Hospitalization or Outpatient Treatment for Acute Pulmonary Embolism - a Retrospective Cohort Study of 439 Consecutive Patients with Community-Aquired Pulmonary Embolism

• Published in: Blood Vol. 120; no. 21; p. 3416
• Main Authors: Werth, Sebastian, Kamvissi, Virginia, Kuhlisch, Eberhard, Beyer-Westendorf, Jan
• Format: Journal Article
• Language: English
• Published: Elsevier Inc 16.11.2012
• ISSN: 0006-4971; 1528-0020
• DOI: 10.1182/blood.V120.21.3416.3416

Abstract 3416 Therapy of pulmonary embolism (PE) today is based on risk stratification scores. Outpatient treatment for selected low-risk patients seems feasible, but data are derived from selected patient cohorts. Little is known about risk factors or clinical outcomes in unselected cohorts. In our hospital, outpatient treatment of low-risk-PE has been standard for nearly ten years. We retrospectively analyzed risk profile and 6-month-outcome of in-hospital or outpatient treatment in patients with community-aquired acute PE (CA-PE). To evaluate the proportion of patients with outpatient or early discharge treatment of CA-PE, to evaluate the value of HESTIA score to discriminate between low and high risk patients and to assess 6-month outcome. Retrospective evaluation of all cases with CA-PE. Inclusion criteria: 1) PE symptoms as reason for hospitalization (exclusion of hospital-aquired PE); 2) symptomatic and confirmed PE (CT or V/Q scan). Evaluation of patient characteristics, hemodynamic and echocardiographic parameters and lab values and group comparisons between outpatient treatment (OT; hospitalized < 24h), early discharge (ED; hospitalized < 72h) and in-hospital treatment (HT) were performed. Between 2000 and 2010, 439 patients were diagnosed with acute CA-PE (table 1). About 25% of patients could be treated as outpatients (n=49; 11.2%) or early discharged (n=63; 14.4%). Patients with in-hospital treatment of PE were significantly older and had more severe PE. Interestingly, the rate of patients with a positive history of VTE was highest in the group of outpatients (45%), followed by the early-discharge group (32%), indicating that these patients are diagnosed at an earlier stage with less severe PE. In contrast, only 25% of patients requiring in-hospital treatment of PE had a positive VTE history.Table 1Patient characteristics and clinical presentation of PE patients; OT = outpatient; ED = early discharge; HT = in-hospital treatmentcriteriaOT, n= 49 mean±SDED; n=63 mean±SDHT; n=327 mean±SDp-value OT vs EDp-value ED vs HTp-value OT vs HTp-value OT/ED vs HTp-value OT vs. ED/HTs HAge (y)57.3±16.957.9±14.766.8±16.40.98<0.001<0.001<0.0010.003RR sys (mmHg)143.2±21.1134.1±23.4135.1±24.70.170.960.120.660.08RR dia (mmHg)87.1±18.878.2±13.577.4±12.80.0050.91<0.0010.01<0.001HF (bpm)79.1±11.888.1±18.793.2±21.10.010.19<0.001<0.001<0.001OT, n= 49%ED; n=63%HT; n=327%History of VTE44.9%31.7%24.8%0.450.750.010.020.01Troponin >2.0%33.3%61.8%<0.001<0.001<0.001<0.001<0.001Oxygen supplementation2.0 %20.6%38.2%0.180.0050.005<0.0010.001Right ventricular dysfunction10.2 %14.3%39.1%1.00<0.0010.006<0.0010.01High risk PE (ESC-Score)0.0%6.3%12.8%0.270.001<0.001<0.001<0.001HESTIA-Score > 012.2%47.6%78.0%<0.001<0.001<0.001<0.001<0.001 Despite the differences in baseline characteristics, outcomes with regard to recurrent VTE, pulmonary hypertension or mortality were not significantly different between outpatients and early discharge patients. In contrast, outcomes of patients with in-hospital treatment was significantly different with higher mortality (0.0% vs. 3.2% vs. 15.8%).Table 26-month outcomescriteriaOT, n= 49 mean±SDED; n=63 mean±SDHT; n=327 mean±SDp-value OT vs EDp-value ED vs HTp-value OT vs HTp-value OT/ED vs HTp-value OT vs. ED/HTs HRecurrent VTE at 6 month3 (6.1%)3 (4.8%)11 (3.4%)1.01.01.00.790.84Pulmonary hypertension at 6 month3 (6.1%)3 (4.8%)17 (5.2%)1.01.01.01.01.0Death at 6 month0 (0.0%)2 (3.2%)45 (15.8%)1.00.050.02<0.0010.02 Even before ESC and Hestia scores were implemented, physicians subjective assessment based on hemodynamic, echocardiographic and laboratory parameters clearly discriminated between low, intermediate and high risk PE patients and allowed for outpatient treatment in low-risk PE in 11% of all PE patients. Early discharge was possible in 14% of all patients, despite higher HESTIA scores and a higher rate of elevated troponin levels, initial oxygen requirement or right heart strain in echocardiography. In contrast, patients requiring in-hospital PE treatment were older, had more severe PE and a high 6-month mortality. Despite a positive Hestia score in many patients, about 25% of all community-aquired PE patients can be safely treated as outpatient or early discharge treatment with low 6-month mortality. No relevant conflicts of interest to declare.