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]; Rim Halaby, M.D. [3]
Overview
While hospital admission is necessary for patients who have a massive or submassive pulmonary embolism (PE), patients with low risk PE who have no evidence of hypotension, right ventricular dysfunction, or myocardial necrosis can be discharged early on and put on an outpatient treatment regimen.[1] 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 outpatient anticoagulation therapy is vitamin K antagonists (VKA); whereas the first line treatment among cancer patients is low molecular weight heparin.
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.[2] 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.[2] 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 who have no evidence of hypotension, right ventricular dysfunction, or myocardial necrosis can be discharged early on and put on an outpatient treatment regimen.[1]
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).[3]
Shown below is an algorithm depicting the long term outpatient anticoagulation therapy for patients with PE.[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 | ||||||||||||||||||||||||||||||||||||
Extended therapy or until cancer is cured ❑ LMWH (first line) OR ❑ VKA OR ❑ Dabigatran OR ❑ Rivaroxaban | |||||||||||||||||||||||||||||||||||||||
| 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.
References
- ↑ 1.0 1.1 Agnelli G, Becattini C (2010). "Acute pulmonary embolism". N Engl J Med. 363 (3): 266–74. doi:10.1056/NEJMra0907731. PMID 20592294.
- ↑ 2.0 2.1 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) - ↑ 3.0 3.1 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