Does the Pulmonary Embolism Severity Index accurately identify low risk patients eligible for outpatient treatment?

Erkens, Petra M. G.; Gándara, Esteban; Wells, Philip S.; Shen, Alex Yi-Hao; Bose, Gauruv; Gal, Grégoire Le; Rodger, Marc; Prins, Martin H.; Carrier, Marc

doi:10.1016/j.thromres.2011.08.025

Cited by 45 publications

(41 citation statements)

References 20 publications

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“…Retrospective analyses conducted in Ireland [72] and Canada [73,74] also support the concept of outpatient treatment of low-risk PE. The largest dataset comes from a meta-analysis of published studies, in which ZONDAG et al [75] compared outcomes in 1657 patients with low-risk PE treated either entirely in hospital, discharged within 72 h or treated solely as outpatients.…”

Section: Inpatient Versus Outpatient Management Of Pementioning

confidence: 79%

Developments in the management and treatment of pulmonary embolism

Limbrey

Howard

2015

Eur Respir Rev

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Pulmonary embolism (PE) is a serious and costly disease for patients and healthcare systems. Guidelines emphasise the importance of differentiating between patients who are at high risk of mortality (those with shock and/or hypotension), who may be candidates for thrombolytic therapy or surgery, and those with less severe presentations. Recent clinical studies and guidelines have focused particularly on risk stratification of intermediate-risk patients. Although the use of thrombolysis has been investigated in these patients, anticoagulation remains the standard treatment approach. Individual risk stratification directs initial treatment. Rates of recurrence differ between subgroups of patients with PE; therefore, a review of provoking factors, along with the risks of morbidity and bleeding, guides the duration of ongoing anticoagulation. The direct oral anticoagulants have shown similar efficacy and, in some cases, reduced major bleeding compared with standard approaches for acute treatment. They also offer the potential to reduce the burden on patients and outpatient services in the post-hospital phase. Rivaroxaban, dabigatran and apixaban have been shown to reduce the risk of recurrent venous thromboembolism versus placebo, when given for >12 months. Patients receiving direct oral anticoagulants do not require regular coagulation monitoring, but follow-up, ideally in a specialist PE clinic in consultation with primary care providers, is recommended. @ERSpublications Direct oral anticoagulants have the potential to improve management of patients with pulmonary embolism http://ow.ly/NV7K6

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Section: Inpatient Versus Outpatient Management Of Pementioning

confidence: 79%

Developments in the management and treatment of pulmonary embolism

Limbrey

Howard

2015

Eur Respir Rev

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“…Observations from this study support a shift in the care of patients with VTE. The availability of oral drugs that do not require prior parenteral drug administration is expected to increase the number of patients who can be treated directly at home, including low‐risk patients with acute PE 16. This potential shift in care is supported by evidence from EINSTEIN DVT and EINSTEIN PE, in which hospitalized patients receiving rivaroxaban had a significantly shorter length of stay compared with patients receiving enoxaparin/VKA 17.…”

Section: Discussionmentioning

confidence: 99%

Use of Prestudy Heparin Did Not Influence the Efficacy and Safety of Rivaroxaban in Patients Treated for Symptomatic Venous Thromboem‐bolism in the EINSTEIN DVT and EINSTEIN PE Studies

Prandoni

Prins

Cohen

et al. 2015

Academic Emergency Medicine

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ObjectivesIn the EINSTEIN DVT and EINSTEIN PE studies, the majority of patients received heparins to bridge the period during venous thromboembolism (VTE) diagnosis confirmation and the start of the study. In contrast to vitamin K antagonists (VKAs), rivaroxaban may not require initial heparin treatment.MethodsTo evaluate the effect of prestudy heparin on the efficacy and safety of rivaroxaban relative to enoxaparin/VKA, the 3‐month incidence of recurrent VTE, and the 14‐day incidence of major and nonmajor clinically relevant bleeding were compared in patients who did and did not receive prestudy heparin.ResultsOf the 8,281 patients randomized, 6,937 (83.8%) received prestudy heparin (mean ± SD duration = rivaroxaban: 1.04 [± 0.74] days; enoxaparin 1.03 [± 0.42] days), and 1,344 (16.2%) did not. In patients who did not receive prestudy heparin, the incidences of recurrent VTE were similar in rivaroxaban (15 of 649, 2.3%) and enoxaparin/VKA (13 of 695, 1.9%) patients (adjusted hazard ratio [HR] = 1.11; 95% confidence interval [CI] = 0.52 to 2.37). The incidences of recurrent VTE were also similar in rivaroxaban (54 of 3,501, 1.5%) and enoxaparin/VKA (69 of 3,436, 2.0%) patients who did receive prestudy heparin (adjusted HR = 0.74; 95% CI = 0.52 to 1.06; pinteraction = 0.32). The incidences of major or nonmajor clinically relevant bleeding with rivaroxaban were not significantly different from those with enoxaparin/VKA, either with (105 of 3,485, 3.0% vs. 104 of 3,428, 3.0%; adjusted HR = 0.98; 95% CI = 0.75 to 1.29) or without (24 of 645, 3.7% vs. 30 of 688, 4.4%; adjusted HR = 0.81; 95% CI = 0.46 to 1.40; pinteraction = 0.68) prestudy heparin.ConclusionsAlthough the majority of patients in the EINSTEIN studies received prestudy heparin, there were no notable differences in treatment effect of rivaroxaban versus enoxaparin/VKA in those who did and did not receive it.

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“…The FAST score combines heart-type fatty acid binding protein (H-FABP) (≥ 6 ng mL À1 ), heart rate (> 110 bpm), and syncope [18]. In normotensive patients with PE, the positive predictive value of the FAST score and sPESI for PE-related complications were 22% (95% CI, [14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33] and 11% (95% CI, [8][9][10][11][12][13][14][15][16][17], respectively [18]. Combining patient data from six studies involving 2874 normotensive patients with PE, Bova et al developed a prognostic model for intermediate-risk PE.…”

Section: Studymentioning

confidence: 99%

Pulmonary embolism: whom to discharge and whom to thrombolyze?

Meyer

Planquette

Sanchez

2015

Journal of Thrombosis and Haemostasis

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Summary Patients with pulmonary embolism can be divided in two groups according to their risk of death or major complication: a small group of high‐risk patients defined by the presence of systemic hypotension or cardiogenic shock and a large group of normotensive patients. Among normotensive patients, further risk stratification, based on clinical grounds alone or on the combination of clinical data, biomarkers, and imaging tests, allows selection of low‐risk patients and intermediate‐risk patients. The safety of outpatient treatment for low‐risk patients has been established mainly on the basis of retrospective and prospective cohorts using different selection tools. In most studies, about 50% of the patients have been safely treated at home. Although thrombolytic therapy has a favorable benefit to risk profile in patients with high‐risk pulmonary embolism, the risk of major and especially intracranial bleeding outweighs the benefits in terms of hemodynamic decompensation in patients with intermediate‐risk pulmonary embolism.

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Does the Pulmonary Embolism Severity Index accurately identify low risk patients eligible for outpatient treatment?

Cited by 45 publications

References 20 publications

Developments in the management and treatment of pulmonary embolism

Developments in the management and treatment of pulmonary embolism

Use of Prestudy Heparin Did Not Influence the Efficacy and Safety of Rivaroxaban in Patients Treated for Symptomatic Venous Thromboem‐bolism in the EINSTEIN DVT and EINSTEIN PE Studies

Pulmonary embolism: whom to discharge and whom to thrombolyze?

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