Supporting the treatment of patients with low-risk pulmonary embolism at home
Patient case: Helping patients return home
- Susan, aged 38 years, recently presented with an acute pulmonary embolism (PE) in hospital
- She is a young, active mother of two who regularly takes long flights for her hectic job and lifestyle. She lives with her stay-at-home husband in a busy city
- She is an occasional smoker and has a family history of venous thromboembolism (VTE)
- Susan was initially treated with rivaroxaban in the emergency department and remained in hospital overnight; she doesn’t want to be in hospital for much longer and is asking whether she can go home
Why treat patients with low-risk PE at home?
Acute PE is a feared clinical presentation of VTE and is a frequent cause of cardiovascular mortality worldwide. However, PE is characterized by a wide spectrum of severity and there are many benefits to adopting the appropriate management strategy for patients depending on risk.1,2
Treating patients with low-risk PE at home has the potential to reduce the burden on healthcare systems associated with treatment in hospital, minimize complications related to hospitalization such as infection and improve patient satisfaction.2-4
Data suggests that 30–55% of patients with PE who are at low mortality risk may be suitable for early discharge and home treatment.3 A recent database analysis demonstrated that only 6% of patients with stable PE across the United States who were not on shock or ventilator support were treated at home. This is a surprisingly low number given that these patients were stable and suggests that the hospital burden of PE remains unnecessarily high.5
Home treatment is underused in patients with stable PE without shock or ventilator support5
In a prospective management study, 89% of patients with low risk-PE indicated a preference for home treatment again if experiencing a PE in the future.4
This shows that Susan is not alone in her preference for home treatment of PE.
What do the guidelines for PE say about home treatment?
The 2016 CHEST and 2019 European Society of Cardiology (ESC) guidelines recommend early discharge and home treatment for carefully selected patients with low-risk PE with adequate home circumstances and proper outpatient care with anticoagulants.6,7
ESC Guidelines for the management of acute PE7
The PE Severity Index (PESI) and Hestia criteria are clinical prognostic tools that take into account clinical characteristics such as haemodynamic instability, history of heart failure, bleeding risk and renal or liver impairment to distinguish patients with low-risk PE. Furthermore, prognostic sensitivity is increased when these clinical criteria are combined with an absence of right ventricular dysfunction.6,7 This has allowed for evolving and tailored management strategies for treating this select group of patients.
Non-vitamin K antagonist oral anticoagulants (NOACs) are becoming the standard of care for the treatment of acute PE and are recommended in the CHEST and ESC guidelines as the first choice for anticoagulation treatment in eligible patients (without cancer) over vitamin K antagonists or low molecular weight heparin.6,7
Rivaroxaban and apixaban are NOACs that can be administered as a single oral drug regimen, removing the need for parenteral care and allowing patients to adhere to a simple regimen suitable for home treatment.1,2,6 Available data demonstrating the feasibility and safety for the treatment of patients with low-risk PE at home using rivaroxaban was shown in the HoT-PE study (see information box).1,7
The HoT-PE study
HoT-PE was a phase IV, prospective management study, which demonstrated that early discharge and outpatient treatment with rivaroxaban is feasible, effective and safe in patients with acute, low-risk PE. Rivaroxaban was dosed at 15 mg twice daily for 21 days followed by 20 mg once daily for ≥3 months.1,8
The rate of symptomatic recurrent VTE or fatal PE within 3 months was 0.6%, thus permitting the early termination of the study based on the efficacy of this regimen.
These results support the selection of appropriate patients with PE for treatment at home with a NOAC and offers the potential to reduce hospital-related complications and rationalize the use of healthcare resources.1
Incidence of recurrent VTE or fatal PE in patients with acute low-risk PE treated at home with rivaroxaban1
Summary
Could Susan be discharged?
Susan is a low-risk PE patient based on the PESI and Hestia criteria, and there are no concerns about the social or practical aspects of home treatment. Therefore, the ESC guidelines for the management of acute PE recommend home treatment.7
Alongside the impact that home treatment might have on Susan’s quality of life, and the reduced burden on healthcare systems, suggests this may be a very effective approach.
If there was any previous uncertainty on how you would respond to Susan’s request, recent guidelines and clinical evidence for the treatment of patients with low-risk PE provide reassurances on the feasibility of effective and safe treatment at home.
References
- Barco S, Schmidtmann I, Ageno W et al. Early discharge and home treatment of patients with low-risk pulmonary embolism with the oral factor Xa inhibitor rivaroxaban: an international multicentre single-arm clinical trial. Eur Heart J 2019: doi:10.1093/eurheartj/ehz367. Return to content
- Peacock WF, Singer AJ. Reducing the hospital burden associated with the treatment of pulmonary embolism. J Thromb Haemost. 2019;17(5):720–36. Return to content
- Wang L, Baser O, Wells P, Peacock WF, Coleman CI, Fermann GJ, et al. Benefit of early discharge among patients with low-risk pulmonary embolism. PLoS One. 2017;12(10):e0185022. Return to content
- Bledsoe JR, Woller SC, Stevens SM et al. Management of low-risk pulmonary embolism patients without hospitalization: the Low-Risk Pulmonary Embolism prospective management study. Chest 2018;154:249–256. Return to content
- Stein PD, Matta F, Hughes MJ. National trends in home treatment of acute pulmonary embolism. Clin Appl Thromb Hemost. 2018;24(1):115–21. Return to content
- Kearon C., Akl E.A., Ornelas J. et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest 2016;149(2):315-52. Return to content
- Konstantinides SV, Meyer G, Becattini C et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2020;41:543–603. Return to content
- Bayer AG. Summary of Product Characteristics. Berlin: Germany. Return to content
See Also
Managing anticoagulation during the COVID-19 pandemic
See Also
Keeping it simple: Single drug approaches to VTE treatment
See Also
Time for a change? Switching anticoagulants in patients with AF or VTE
See Also
The importance of real-world evidence: A look at stroke prevention in atrial fibrillation
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Updated date 10/10/2022
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