British Thoracic Society Guideline for the Initial Outpatient Management of Pulmonary Embolism

Overview

This Guidelines summary presents the recommendations and good practice points of the British Thoracic Society guideline for the initial outpatient management of pulmonary embolism. Please refer to the full guideline for the key to evidence statements and grades of recommendations. 

Outcomes of Outpatient Care for Low-risk Pulmonary Embolism

Recommendations

• Patients with pulmonary embolism (PE) should be assessed for suitability for management as outpatients (OPs) (Grade B)
• Patients assessed as low risk and suitable for OP management should be offered treatment in an OP setting where a robust pathway exists for follow-up and monitoring (Grade B)

Inclusion and Exclusion Criteria for OP Management or Early Discharge

Recommendations

• Patients with confirmed PE should be risk-stratified using a validated clinical risk score (Grade B)
• Patients in Pulmonary Embolism Severity Index (PESI) class I/II, simplified version of the PESI (sPESI) 0 or meeting the Hestia criteria should be considered for OP management of PE (Grade B)
• Where PESI or sPESI is used and indicates a low risk, a set of exclusion criteria should be applied to patients being considered for outpatient management of confirmed PE. (Grade B) Exclusion criteria include:
  • haemodynamic instability (HR>110 bpm; systolic blood pressure (SBP)<100 mmHg; requirement for inotropes and critical care; requirement for thrombolysis or embolectomy)
  • oxygen saturations <90% on air
  • active bleeding or risk of major bleeding (e.g. recent gastrointestinal [GI] bleed or surgery, previous intracranial bleeding, uncontrolled hypertension)
  • on full-dose anticoagulation at the time of the PE
  • severe pain (e.g. requiring opiates)
  • other medical comorbidities requiring hospital admission
  • chronic kidney disease (CKD) stages 4 or 5 (estimated glomerular filtration rate [eGFR]<30 ml/min) or severe liver disease
  • heparin-induced thrombocytopenia within the last year and where there is no alternative to repeating heparin treatment
  • social reasons which may include inability to return home, inadequate care at home, lack of telephone communication, concerns over compliance, etc
• No specific assessment of bleeding risk is required in patients who are deemed low risk by PESI/sPESI/Hestia criteria (Grade B)
• Measurement of right ventricular (RV):left ventricular (LV) ratio on CT or assessment of RV function on echocardiography is not obligatory for the identification of low-risk patients for OP management (Grade C)
• Where RV dilatation has been identified on CT scanning or echocardiography in patients who are suitable for OP management, consider measuring laboratory cardiac biomarkers (B-type natriuretic peptide (BNP), N-terminal pro B-type natriuretic peptide (NT-proBNP), high-sensitivity troponin I or T [hsTnI or hsTnT]). Normal values may be used to identify low-risk patients; elevated biomarkers in this context should prompt inpatient (IP) admission for observation (Grade C)

Good Practice Point

• In the context of low-risk PE and an incidental finding of elevated troponin, senior review is required and alternative causes for troponin release should be considered 

Management of Patients With Suspected PE, Where a Diagnosis Has Yet to be Confirmed

Recommendation

• Patients with suspected PE should, where reasonably practical, undergo investigation on the same day of presentation to exclude a diagnosis of PE. An alternative strategy of anticoagulation followed by OP imaging within 24 hours may be considered in patients with suspected PE, who have been deemed low risk and eligible for OP care as per confirmed PE. Robust systems should be in place to facilitate next day investigation and review (Grade D)

Treatment of Suspected/Confirmed PE in the OP Setting

Recommendations

• Patients with confirmed PE being treated in the OP setting should be offered treatment with either low molecular weight heparin (LMWH) and dabigatran, LMWH and edoxaban or a single-drug regimen (apixaban or rivaroxaban) (Grade A)
• Patients with suspected PE being treated in the OP setting may be treated with apixaban or rivaroxaban pending diagnosis as an alternative to LMWH (Grade D)

Good Practice Point

• Using a single direct oral anticoagulant (DOAC) in a pathway is preferred to minimise potential confusion over dosing and administration

Assessing Patients Transitioning from Inpatient Care to Early Discharge/OP Care

Recommendation

• Patients who have been admitted with an intermediate risk PE (PESI class III) can be considered for early discharge when they meet the criteria for low risk (PESI class I/II or sPESI score 0) (Grade C)

Good Practice Points

• Those with PESI48 class III or sPESI48 score of >0 are considered to be at higher risk of adverse outcome and senior review is necessary prior to discharge; PESI and sPESI may remain elevated due to non-reversible factors (e.g., cancer, age) which should be taken into consideration when using clinical judgement 
• Consideration should be given to repeating assessment of RV function with echocardiography or biomarkers in those admitted with RV dysfunction or biomarker elevation at baseline

Level of Seniority of Review

Good Practice Points

• Patients with confirmed or suspected PE should be reviewed by a consultant prior to discharge on an OP PE pathway. If no consultant is available, then patients may be reviewed by a senior trainee (ST3 or above; ST4 in the case of Emergency Medicine) by a staff or similar substantive career grade doctor, advanced nurse practitioner or clinical nurse specialist designated to undertake this role within the department with consultant advice available 
• If patients are on an OP pathway for suspected PE and being considered for discharge and scanning the following day, a local protocol should be in place to guide a full cardiorespiratory assessment to exclude other causes for symptoms (including full history, examination, ECG, and chest radiograph), including risk assessment

Follow-up of Patients Specific to Those Managed in the OP Setting

Recommendations

• Patients with confirmed PE who are eligible for OP care should be provided with verbal and written information on the signs and symptoms of recurrence, major bleeding and additional complications. Individual centres should also provide an appropriate point of contact in the event of complications or concerns, both in and out of hours (Grade B)
• Patients should have a formal review (telephone/face to face) at least once during the first week after discharge to ensure therapeutic compliance along with the absence of complications (Grade B)
• Hospitals should have local protocols and pathways in place for follow-up of all patients with PE, whether treated as an IP or OP. This should include assessment of ongoing symptoms (with further directed investigation as appropriate) and consideration of optimal duration/modality of anticoagulation (Grade D)

Good Practice Points

• Consider initial assessment of provoking risk factors for the index PE at an early stage, for example, immobility, surgery, cancer, intercurrent illness, etc, since this will determine duration of anticoagulation. Screening policies for malignancy are out of scope for this guideline, but when screening investigations are performed, a mechanism should be in place to review results within a prompt time frame
• Follow-up of PE should be performed by clinicians with a special interest in venous thromboembolism (VTE)

Management of PE in the OP Setting in Specific Circumstances

Pregnancy/Puerperium

• All pregnant and postpartum women presenting with suspected PE or confirmed PE should be reviewed by a consultant and discussed with maternity services prior to discharge
• OP care pathways may be considered for suspected or confirmed PE in pregnancy and/or the postpartum period
• Clinical risk scores derived for non-pregnant patients, such as PESI/sPESI, should not be used in pregnant women
• DOACs or vitamin K antagonists (VKAs) should not be used in pregnant patients with suspected or proven PE

Cancer

Recommendation

• The Hestia criteria may be used to evaluate patients with active cancer for suitability for OP management of PE (Grade D)

Good Practice Points

• Patients with active cancer should be reviewed by a consultant prior to discharge given the higher risk of 30-day mortality
• Patients with incidental PE should be managed in the same way with respect to OP management as those with symptomatic PE

Good Practice Point

• Intravenous drug abusers with suspected PE should be admitted for further investigation and management

Patient Information and Support Needs

Recommendation

• Written patient information and education should be integral to OP PE pathways (Grade D)

Good Practice Point

• Succinct written information should be provided to the patient on discharge, using non-technical language and including telephone numbers/email addresses for advice on dealing with any subsequent changes in the patient’s condition. An example, from Sheffield Teaching Hospitals, is included in online supplementary web appendix 3. The information material produced by the thrombosis charity Thrombosis UK (www.thrombosisuk.org) may also prove helpful.