A Review on State‐of‐the‐Art Data Regarding Safe Early Discharge Following Admission for Pulmonary Embolism: What Do We Know?

Abstract

Background Although most patients with acute pulmonary embolism (PE) remain hospitalized during initial therapy, some may be suitable for partial or complete outpatient management, which may have a significant impact on healthcare costs. Hypothesis This article reviews the state‐of‐the‐art data regarding recognition of very‐low‐risk PE patients who are potentially eligible for outpatient treatment, along with the safety, management, and cost‐effectiveness of this strategy. We propose an algorithm based on collected data that may be useful/practical for identifying patients truly eligible for early discharge. Methods Comprehensive review of scientific data collected from the MEDLINE and Cochrane databases. Studies selected based on potential scientific interest. Qualitative information extracted regarding feasibility, safety, and cost‐effectiveness of outpatient treatment, postdischarge management, and selection of truly low‐risk patients. Results Early discharge of low‐risk patients seems feasible, safe, and particularly cost‐effective. Several risk scores have been developed and/or tested as prediction tools for the recognition of low‐risk individuals: the Pulmonary Embolism Severity Index (PESI), simplified PESI, Hestia criteria, Geneva score, the Low‐Risk Pulmonary Embolism Decision rule, and the Global Registry of Acute Cardiac Events, among others. PESI is the most well‐validated model, offering the safest approach at the current time, especially when combined with additional parameters such as troponin I, N‐terminal prohormone of brain natriuretic peptide, and echocardiographic markers of right‐ventricular dysfunction. Conclusions Recognition of truly low‐risk patients entitled to early hospital discharge and outpatient treatment is possible with current risk‐stratification schemes along with selected prognostic parameters, and it may have a colossal impact on healthcare costs.

Factors associated with clinical deterioration shortly after PE

“…Low-risk patients may be eligible for outpatient treatment with heparin or novel oral anticoagulants. 15 25 Meta-analyses, systematic reviews and a large clinical trial support the safety of this approach 15 26 27. Piran et al 26 found that selected patients with PE treated as outpatients had low rates of recurrent venous thromboembolism (VTE) (1.47%), fatal PE (0.47%) and major bleeding (0.81%), and Vinson et al 28 found that outpatient treatment was associated with low 90-day VTE-related mortality.…”

Comparison and combination of a hemodynamics/biomarkers-based model with simplified PESI score for prognostic stratification of acute pulmonary embolism: findings from a real world study

“…Despite many prognostic model have been proposed, such as the ESC prognostic model, the original and sPESI score, the Geneva prognostic model, the LR-PED, the HESTIA criteria, the Spanish score and other, which is the best prognosticator for the identification of 30-days mortality in PE patients in real world remains unclear. 4,5,9,10,[17][18][19][20] Moreover, the majority of the proposed prognostic models focus only on early mortality risk without bleeding risk stratification. On the other hand, few bleeding risk scores have been proposed, but, anyway, these do not give information about PE-related early mortality risk.…”

“…2,3 Many prognostic models for risk stratification of acute PE have been proposed, but which is the best prognosticator remains unclear, especially in daily real practice. 4 In 2008 for the first time, the European Society of Cardiology proposed a model based on hemodynamics and cardiac biomarkers. 5 This model has represented a cornerstone in acute management of PE.…”

New insights into treatment of venous thromboembolism

“…Several scores have been developed (and were recently reviewed 33 ) to assess PE patients' risk for poor outcome in the weeks after the PE diagnosis, but most were not developed for the determination of whom to treat on an outpatient or inpatient basis, but rather as tools to assess risk of good or poor outcomes from the PE. The HESTIA criteria, recently evaluated in a multicenter prospective cohort study, were developed for inpatient/outpatient management decisions and use common sense parameters to determine hospital admission need 34 ( Table 2).…”