Pulmonary embolism discharge care and long term treatment

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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

• The mortality of low risk PE, submassive (intermediate risk) PE, and massive (high risk) PE increases from <3%, to 3-15%, to >15% respectively. Given the elevated rate of mortality in cases of submassive and massive PE, hospital admission is necessary for patients who are stratified within these categories.ref name="pmid18757870">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. CS1 maint: Multiple names: authors list (link) </ref> Hemodynamic stability is not the criteria for discharge. Patients who are hemodynamically stable but have right ventricular dysfunction (stratified as submassive PE), should be admitted.

• Patients with low risk PE whom have no evidence of hypotension, Right ventricular dysfunction, or myocardial necrosis can be discharged and put on out-patient treatment.

Discharge Medications

Initial Anticoagulation Therapy

• Low risk PE patients can have an early discharge and outpatient treatment. For more details about the choices of treatment, click here.

Long Term Anticoagulation Therapy

• 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).

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 ❑ VKA (first line) OR ❑ LMWH OR ❑ Dabigatran OR ❑ Rivaroxaban

Extended therapy or until cancer is cured ❑ LMWH (first line) OR ❑ VKA OR ❑ Dabigatran OR ❑ Rivaroxaban

Therapy for ≥ 3 months ❑ VKA (first line) OR ❑ LMWH OR ❑ Dabigatran OR ❑ Rivaroxaban

Extended therapy ❑ VKA (first line) OR ❑ LMWH OR ❑ Dabigatran OR ❑ Rivaroxaban

Therapy for 3 months ❑ VKA (first line) OR ❑ LMWH OR ❑ Dabigatran OR ❑ Rivaroxaban

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 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.