Portal de Periódicos da CAPES

Outpatient treatment of pulmonary embolism

2009; EMH Swiss Medical Publishers Ltd.; Linguagem: Inglês

10.4414/smw.2009.12661

0036-7672

Lucia Mazzolai,

Acute Myocardial Infarction Research

Pulmonary embolism (PE) is traditionally treated in hospital.Growing evidence from non randomized prospective studies suggests that a substantial proportion of patients with non-massive PE might be safely treated in the outpatient setting using low molecular weight heparins.Based on this evidence, professional societies started to recommend outpatient care for selected patients with non-massive PE.Despite these recommendations, outpatient treatment of non-massive PE appears to be uncommon in clinical practice.The major barriers to PE outpatient care are, firstly, the uncertainty as how to identify low risk patients with PE who are candidates for outpatient care and secondly the lack of high quality evidence from randomized trials demonstrating the safety of PE outpatient care compared to tradi-tional inpatient management.Also, although clinical prognostic models, echocardiography and cardiac biomarkers accurately identify low risk patients with PE in prospective studies, the benefit of risk stratification strategies based on these instruments should be demonstrated in prospective management studies and clinical trials before they can be implemented as decision aids to guide PE outpatient treatment.Before high quality evidence documenting the safety of an outpatient treatment approach is published, outpatient management of non-massive PE cannot be generally recommended. Key words: pulmonary embolism; prognosis; outpatient treatmentCardiology guidelines suggested considering low risk patients with PE, i.e., those without principal PE-related risk factors, for early discharge if proper outpatient care and anticoagulant treatment can be provided.[9] It has been estimated that up to 50% of patients with PE could be safely treated in an outpatient setting.[10] Kovacs 2000 [43] 81 Active bleeding or high bleeding risk, low compliance, renal failure, Dalteparin 200 IU/kg sc VTE recurrence: 6.2% haemodynamic instability, requirement of oxygen, severe pain requiring once daily Major bleeding: 1.2% parenteral narcotics, or hospitalisation necessary for other reasons Overall mortality: 4.9% Beer 2003 [44] 43 Geneva Prognostic Score >2, contraindication to anticoagulants, Nadroparin 171 IU/kg sc VTE recurrence: 2.3% drug addiction, non-compliance, psychiatric conditions, body once daily Major bleeding: 0% weight >110/kg, renal failure, thrombocytopenia, concomitant Overall mortality: 0% thrombolysis, prior treatment with oral anticoagulants, or patients presenting on weekends Wells 2005 [45] 90 Active bleeding or high bleeding risk, no fixed address, history Dalteparin 200 IU/kg VTE recurrence: 2.2% of heparin-induced thrombocytopenia, renal failure, arterial or Tinzaparin 175 U/kg sc Major bleeding: 0% hypotension, hypoxaemia, severe pain requiring intravenous analgesia, once daily Overall mortality: 3.3% or hospitalisation necessary for other reasons Siragusa 2005* [46] 32 Poor clinical condition, other illness requiring hospitalisation, Unspecified low-molecular-VTE recurrence: 5.6% poor compliance, active bleeding or high bleeding risk, renal failure, weight heparin sc once or Major bleeding: 2.8% acute anaemia, or pain requiring parenteral narcotics twice daily.Overall mortality: 30.6%Olsson 2006 [16] 100 Extensive PE based on lung scintigraphy or other reasons necessitating Tinzaparin 175 U/kg sc VTE recurrence: 0% hospitalisation (e.g., intensive pain, status post surgery, active bleeding) once daily in a patient hotel Major bleeding: 0% close to the hospital Overall mortality: 0% Davies 2007 [47] 156 Admission necessary for other medical reason, additional monitoring Tinzaparin 175 U/kg sc VTE recurrence: 0% required, history of prior PE, concomitant major DVT, bleeding once daily Major bleeding: 0% disorders or active bleeding, poor compliance, or patient preference Overall mortality: 0% VTE = venous thromboembolism; PE = pulmonary embolism; DVT = deep vein thrombosis.*Study enrolled patients with cancer only.