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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.
[(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.

Search 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)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Kovacs MJ 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	5.6%	Comparatively small numbers
			Major haemorrhage	1.9%
			Death	3.7% - none due to PE or bleed
Wells PS 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	3.6%	Small number of patients with PE
			Major haemorrhage	2.0%
			Minor haemorrhage	5.1%
			Death	7.2% - 11 died of metastatic carcinoma, 1 or sepsis and 1 MI
Labas P et al, 2001, Slovakia	28 patients diagnosed with concurrent PE and DVT treated at home	Prospective cohort	Death	None	No details given regarding diagnostic criteria for PE
Beer JH 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	1/43

Comment(s)

There are no large studies validating this approach to the treatment of pulmonary embolism.

Clinical Bottom Line

It may be safe to treat a low risk group of patients with pulmonary embolic disease at home.

References

1. Kovacs MJ, Anderson D, Morrow B, et al. Outpatient treatment of pulmonary embolism with dalteparin. Throm Haemost 2000;83(2):209-11.
2. 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. Arch Intern Med 1998;158(16):1809-12.
3. Labas P, Ohradka B, Cambal M. Could deep vein thrombosis be safely treated at home. Bratislavske Lekarske Listy 2001;102(10):458-61.
4. Beer JH, Burger M, Gretener S, et al. Outpatient treatment of pulmonary embolism is feasible and safe in a substantial proportion of patients. Journal of Thrombosis and Haemostasis 2002;1:186-202.