The British Thoracic Society recommend that pulmonary embolism (PE) patients with low-risk Pulmonary Embolism Severity Index (PESI) scores are considered for outpatient (OP) management, in settings where robust pathways for follow-up and monitoring exist.
Methods:
Retrospective cohort study. We reviewed the electronic records of 109 consecutive PE patients considered appropriate for OP management. Primary outcomes were the incidence of recurrent venous thromboembolism, major bleeding, mortality at 1 year and evidence of chronic thromboembolic pulmonary hypertension (CTEPH).
Results:
Low-risk PESI scores (I–II) were recorded in 78 (72%) patients, with higher scores a consequence of age and comorbidity rather than haemodynamic instability. There was a low rate of adverse outcomes despite a lack of formal follow up for most patients. There was no evidence of CTEPH in 34 patients who underwent echocardiography.
Conclusion:
Our analysis challenges the need for robust follow-up pathways for all patients with pulmonary embolism.
EldredgeJSpyropoulosAC.Direct oral anticoagulants in the treatment of pulmonary embolism. Curr Med Res Opin2018; 34(1): 131–40.
4.
HowardLSBardenSCondliffeR, et al. British Thoracic Society Guideline for the initial outpatient management of pulmonary embolism (PE). Thorax2018; 73(Suppl 2): ii1–29.
5.
NICE guideline 158. Venous thromboembolic diseases: diagnosis, management and thrombophilia testing, www.nice.org.uk/guidance/ng158 (2020, accessed 2 August 2023).
6.
KonstantinidesSVMeyerGBecattiniC, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Respir J2019; 54: 1901647.
7.
KlokFAAgenoWAyC, et al. Optimal follow-up after acute pulmonary embolism: a position paper of the European Society of Cardiology Working Group on Pulmonary Circulation and Right Ventricular Function, in collaboration with the European Society of Cardiology Working Group on Atherosclerosis and Vascular Biology, endorsed by the European Respiratory Society. Eur Heart J2022; 43(3): 183–9.
8.
TagalakisVPatenaudeVKahnSR, et al. Incidence of and mortality from venous thromboembolism in a real-world population: the Q-VTE Study Cohort. Am J Med2013; 126(9): 832–e13
9.
RobertsonLKestevenPMcCaslinJE.Oral direct thrombin inhibitors or oral factor Xa inhibitors for the treatment of pulmonary embolism. Cochrane Database Syst Rev2023; 4: CD010957.
10.
MooresLZamarroCGomezV, et alon behalf of the Instituto Ramo ́n y Cajal de Investigacio ́n Sanitaria Pulmonary Embolism Study Group. Changes in PESI scores predict mortality in intermediate-risk patients with acute pulmonary embolism. Eur Respir J2013; 41: 354–9.
11.
ReschenMERabyJBowenJ, et al. A retrospective analysis of outcomes in low- and intermediate-high-risk pulmonary embolism patients managed on an ambulatory medical unit in the UK. ERJ Open Res. 2019; 5(2): 00184-2018.
12.
LutseyPLWalkerRFMaclehoseRF, et al. Inpatient versus outpatient acute venous thromboembolism management: trends and postacute healthcare utilization from 2011 to 2018. J Am Heart Assoc2021; 10: e020428.
13.
EichingerSWeltermannAMinarE, et al. Symptomatic pulmonary embolism and the risk of recurrent venous thromboembolism. Arch Intern Med. 2004; 164(1): 92–6.
14.
HwangHGChoiWILeeB, et al. Incidence and Risk Factors of Recurrent Venous Thromboembolism after Pulmonary Embolism. Tuberc Respir Dis2019; 82(4): 341–7.
15.
KhanFRahmanACarrierM, et alfor the MARVELOUS Collaborators. Long term risk of symptomatic recurrent venous thromboembolism after discontinuation of anticoagulant treatment for first unprovoked venous thromboembolism event: systematic review and meta-analysis. BMJ2019; 366: l4363.
16.
Ende-VerhaarYMCannegieterSCVonk NoordegraafA, et al. Incidence of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism: a contemporary view of the published literature. Eur Respir J. 2017; 49(2): 1601792.
17.
DurringtonCHurdmanJAElliotCA, et al. Systematic pulmonary embolism follow-up increases diagnostic rates of chronic thromboembolic pulmonary hypertension and identifies less severe disease: results from the ASPIRE Registry. Eur Respir J. 2024; 63(3): 2300846.
18.
HowardLSPriceLC.Systematic pulmonary embolism follow-up: why we should all do it!Eur Respir J. 2024; 63(3): 2400253.
19.
SistaAKKlokFA.Late outcomes of pulmonary embolism: the post-PE syndrome. Thromb Res2018; 164: 157–62.
20.
KahnSRHirschAMAkaberiA, et al. Functional and exercise limitations after a first episode of pulmonary embolism: results of the ELOPE prospective cohort study. Chest. 2017; 151(5): 1058–68.
21.
JervanØHaukeland-ParkerSGleditschJ, et al. The effects of exercise training in patients with persistent dyspnea following pulmonary embolism: a randomized controlled trial. Chest. 2023; 164(4): 981–91.
22.
WestaferLMShiebM-SPekowPS, et al. Outpatient Management of Patients Following Diagnosis of Acute Pulmonary Embolism. Acad Emerg Med2021; 28: 336–45.
23.
Directory of Ambulatory Emergency Care for Adults. The Ambulatory Emergency Care Network, www.ambulatoryemergencycare.org.uk (2018, accessed September 2024).
24.
MohrKKeelingBKaierK, et al. Modelling costs of interventional pulmonary embolism treatment: implications of US trends for a European healthcare system. Eur Heart J Acute Cardiovasc Care. 2024; 13(6): 501–5.
25.
AgwanSMansourINedunchezhianI, et al. Audit of clinical follow-up and complications after acute pulmonary embolism in an Australian Metropolitan Health Service. Intern Med J. 2023; 53(5): 850–3.
