Is it safe to send someone home with a low-risk PE on a rivaroxaban or apixaban?
This systematic
review identified 12 studies (four RCT’s and 8 prospective cohort
studies) that might provide us the answer. Of course, the foundation author is
Jeff Kline.
Patients
were mostly categorized as “low risk” by using the HESTIA, PESI, or sPESI
scores. (I personally like the HESTIA
score as it has face validity and seems to send a lot of patients home.)
1,814 patients were included in this systematic
review and they pretty much all did fine. Rates of mortality, recurrent
VTE, and major bleeding was all below 1%.
“There was a
single instance of PE related mortality within 90 days among the 1,814 outpatients
in high quality studies.”
The authors
state they have three main findings.
First, there
are few controlled studies. But to answer the question, I don’t think we need a
control arm. A well conducted cohort study should be fine.
Second, there
were low rates of major adverse outcomes.
Third, there
was no difference in patient outcomes with warfarin or with DOACs. For what it’s
worth, 97% of the DOACs chosen were rivaroxaban.
It appears that
the preponderance of evidence shows that sending low-risk patients home with
oral rivaroxaban is safe.
However, there
is a currently a large
study by Jeff Kline enrolling patients in 33 hospitals in the USA to look
at a protocol for outpatient management of VTE. So of
course, our thoughts could all change.
Covering:
Maughan B,
Frueh L, McDonagh MS, et al. Outpatient Treatment of Low-risk Pulmonary
Embolism in the Era of Direct Oral Anticoagulants: A Systematic Review. Acad
Emerg Med 2021;28:226-239. [Link to
article]