopenia<70,000)
    

  • Expected compliance
    

  • Patient feels well enough
    

• Recommend use of PESI <85 or Simplified PESI of zero
  

• Evidence: moderate
  

These are externally validated scores that may be used to help guide clinical decision-making.

Both are equally accurate.

Class I & II PESI patients can be considered for outpatient treatment of PE

So, is he discharged yet?

The CTA showed segmental PEs in all 4 quadrants. His labs were all normal including troponins. So what does this mean? He is clinically stable, there are no contraindications to anticoagulation, he has access to NOACs and feels well. In addition, he has a PESI score of 54 making him Class I – very low risk. The Chest Guidelines and PESI score are reassuring for him to go home. But decision rules and guidelines aren’t everything; he has a pretty significant PE and is obviously at higher risk of recurrence given this is his second PE. In his case, I didn’t have all the data at hand, so we started apixaban and placed him on observation. With all the data I have since gathered, I believe he could have been sent home. It seems a little scary with his CTA results, but I think the evidence is decent to say, along with all the other metrics, that several days of hospitalization are unlikely to change his outcomes for the better. Admission to the hospital may actually led to a worse outcome given that hospitalization carries its own risks. We have to start making changes sometimes, even if we aren’t used to them.

Let’s go one step further and start the discussion about PEs that may not need to be anticoagulated:

#19 – In patients with subsegmental PE (no involvement of more proximal pulmonary arteries) and no proximal DVT in the legs who have a (1) low risk for recurrent VTE, we suggest clinical surveillance over anticoagulation and (2) high risk for recurrent VTE we suggest anticoagulation over clinical surveillance

• There has been an increase in subsegmental PE diagnosis (from 5% to 10%) with improved CTA technology

• In general, these are more likely to be false-positive tests, But, it is more likely to be true positive if:
  

  • Good opacification of the distal pulmonary arteries
    

  • Multiple intraluminal defects
    

  • More proximal of the subsegmental arteries
    

  • Defects are seen in more than one image or more than one projection
    

  • Defects are surrounded by contrast, not appearing adherent to the wall
    

  • Patient is symptomatic
    

  • High pretest probability
    

  • Elevated d-dimer
    

• The risk of progressive or recurrent VTE without anticoagulation is expected to be lower than in patients with a large PE
  

• If no associated DVT detected, it is unclear if anticoagulation need be initiated
  

  • If no anticoagulation, recommend two week repeat DVT study
    

• Anticoagulate if higher likelihood of true positive test & comorbid risk factors – hospitalized, reduced mobility, cancer, low cardiopulmonary reserve, no reversible risk factor
  

• Evidence: No RCTs, low quality
  

Conclusion: Though this last recommendation is within a guideline, it is heavily based on opinion and theory. The theory seems sound, so it is time to generate some higher quality research to support it. I don’t think I would recommend no treatment for a patient whose CTA shows PE yet, but I am looking forward to choosing this option sometime in my career.

References

Vinson DR, Zehtabchi S, Yealy DM. Can selected patients with newly diagnosed pulmonary embolism be safely treated without hospitalization? A systematic review. Ann Emerg Med. 2012 Nov;60(5):651-662.e4. doi: 10.1016/j.annemergmed.2012.05.041. Epub 2012 Sep 1. Review. Erratum in: Ann Emerg

Med. 2015 Feb;65(2):177. PubMed PMID: 22944455

Aujesky D, Roy PM, Verschuren F, Righini M, Osterwalder J, Egloff M, Renaud B, Verhamme P, Stone RA, Legall C, Sanchez O, Pugh NA, N’gako A, Cornuz J, Hugli O, Beer HJ, Perrier A, Fine MJ, Yealy DM. Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomized, non-inferiority trial. Lancet. 2011 Jul 2;378(9785):41-8. doi:10.1016/S0140-6736(11)60824-6. Epub 2011 Jun 22. PubMed PMID: 21703676.

Beam DM, Kahler ZP, Kline JA. Immediate Discharge and Home Treatment With Rivaroxaban of Low-risk Venous Thromboembolism Diagnosed in Two U.S. Emergency Departments: A One-year Preplanned Analysis. Acad Emerg Med. 2015 Jul;22(7):788-95. doi: 10.1111/acem.12711. Epub 2015 Jun 25. PubMed PMID:26113241

Kearon C, Akl EA, Ornelas J, Blaivas A, Jimenez D, Bounameaux H, Huisman M, King CS, Morris TA, Sood N, Stevens SM, Vintch JR, Wells P, Woller SC, Moores L. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest. 2016 Feb;149(2):315-52. doi: 10.1016/j.chest.2015.11.026. Epub 2016 Jan 7. PubMed PMID: 26867832

MDCalc http://www.mdcalc.com/pulmonary-embolism-severity-index-pesi/?#about-equation

The following two tabs change content below.

• Bio
• Latest Posts

Brian

Kings County Hospital | SUNY Downstate Emergency Medicine Resident -Clinical Monster Webmaster

Latest posts by Brian (see all)

• Patellar Dislocation and Reduction - January 10, 2017
• ED Management of Hypercalcemia of Malignancy - November 12, 2016
• Disseminated Gonorrhea - August 17, 2016