Regular ArticleOutpatient treatment of symptomatic pulmonary embolism: A systematic review and meta-analysis☆
Introduction
Patients with acute deep vein thrombus (DVT) can safely be treated as outpatients [1], [2], [3], [4]. Outpatient treatment of DVT is recommended with grade 1B evidence in the most recent American College of Chest Physicians (ACCP) guidelines [5]. However the ACCP guidelines and other scientific societies have not firmly recommended outpatient therapy for patients with low-risk acute pulmonary embolism (PE) [5], [6]. Clinicians appear reluctant to discharge PE patients due to a perceived lack of high quality data regarding both appropriate patient selection and outcomes with home treatment [7].
Several studies have reported that outpatient management or early discharge of patients with acute PE is safe and effective [8], [9], [10], [11], [12], [13]. Two systematic reviews suggested that patients with acute PE treated as outpatients had low incidences of major bleeding, recurrent venous thromboembolism (VTE), and mortality [14], [15]. However the quality of the included studies was low and subsequent and recent larger observational studies and randomized control trials were not included [8], [11], [16], [17]. More recently, two additional systematic reviews of the outpatient management of acute symptomatic PE were published [18], [19]. However the first review did not include studies of patients with acute PE managed with early discharge and did not perform a meta-analysis [18]. The last review included both retrospective and prospective studies which lower the overall quality of evidence from which the event rates are derived [7], [19].
In this systematic review and meta-analysis we sought to determine the feasibility and safety of outpatient treatment (including early discharge). Furthermore, we attempted to compare the outcome event rates when risk stratification models are applied versus using clinical gestalt to select appropriate patients for outpatient management. Finally, short-term (< 14 days) outcome event rates were evaluated.
Section snippets
Search Strategy
We conducted a systematic literature search to identify potential studies on MEDLINE (1950 to week 4 of June 2012), EMBASE (1980 to end of June 2012), the Cochrane Central Register of Controlled Trials, and all evidence-based medicine reviews (e-Table 1 – online). We also sought publications through a hand-search of potentially relevant journals and International Society of Thrombosis and Haemostasis conference proceedings (2003-2011). We also reviewed the references of included studies and
Results
We identified 1564 citations in our literature search and 16 articles were found to be potentially eligible (Appendix Fig. 1 – online). Five of these articles were then excluded. Three articles because the outcome measures were not reported specifically for patients with acute PE [26], [27], [28] and two because patients had not been managed as outpatients [29], [30]. The remaining 11 studies were included in our systematic review. Eight were prospective cohort studies [8], [11], [12], [13],
Discussion
The results of our systematic review suggest that the short term and long-term (up to 3 months) rates of adverse outcomes are low and patients with low-risk acute symptomatic PE can safely be treated at home. Furthermore, both clinical gestalt and risk stratification models appear to be able to effectively and safely identify low risk patients with acute PE that can be managed as outpatients.
The risk of recurrent VTE, major bleeding episodes and overall mortality after 3 months of follow-up were
Conflict of Interest
All authors have fulfilled the conditions required for authorship and the authors report no potential conflicts of interest.
Funding
Grant Support: SP is a recipient of an American Society of Hematology Trainee Research Award. MC is a recipient of a New Investigator Award from the Heart and Stroke Foundation of Canada. MR is the recipient of a Career Scientist Award from the Heart and Stroke Foundation of Ontario. PW is a recipient of a Canada Research Chair in Venous Thromboembolism.
Acknowledgements
Authorship
MC and SP designed the study, performed research, collected, analyzed and interpreted data, performed statistical analysis and wrote the manuscript; GL collected, analyzed, and interpreted data, performed statistical analysis and wrote the manuscript; MR analyzed and interpreted the data, performed statistical analysis and wrote the manuscript; PW, MAR and EG analyzed and interpreted the data and provided vital reviews to the manuscript.
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The research was mainly carried out at The Ottawa Hospital, 501 Smyth Road Ottawa, ON K1H 8L6 Marc Carrier MD, MSc, FRCPC.