ERJ
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Permissions
Right arrowRequest Permissions
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Otero, R.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Otero, R.
Eur Respir J 2008; 31:686-687
Copyright ©ERS Journals Ltd 2008

Pulmonary embolism at home

R. Otero1, D. Jiménez2 on behalf of the Cooperative Study for the Ambulatory Treatment of Patients with Pulmonary Embolism Research Study Group

1 Pneumology Dept, Virgen del Rocío Hospital, Seville, and 2 Pneumology Dept, Ramón y Cajal Hospital, Madrid, Spain.

To the Editors:

We wish to express serious concern about an article in a recent issue of the European Respiratory Journal, in which Davies et al. 1 reported on an outpatient treatment study in patients with acute pulmonary embolism (PE). In this study 1, the authors identified criteria for the safe discharge of PE patients, and these criteria were validated in a series of 157 patients with confirmed PE. At the end of acute low-molecular-weight heparin treatment, there were no in-hospital adverse events (thromboembolic recurrences, bleeding complications or deaths).

First, some variables that have been associated with prognosis in patients with PE were not considered by the clinicians responsible for patient care. Data from large observational studies of PE have confirmed systolic arterial hypotension as the most significant prognostic indicator of outcome in PE patients 2, 3, but this was not an explicit exclusion criterion in the study of Davies et al. 1. Conversely, deep venous thrombosis has been associated with prognosis in one study 4, but not in another 5.

Secondly, the number of adverse events in both phases of the study was extremely low as compared with any treatment trial 6 or PE registry 3. For example, the 30-day mortality rate of the PE severity index low risk strata has ranged from 1.4 7 to 3.1% 8.

The present authors validated this score in a prospective series of 805 consecutive patients with an objective diagnosis of acute symptomatic PE. Of these, 350 patients were excluded due to the presence of proximal deep venous thrombosis. Additional patients were excluded due to active bleeding (n = 19), previous PE (n = 44), hypotension (n = 17), hypoxaemia (n = 162), chronic obstructive pulmonary disease (n = 9), congestive heart failure (n = 8) and haemodynamic instability (n = 6). The prevalence of adverse events during the first 10 days of treatment in the remaining 190 (24%) patients is shown in table 1Go.


View this table:
[in this window]
[in a new window]

  		Table 1— Prevalence of adverse events during the first 10 days after diagnosis

 
We share the idea that a highly selected group of pulmonary embolism patients could be treated at home. However, data from the literature cause us to exercise caution when interpreting the results of this study 1. We are concerned that an excessively optimistic message diverges from the complex reality of pulmonary embolism patients.

Statement of interest

None declared.

REFERENCES

  1. Davies CW, Wimperis J, Green ES, et al. Early discharge of patients with pulmonary embolism: a two-phase observational study. Eur Respir J 2007;30:708–714.[Abstract/Free Full Text]
  2. Konstantinides S, Geibel A, Olschewski M, et al. Association between thrombolytic treatment and the prognosis of hemodynamically stable patients with major pulmonary embolism: results of multicenter registry. Circulation 1997;96:882–888.[Abstract/Free Full Text]
  3. Goldhaber SZ, Visana L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 1999;353:1386–1389.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
  4. Wicki J, Perrier A, Perneger TV, Bounameaux H, Junod AF. Predicting adverse outcome in patients with acute pulmonary embolism: a risk score. Thromb Haemost 2000;84:548–552.[Web of Science][Medline] [Order article via Infotrieve]
  5. Girard P, Sanchez O, Leroyer C, et al. Deep venous thrombosis in patients with acute pulmonary embolism: prevalence, risk factors, and clinical significance. Chest 2005;128:1593–1600.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
  6. Koopman MM, Prandoni P, Piovella F, et al. Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcutaneous low-molecular-weight heparin administered at home. The Tasman Study Group. N Engl J Med 1996;334:682–687.[Abstract/Free Full Text]
  7. Jiménez D, Yusen RD, Otero R, et al. Prognostic models for selecting patients with acute pulmonary embolism for initial outpatient therapy. Chest 2007;132:24–30.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
  8. Aujesky D, Obrosky DS, Stone RA, et al. Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med 2005;172:1041–1046.[Abstract/Free Full Text]




This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Permissions
Right arrowRequest Permissions
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Otero, R.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Otero, R.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS