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.
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]