Impact of Relative Contraindications to Home Management in Emergency Department Patients with Low-Risk Pulmonary Embolism

Abstract

Rationale: Studies of adults presenting to the emergency department (ED) with acute pulmonary embolism (PE) suggest that those who are low risk on the PE Severity Index (classes I and II) can be managed safely without hospitalization. However, the impact of relative contraindications to home management on outcomes has not been described.Objectives: To compare 5-day and 30-day adverse event rates among low-risk ED patients with acute PE without and with outpatient ineligibility criteria. Methods:We conducted a retrospective multicenter cohort study of adults presenting to the ED with acute low-risk PE between 2010 and 2012. We evaluated the association between outpatient treatment eligibility criteria based on a comprehensive list of relative contraindications and 5-day adverse events and 30-day outcomes, including major hemorrhage, recurrent venous thromboembolism, and all-cause mortality.Measurements and Main Results: Of 423 adults with acute lowrisk PE, 271 (64.1%) had no relative contraindications to outpatient treatment (outpatient eligible), whereas 152 (35.9%) had at least one contraindication (outpatient ineligible). Relative contraindications were categorized as PE-related factors (n = 112; 26.5%), comorbid illness (n = 42; 9.9%), and psychosocial barriers (n = 19; 4.5%). There were no 5-day events in the outpatient-eligible group (95% upper confidence limit, 1.7%) and two events (1.3%; 95% confidence interval [CI], 0.1-5.0%) in the outpatient-ineligible group (P = 0.13). At 30 days, there were five events (two recurrent venous thromboemboli and three major bleeding events) in the outpatient-eligible group (1.8%; 95% CI, 0.7-4.4%) compared with nine in the ineligible group (5.9%; 95% CI, 2.7-10.9%; P , 0.05). This difference remained significant when controlling for PE severity class.Conclusions: Nearly two-thirds of adults presenting to the ED with low-risk PE were potentially eligible for outpatient therapy. Relative contraindications to outpatient management were associated with an increased frequency of adverse events at 30 days among adults with low-risk PE.

Findings From 12‐lead Electrocardiography That Predict Circulatory Shock From Pulmonary Embolism: Systematic Review and Meta‐analysis

“…We submit that the six ECG findings provide a composite biomarker of RV failure and thus provide specific bedside evidence of the need for intensive care services and therapies known to reduce pulmonary arterial pressure, including systemic or catheter‐based fibrinolysis or possibly pulmonary selective vasodilation . Moreover, the pooled data suggest that a Daniel score should be used in the decision to evaluate a patient with PE for possible home treatment . Our data suggest that a patient with PE and a Daniel ECG score > 5, or ST elevation in aVR or atrial fibrillation, should be considered to have a risk of hemodynamic collapse that is too high to safely allow home treatment, even if the patient is low risk by other criteria …”

“…Experts generally agree that patients with PE and right ventricular (RV) failure have an elevated risk of hemodynamic collapse and should be considered for additional treatment beyond standard anticoagulation, including fibrinolytic therapy . Patients with low‐risk PE might be considered for immediate treatment at home . Well‐recognized methods for risk stratification include scoring systems, blood biomarkers (troponins I and T, brain natriuretic peptides), echocardiographic findings of RV strain, and findings of a dilated RV on computed tomography (CT) scanning .…”

Comparison of Four Bleeding Risk Scores to Identify Rivaroxaban‐treated Patients With Venous Thromboembolism at Low Risk for Major Bleeding

“…In current practice, physicians admit most patients with acute PE diagnosed in the outpatient or emergency care setting 13. However, it should be realized that many patients who have acute symptomatic DVT, including those who are currently treated on an outpatient basis, may also have concomitant asymptomatic PE 14.…”

Outpatient Management Eligibility Criteria for Patients Who Have Acute Symptomatic Pulmonary Embolism

“…666-673) address the issue of outpatient initial PE therapy (11). They conducted a retrospective study of patients from four community EDs within a healthcare delivery system in Northern California.…”

“…Published studies of initial outpatient therapy for PE have not addressed the use of target-specific (non-VKA) oral anticoagulants (5,7,8,11). Randomized controlled trials of these anticoagulants have shown relatively low event rates in patients who likely had similar or higher PESI scores in comparison to the Aujesky (9) and Vinson (11) studies.…”