Outpatient treatment of pulmonary embolism
Date First Published:
March 19, 2003
Last Updated:
July 1, 2003
Report by:
Dr Kerstin Hogg, Clinical Research Fellow (Manchester Royal Infirmary)
Search checked by:
Debbie Dawson, Manchester Royal Infirmary
Three-Part Question:
Is it [safe] to treat a patient with [pulmonary embolic disease] as an [outpatient]?
Clinical Scenario:
A 40 year old woman presents to the emergency department with pleuritic chest pain. She comments that she has had 'cramp' in her left leg since discharge from the surgical ward, post hysterectomy. Her ventilation-perfusion scan shows a high probability of pulmonary embolism. You have scored her as a high clinical probability of PE and therefore diagnose pulmonary embolic disease. She is comfortable with normal oxygen saturations, and keen to return home to her family. You wonder whether treating her as a outpatient would be an option.
Search Strategy:
Medline 1966-04/03 using the OVID interface.
Search Details:
[(pulmonary embol$.mp OR exp Pulmonary Embolism OR PE.mp OR exp Thromboembolism OR pulmonary infarct$.mp) AND (treatment.mp OR exp Therapeutics OR LMWH.mp OR exp Heparin, Low-Molecular-Weight OR low molecular weight.mp OR exp Anticoagulants) AND (outpatient.mp OR exp Outpatients OR clinic.mp OR exp Outpatient clinics, hospital)] LIMIT to human AND English.
Outcome:
282 papers were found, of which 3 were relevant. One further paper (4) found by a hand-search of the literature.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Outpatient treatment of pulmonary embolism with dalteparin. Kovacs MJ, Anderson D, Morrow B, et al. 1998, Canada | 81 patients treated at home for pulmonary embolism. Further 27 managed at home after average 2.5 days in hospital | Prospective cohort | Recurrent thromboembolic event in 3 month follow-up | 5.60% | Comparatively small numbers |
| Major haemorrhage | 1.90% | ||||
| Death | 3.7% - none due to PE or bleed | ||||
| Expanding eligibility for outpatient treatment of deep venous thrombosis and pulmonary embolism with low-molecular-weight heparin: a comparison of patient self-injection with homecare injection. Wells PS, Kovacs MJ, Bormanis J, et al. 1998, Canada | 184 patients with either DVT or PE (34 had PE) deemed at low risk of complications randomised to self administration dalteparin or homecare nurse administration. All treated at home | Prospective cohort | Recurrent thromboembolic event in 3 month follow-up | 3.60% | Small number of patients with PE |
| Major haemorrhage | 2.00% | ||||
| Minor haemorrhage | 5.10% | ||||
| Death | 7.2% - 11 died of metastatic carcinoma, 1 or sepsis and 1 MI | ||||
| Could deep vein thrombosis be safely treated at home. Labas P, Ohradka B, Cambal M. 2001, Slovakia | 28 patients diagnosed with concurrent PE and DVT treated at home | Prospective cohort | Death | No details given regarding diagnostic criteria for PE | |
| Outpatient treatment of pulmonary embolism is feasible and safe in a substantial proportion of patients. Beer JH, Burger M, Gretener S, et al. 2002, Switzerland | 43 symptomatic PE patients at low predicted risk, treated as outpatients | Prospective cohort | Death in following 3 months | 0/43 | Small cohort |
| Bleeding in following 3 months | 0/43 | ||||
| Recurrent PE | Jan-43 |
Author Commentary:
There are no large studies validating this approach to the treatment of pulmonary embolism.
Bottom Line:
It may be safe to treat a low risk group of patients with pulmonary embolic disease at home.
References:
- Kovacs MJ, Anderson D, Morrow B, et al.. Outpatient treatment of pulmonary embolism with dalteparin.
- Wells PS, Kovacs MJ, Bormanis J, et al.. Expanding eligibility for outpatient treatment of deep venous thrombosis and pulmonary embolism with low-molecular-weight heparin: a comparison of patient self-injection with homecare injection.
- Labas P, Ohradka B, Cambal M.. Could deep vein thrombosis be safely treated at home.
- Beer JH, Burger M, Gretener S, et al.. Outpatient treatment of pulmonary embolism is feasible and safe in a substantial proportion of patients.