Can selected patients with newly diagnosed pulmonary embolism be safely treated without hospitalization? A systematic review

Abstract

Study objective: Omitting inpatient therapy for emergency department patients with newly diagnosed pulmonary embolism occurs infrequently in the United States. We seek to describe the safety of initial outpatient management of these patients and their demographics, comorbidities, risk stratification, treatment, and outcomes.

Methods: We identified studies from searches of MEDLINE, EMBASE, and other databases from inception through March 22, 2012. We supplemented this with a search of conference proceedings and consultation with experts. We selected prospective studies of adults with acute, symptomatic, objectively confirmed pulmonary embolism who were discharged home without hospitalization. All contributing studies explicitly defined inclusion and exclusion criteria plus objectively confirmed outcome measures: recurrent thromboembolism, major hemorrhage, and mortality. Two investigators independently identified eligible studies and extracted data. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria to assess study quality.

Results: From 2,286 screened titles/abstracts, we selected 8 studies with a total of 777 patients. Seven observational studies were rated low in quality. The one randomized controlled trial was higher in quality, used stricter inclusion criteria, and found that 90-day outcomes for outpatient management were not inferior to inpatient care. Among the 7 studies that reported 90-day outcome measures, the overall incidence of venous thromboembolic-related and hemorrhage-related mortality was very low: 0 of 741 (upper 95% confidence limit 0.62%).

Conclusion: The data on exclusive outpatient management of acute symptomatic pulmonary embolism are limited, but the existing evidence supports the feasibility and safety of this approach in carefully selected low-risk patients.