QJM Advance Access published October 9, 2015

Can patients with pulmonary embolism be managed as an outpatient?

Sophy HItchen

Jecko Thachil

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University of Manchester; Manchester. United Kingdom. Department of Haematology, Central Manchester University Hospitals NHS Foundation Trust,

Manchester, United Kingdom.

Corresponding author: Dr Jecko Thachil, Department of Haematology, Central Manchester University Hospitals NHS Foundation Trust, Oxford Road, Manchester, United Kingdom. M13 9WL. Email: [email protected] Phone: 0044 161 276 4812 Fax: 0044 161 276 8085

© The Author 2015. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: [email protected]

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Suspected deep vein thrombosis (DVT) and pulmonary embolism (PE) are two of the commonest presentations to hospitals. Increasingly, physicians are comfortable in managing DVT as an outpatient especially with the arrival of non-vitamin K based anticoagulants which have facilitated this approach. However, most patients who are confirmed to have a PE are still managed as an inpatient. Is there a possibility that at least some of these patients can be managed for their thrombotic condition out of hospital?

Firstly, it would be useful to ascertain whether outpatient management of PE is necessary. The diagnosis of PE is increasing due to several reasons. This is primarily due to an increased awareness of this condition, especially in high-risk population including those who recently had surgery or prolonged periods of immobility and those with chronic medical conditions. Secondly, there are an increased number of requests for computerised tomography (CT) of the thorax; for staging of newly diagnosed malignancy and to exclude pathology for non-specific symptoms for the fear of medico-

evidence of thrombosis detected on imaging studies performed for other indications such as cancer staging (1-2% of all CT thorax) and ‘sub-segmental’ PE which are clots restricted to the smaller 2,3

segments of the pulmonary artery which may be of clinical consequence.

Sub-segmental PE is the

consequence of more sensitive CT imaging technique which has resulted in the incidence of emboli confined to sub-segmental arteries increasing from 4.7% with the single detector to up to 15% with multi-row detector CT.3 At least until randomized trials are published, the current recommendations are both these types of PE should be managed with anticoagulation. 2,4 In summary, the increasing number and sensitivity of imaging techniques are leading to a larger number of PE diagnoses.

Outpatient management of any condition has its obvious benefits but also needs to safely implemented especially in a potentially fatal condition like PE. A meta-analysis published recently has suggested ambulatory management may be safe under certain circumstances.5 This report looked at the outcomes including recurrent venous thromboembolism, major bleeding and all-cause mortality in several studies where PE was managed as outpatients (discharge 80 years – points according to age in years, altered mental status (60 points) Male

sex, history of heart failure or chronic lung disease (10 points each), heart rate >100/min, respiratory rate >30 breaths/min, temperature

Can patients with pulmonary embolism be managed as an outpatient?

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