Pulmonary embolism discharge care and long term treatment: Difference between revisions
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=== Discharge Medications === | === Discharge Medications === | ||
* | * The long term management of [[PE]] depends on whether the episode is the first one or not, whether it is provoked or unprovoked, and on the risk of bleeding of the patient. Among non cancer patients, the first line therapy for long term management of [[PE]] is [[vitamin K antagonist]]s (VKA); whereas the first line treatment among cancer patients is [[low molecular weight heparin]]. '''If long term treatment with VKA is decided, VKA should be started at the same day with heparin allowing for at least 5 days of overlap until the [[INR]] is ≥2 for at least 24 hours'''. Among patients on extended [[anticoagulation therapy]], the risk vs benefits of the [[anticoagulation therapy]] should be assessed regularly (for example annually).<ref name="pmid22315268">{{cite journal| author=Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ et al.| title=Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e419S-94S | pmid=22315268 | doi=10.1378/chest.11-2301 | pmc=PMC3278049 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315268 }} </ref> | ||
{{Family tree/start}} | |||
{{familytree | | | | | | | | | | A01 | | | | | | | | A01= '''Is this the first episode of PE?'''}} | |||
{{familytree | | | | | |,|-|-|-|-|^|-|-|-|-|.| | | | }} | |||
{{familytree | | | | | B01 | | | | | | | | B02 | | | B01= '''YES'''| B02= '''NO'''}} | |||
{{familytree | | | | | |!| | | | | | | | | |!| | | | }} | |||
{{familytree | | | | | C01 | | | | | | | | C02 | | | C01= '''Is PE provoked?'''| C02= '''[[Pulmonary embolism resident survival guide#Assessment of Risk of Bleeding|What is the risk of bleeding?]]'''}} | |||
{{familytree | |,|-|-|-|+|-|-|-|.| | | |,|-|^|-|.| | }} | |||
{{familytree | D01 | | D02 | | D03 | | D04 | | D05 | | D01= '''Yes, transient reversible risk factor'''| D02= '''Yes, [[cancer]]'''| D03= '''No (unprovoked)'''| D04= '''[[Pulmonary embolism resident survival guide#Assessment of Risk of Bleeding|Low or moderate]]'''| D05= '''[[Pulmonary embolism resident survival guide#Assessment of Risk of Bleeding|High]]'''}} | |||
{{familytree | |!| | | |!| | | |!| | | |!| | | |!| | }} | |||
{{familytree | E01 | | E02 | | E03 | | E04 | | E05 | | E01= '''Therapy for 3 months'''<br><div style="float: left; text-align: left; padding:1em;">❑ [[VKA]] (first line)<br> OR <br> ❑ [[LMWH]] <br> OR <br> ❑ [[Dabigatran]] <br> OR <br> ❑ [[Rivaroxaban]] </div>| E02= '''Extended therapy or until cancer is cured'''<br><div style="float: left; text-align: left; padding:1em;">❑ [[LMWH]] (first line)<br> OR <br> ❑ [[VKA]] <br> OR <br> ❑ [[Dabigatran]] <br> OR <br> ❑ [[Rivaroxaban]] </div>| E03= '''Therapy for ≥ 3 months'''<br><div style="float: left; text-align: left; padding:1em;">❑ [[VKA]] (first line)<br> OR <br> ❑ [[LMWH]] <br> OR <br> ❑ [[Dabigatran]] <br> OR <br> ❑ [[Rivaroxaban]] </div>| E04= '''Extended therapy'''<br><div style="float: left; text-align: left; padding:1em;">❑ [[VKA]] (first line)<br> OR <br> ❑ [[LMWH]] <br> OR <br> ❑ [[Dabigatran]] <br> OR <br> ❑ [[Rivaroxaban]] </div>| E05= '''Therapy for 3 months'''<br><div style="float: left; text-align: left; padding:1em;">❑ [[VKA]] (first line)<br> OR <br> ❑ [[LMWH]] <br> OR <br> ❑ [[Dabigatran]] <br> OR <br> ❑ [[Rivaroxaban]] </div>}} | |||
{{familytree | | | | | | | | | |!| | | | | | | | | | }} | |||
{{familytree | | | | | | | | | F01 | | | | | | | | | F01= '''[[Pulmonary embolism resident survival guide#Assessment of Risk of Bleeding|Re-assess the risk of bleeding]]'''}} | |||
{{familytree | | | | | | | |,|-|^|-|.| | | | | | | | }} | |||
{{familytree | | | | | | | G01 | | G02 | | | | | | | G01= '''[[Pulmonary embolism resident survival guide#Assessment of Risk of Bleeding|Low or moderate]]'''| G02= '''[[Pulmonary embolism resident survival guide#Assessment of Risk of Bleeding|High]]'''}} | |||
{{familytree | | | | | | | |!| | | |!| | | | | | | | }} | |||
{{familytree | | | | | | | H01 | | H02 | | | | | | | H01= '''Extended therapy'''| H02= '''Do not extend the therapy beyond the initial 3 months'''}} | |||
{{familytree/end}} | |||
''Note that [[edoxaban]]<ref name="pmid23991658">{{cite journal| author=Hokusai-VTE Investigators. Büller HR, Décousus H, Grosso MA, Mercuri M, Middeldorp S et al.| title=Edoxaban versus warfarin for the treatment of symptomatic venous thromboembolism. | journal=N Engl J Med | year= 2013 | volume= 369 | issue= 15 | pages= 1406-15 | pmid=23991658 | doi=10.1056/NEJMoa1306638 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23991658 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24445714 Review in: Ann Intern Med. 2014 Jan 21;160(2):JC4] [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24638182 Review in: Ann Intern Med. 2014 Mar 18;160(6):JC4] </ref> has been evaluated for the treatment of [[VTE]] and is currently seeking approval for this indication.'' | |||
* An ongoing trial is discussing whether or not to withhold anticoagulation among patients with subsegmental PE. (ClinicalTrials.gov number, NCT01455818) [http://clinicaltrials.gov/ct2/show/NCT01455818?term=nct01455818&rank=1]. The result of this trial will further enlighten physicians about discharge care in PE patients. | * An ongoing trial is discussing whether or not to withhold anticoagulation among patients with subsegmental PE. (ClinicalTrials.gov number, NCT01455818) [http://clinicaltrials.gov/ct2/show/NCT01455818?term=nct01455818&rank=1]. The result of this trial will further enlighten physicians about discharge care in PE patients. | ||
Revision as of 18:55, 11 July 2014
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Pulmonary Embolism Microchapters |
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Diagnosis |
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Pulmonary Embolism Assessment of Probability of Subsequent VTE and Risk Scores |
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Treatment |
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Follow-Up |
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Special Scenario |
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Trials |
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Case Studies |
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Pulmonary embolism discharge care and long term treatment On the Web |
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FDA on Pulmonary embolism discharge care and long term treatment |
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CDC on Pulmonary embolism discharge care and long term treatment |
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Pulmonary embolism discharge care and long term treatment in the news |
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Blogs on Pulmonary embolism discharge care and long term treatment |
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Directions to Hospitals Treating Pulmonary embolism discharge care and long term treatment |
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Risk calculators and risk factors for Pulmonary embolism discharge care and long term treatment |
Editor(s)-In-Chief: The APEX Trial Investigators, C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]
Overview
Pulmonary embolism patients are at increased risk of a second attack of PE. If un-treated, almost 1/3 of the patients die, usually from recurrent PE. Therefore, a patient should be discharged only after proper diagnosis and discharge medication. Information pertaining to the safety of outpatient treatment of a pulmonary embolism is still inadequate due to the lack of a randomized control trial comparing in-patient and outpatient management.
Discharge Care
Discharge Criteria
High-risk PE patients have a 30-day mortality of greater than 15%, and thus hospital admission is necessary.[1]
Hemodynamic stability is not the criteria for discharge. Patients who are hemodynamically stable, but have right ventricular dysfunction, should be admitted.
Patients having a low-risk score and do not require supplemental oxygen are potential candidates for early discharge and outpatient treatment. Patients with absent Right ventricular dysfunction and a normal troponin level can be discharged and put on out-patient treatment.[2]
Discharge Medications
- The long term management of PE depends on whether the episode is the first one or not, whether it is provoked or unprovoked, and on the risk of bleeding of the patient. Among non cancer patients, the first line therapy for long term management of PE is vitamin K antagonists (VKA); whereas the first line treatment among cancer patients is low molecular weight heparin. If long term treatment with VKA is decided, VKA should be started at the same day with heparin allowing for at least 5 days of overlap until the INR is ≥2 for at least 24 hours. Among patients on extended anticoagulation therapy, the risk vs benefits of the anticoagulation therapy should be assessed regularly (for example annually).[3]
| Is this the first episode of PE? | |||||||||||||||||||||||||||||||||||||||
| YES | NO | ||||||||||||||||||||||||||||||||||||||
| Is PE provoked? | What is the risk of bleeding? | ||||||||||||||||||||||||||||||||||||||
| Yes, transient reversible risk factor | Yes, cancer | No (unprovoked) | Low or moderate | High | |||||||||||||||||||||||||||||||||||
| Therapy for 3 months | Extended therapy or until cancer is cured | Therapy for ≥ 3 months | Extended therapy | Therapy for 3 months | |||||||||||||||||||||||||||||||||||
| Re-assess the risk of bleeding | |||||||||||||||||||||||||||||||||||||||
| Low or moderate | High | ||||||||||||||||||||||||||||||||||||||
| Extended therapy | Do not extend the therapy beyond the initial 3 months | ||||||||||||||||||||||||||||||||||||||
Note that edoxaban[4] has been evaluated for the treatment of VTE and is currently seeking approval for this indication.
- An ongoing trial is discussing whether or not to withhold anticoagulation among patients with subsegmental PE. (ClinicalTrials.gov number, NCT01455818) [3]. The result of this trial will further enlighten physicians about discharge care in PE patients.
References
- ↑ Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P, Bengel F, Brady AJ, Ferreira D, Janssens U, Klepetko W, Mayer E, Remy-Jardin M, Bassand JP (2008). "Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)". Eur. Heart J. 29 (18): 2276–315. doi:10.1093/eurheartj/ehn310. PMID 18757870. Retrieved 2011-12-07. Unknown parameter
|month=ignored (help) - ↑ Agnelli G, Becattini C (2010). "Acute pulmonary embolism". N Engl J Med. 363 (3): 266–74. doi:10.1056/NEJMra0907731. PMID 20592294.
- ↑ Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ; et al. (2012). "Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e419S–94S. doi:10.1378/chest.11-2301. PMC 3278049. PMID 22315268.
- ↑ Hokusai-VTE Investigators. Büller HR, Décousus H, Grosso MA, Mercuri M, Middeldorp S; et al. (2013). "Edoxaban versus warfarin for the treatment of symptomatic venous thromboembolism". N Engl J Med. 369 (15): 1406–15. doi:10.1056/NEJMoa1306638. PMID 23991658. Review in: Ann Intern Med. 2014 Jan 21;160(2):JC4 Review in: Ann Intern Med. 2014 Mar 18;160(6):JC4