Chest
Original Research: Pulmonary Vascular DiseaseManagement of Low-Risk Pulmonary Embolism Patients Without Hospitalization: The Low-Risk Pulmonary Embolism Prospective Management Study
Section snippets
Study Design
This was a single-arm prospective cohort management study performed at five centers: one tertiary referral center with an American College of Surgeons designation of a level 1 trauma center with an annual ED census of > 90,000 visits, and four suburban community hospitals each with an annual census of 20 to 50,000 visits.
Procedures
Consecutive patients diagnosed with low-risk acute PE by CT pulmonary arteriography (CTPA) or high-probability ventilation/perfusion scan, and having a PESI score < 86
Patients
Of 1,003 consecutive patients diagnosed with acute PE and assessed for eligibility, 790 were excluded: 341 had a PESI score > 85, 419 met another exclusion criterion, 123 declined to provide informed consent, and 30 potentially eligible patients could not be screened (e-Appendix 3), leaving 213 patients who initially met all inclusion criteria (Fig 1). Of these, imaging studies resulted in exclusion of six patients (2.8%) who had DVT proximal to the popliteal vein and four patients (1.9%) with
Discussion
We report key outcomes of patients undergoing an outpatient management strategy for low-risk PE. Outpatient management was associated with a low rate of recurrent VTE, major bleeding, and death, and resulted in high patient satisfaction.
Our study used a prospective cohort (management study) methodology, which is similar to prior trials of VTE management.17, 18, 19 Previous studies of outpatient PE treatment, including three randomized controlled trials,4, 5, 20 note a low rate of adverse
Acknowledgments
Author contributions: J. R. B. takes responsibility for the paper as a whole. J. R. B., T. M., T. A., S. M. S., and S. C. W. conceived the study, designed the trial, and obtained research funding. J. R. B. and V. A. supervised the conduct of the trial and data collection. J. R. B., V. A., S. M. S., S. C. W., and R. P. undertook recruitment of participating patients and managed the data, including quality control. T. A., L. D., and J. L. provided additional data acquisition. B. D. H. provided
References (63)
- et al.
Pulmonary embolism and deep vein thrombosis
Lancet
(2012) - et al.
Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER)
Lancet
(1999) - et al.
Home treatment of pulmonary embolism in the era of novel oral anticoagulants
Am J Med
(2016) - et al.
Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial
Lancet
(2011) - et al.
Home treatment in pulmonary embolism
Thromb Res
(2010) - et al.
Outpatient treatment of symptomatic pulmonary embolism: a systematic review and meta-analysis
Thromb Res
(2013) - et al.
Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report
Chest
(2016) - et al.
Definition of major bleeding in clinical investigations of antihemostatic medicinal products in non-surgical patients
J Thromb Haemost
(2005) - et al.
Outpatient treatment of pulmonary embolism is feasible and safe in a substantial proportion of patients
J Thromb Haemost
(2003) - et al.
Ambulatory management of pulmonary embolism: a pragmatic evaluation
J Thromb Haemost
(2010)
Safety of outpatient treatment in acute pulmonary embolism
J Thromb Haemost
Outpatient treatment in patients with acute pulmonary embolism: the Hestia Study
J Thromb Haemost
Out of hospital treatment of acute pulmonary embolism in patients with a low NT-proBNP level
J Thromb Haemost
Adherence to PIOPED II investigators' recommendations for computed tomography pulmonary angiography
Am J Med
A clinical prediction rule for identifying short-term risk of adverse events in patients with pulmonary thromboembolism [in Spanish]
Arch Bronconeumol
Presence of lower limb deep vein thrombosis and prognosis in patients with symptomatic pulmonary embolism: preliminary report
Eur J Vasc Endovasc Surg
The Simplified Pulmonary Embolism Severity Index (PESI): validation of a clinical prognostic model for pulmonary embolism
J Thromb Haemost
Prognostic implications of computed tomographic right ventricular dilation in patients with acute pulmonary embolism
Thromb Res
Outpatient versus inpatient treatment in patients with pulmonary embolism: a meta-analysis
Eur Respir J
Derivation and validation of a prognostic model for pulmonary embolism
Am J Respir Crit Care Med
Validation of a model to predict adverse outcomes in patients with pulmonary embolism
Eur Heart J
Antithrombotic therapy for VTE disease
Chest
Electronic alerts, comparative practitioner metrics, and education improves thromboprophylaxis and reduces thrombosis
Am J Med
Computerized clinical decision support improves warfarin management and decreases recurrent venous thromboembolism
Clin Appl Thromb Hemost
A multiple testing procedure for clinical trials
Biometrics
Discrete sequential boundaries for clinical trials
Biometrika
Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography
JAMA
Computed tomographic pulmonary angiography vs ventilation-perfusion lung scanning in patients with suspected pulmonary embolism: a randomized controlled trial
JAMA
Withholding anticoagulation after a negative result on duplex ultrasonography for suspected symptomatic deep venous thrombosis
Ann Intern Med
Efficacy and safety of outpatient treatment based on the hestia clinical decision rule with or without N-terminal pro-brain natriuretic peptide testing in patients with acute pulmonary embolism. A randomized clinical trial
Am J Respir Crit Care Med
Derivation and validation of multimarker prognostication for normotensive patients with acute symptomatic pulmonary embolism
Am J Respir Crit Care Med
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FUNDING/SUPPORT: This study was funded by the Intermountain Research and Medical Foundation through a grant [Grant No. 641] awarded to J. R. B.