Skip to main content

Main menu

  • Home
  • Current issue
  • ERJ Early View
  • Past issues
  • ERS Guidelines
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • Open access
    • Peer reviewer login
    • WoS Reviewer Recognition Service
  • Alerts
  • Subscriptions
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

User menu

  • Log in
  • Subscribe
  • Contact Us
  • My Cart

Search

  • Advanced search
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

Login

European Respiratory Society

Advanced Search

  • Home
  • Current issue
  • ERJ Early View
  • Past issues
  • ERS Guidelines
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • Open access
    • Peer reviewer login
    • WoS Reviewer Recognition Service
  • Alerts
  • Subscriptions

Early discharge after acute pulmonary embolism: keep quality of life on the radar

Kevin Solverson, Leslie Skeith, Jason Weatherald
European Respiratory Journal 2021 57: 2003811; DOI: 10.1183/13993003.03811-2020
Kevin Solverson
1Division of Respirology, Dept of Medicine, University of Calgary, Calgary, AB, Canada
2Dept of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for Kevin Solverson
Leslie Skeith
3Division of Hematology and Hematological Malignancies, Dept of Medicine, University of Calgary, Calgary, AB, Canada
4Libin Cardiovascular Institute, Calgary, AB, Canada
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Jason Weatherald
1Division of Respirology, Dept of Medicine, University of Calgary, Calgary, AB, Canada
4Libin Cardiovascular Institute, Calgary, AB, Canada
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for Jason Weatherald
  • Article
  • Figures & Data
  • Info & Metrics
  • PDF
Loading

Abstract

Quality of life improves following early discharge for acute PE, but not for all patients. Clinicians need to understand factors affecting quality of life for a given patient and must identify patients needing more support after discharge. https://bit.ly/35dWzgV

Patients with acute pulmonary embolism (PE) present with a spectrum of clinical severity and PE-related outcomes. In recent years, risk stratification based on clinical, biochemical and imaging features has been used to predict the risk of adverse events and determine optimal therapy for patients with PE. The European Society of Cardiology (ESC), in conjunction with the European Respiratory Society (ERS), published recent guidelines for the diagnosis and management of acute PE that support the use of stratification of patients into risk categories to determine the management strategy with an optimal risk–benefit ratio (class I, level B recommendation) [1]. Patients with PE who have haemodynamic instability have the highest risk of mortality and warrant urgent revascularisation. There is a large group of intermediate risk patients who are haemodynamically stable but have other risk features, such as significant tachycardia or right ventricular (RV) dysfunction, for which therapy beyond anticoagulation remains controversial. In contrast, patients who are haemodynamically stable with no high-risk features may be considered for oral anticoagulation and outpatient management [1].

Historically, PE patients were admitted to hospital to monitor for early adverse events and venous thromboembolism (VTE) progression or recurrence. Dating back 20 years ago, cohorts of patients were described to be safely managed as outpatients [2]. Both the Hestia criteria and Pulmonary Embolism Severity Index (PESI) score, including the addition of feasibility criteria for eligibility of outpatient management, have been studied in small clinical trials and cohort studies to assess the safety for early discharge home. The adverse event rate of VTE reoccurrence and PE-related death ranged from 0% to 0.6% [3–5]. The majority of patients in early home discharge studies have used low molecular weight heparin with transition to a vitamin K antagonist, with fewer on a direct oral anticoagulant (DOAC) [3–5].

With the widespread use of DOACs for the treatment of acute PE, outpatient management of low-risk PE patients is appealing, with possible advantages of reduced healthcare costs, decreased hospital complications, and improved patient satisfaction [6, 7]. Health-related quality of life (HRQoL) is known to be impaired in patients after acute PE [8, 9], however, there remains a paucity of data on how early discharge and outpatient management of PE affects HRQoL and patient satisfaction.

In this issue of the European Respiratory Journal, Barco et al. [10] report their findings from a complete analysis of the Home Treatment of Patients with Low-Risk Pulmonary Embolism with the Oral Factor Xa Inhibitor Rivaroxaban (HoT-PE) single arm clinical trial. The HoT-PE study was stopped early after a predefined interim analysis and the present paper includes the additional patients that were enrolled during the interim analysis. The HoT-PE study enrolled a total of 576 patients who met the study definition of low-risk PE, based on Hestia criteria plus no signs of RV dysfunction on computed tomography or echocardiogram. The primary outcome, PE-related mortality or recurrent VTE at 3 months, occurred in three patients (0.5%, one-sided upper 95% CI 1.3%) and all events were non-fatal recurrent PE with the earliest at 7 days post-diagnosis. Major bleeding on rivaroxaban occurred in six patients (1.1%, 95% CI 0.4–2.3%). The 1-year mortality was 2.4% (95% CI 1.3–4.0%), most of which were related to malignancy and none of which were related to PE. The present analysis of the full cohort of 576 did not change the conclusions from those made on the basis of the previously published 525 patients [11], that an early discharge strategy is effective and safe for low-risk PE patients. Among the 576 patients, 551 (88.3%) were admitted to hospital for median of 33 (interquartile range 23–47) h prior to discharge.

The novel results reported in the current issue of the European Respiratory Journal relate to quality of life and its evolution after early discharge for acute PE. The HoT-PE study assessed HRQoL at 3 weeks and 3 months after enrolment using the generic EuroQoL-5D-5L and disease specific PEmb-QoL questionnaires, and patient satisfaction with anticoagulation was assessed using the Anti-Clot Treatment Scale (ACTS). The key findings were that the majority patients have good HRQoL, as defined by over 60% of patients having no complaints using the generic tool EuroQoL-5D-5L, at both time periods. Thus, in addition to being safe, an early discharge strategy is acceptable and does not detrimentally affect quality of life for the majority of patients. Despite the encouraging findings that HRQoL improved in all domains over the 3 month period, an important minority of patients (approximately 10%) still had moderate to severe impairment in the EuroQoL-5D-5L at 3 months [10]. Standard follow-up occurred at 3 months and patients had access to a 24-h emergency telephone number; however, the frequency of unscheduled patient contact was not described; quality of life measures at 3 weeks may be more reflective of transition to outpatient care and frequency of early follow-up rather than impact of hospital discharge itself. Longer term evolution in HRQoL (i.e. over 12 months) is not reported for the HoT-PE study, but others have shown a gradual improvement towards a “normal” HRQoL by 12 months after PE [12].

There are some interesting insights and new questions raised from the HoT-PE study. The radar plot in their figure 1 shows that the most important contributor to the PEmb-QoL score at 3 weeks and 3 months post-PE was “work-related issues”. This domain impairment likely reflects lingering effects of PE and/or treatment, as a short hospital stay (almost half of patients spent two nights in hospital) would likely not contribute to occupational function outwards to 3 months. We hypothesise that a more prolonged hospitalisation for PE management would have further impacted domains within HRQoL, but because there was no comparator arm, this is unknown. Additionally, how soon outpatient follow-up was after hospital discharge in each centre was not described, the timing of which could conceivably impact quality of life in the early days and weeks post-PE.

It is also particularly interesting that PEmb-QoL scores were worse in women, those with elevated body mass index, and patients with cardiopulmonary disease. Male patients are more likely to have persistent, long-term impairment in exercise capacity after acute PE [9], but the reasons for worse HRQoL in women after early discharge are not known. This raises an important question about gender-specific impacts of acute PE and early discharge. Further research is warranted to identify the problems uniquely faced by women, such as how gender roles, family responsibilities, or other sociocultural factors influence HRQoL after an early discharge for acute PE. Patients with obesity or cardiopulmonary disease are known to have worse quality of life after PE [8], and in the HoT-PE study these patients also had worse PEmb-QoL scores at 3 weeks and 3 months [10]. However, since quality of life prior to the diagnosis of acute PE was not recorded for these patients, it is not known whether poor HRQoL after PE simply reflects worse HRQoL in these patients at baseline. Nevertheless, these results suggest that patients with these comorbidities should be identified at the time of discharge to ensure adequate follow-up, care, and for short-term support to be arranged. Older age and cancer diagnosis were not associated with worse quality of life, perhaps because such patients tend to already be well embedded into a supportive outpatient health care network.

There has been increasing interest in evaluating quality of life and patient-important outcomes after VTE. While measures of quality of life can be helpful to identify different domains of interest that are affected or changes over time, more functional measures have been recently proposed, such as the Post-VTE Functional Status scale developed by consensus with VTE researchers and patients [13]. In addition to a better understanding and follow-up of functional limitations that exist post-PE (e.g. post-PE syndrome) [9], important psychological impacts, such as post-PE anxiety and distress, have been described [14, 15]. There are ongoing efforts to standardise common data elements and core outcome sets in VTE randomised controlled trials, and a renewed focus to incorporate patient-important outcomes into trials is needed. By better understanding the functional and psychological recovery post-PE, we can better assess new therapies and develop outpatient targeted interventions to optimise care for our patients.

What is clear from the HoT-PE study is that, while low-risk PE patients can be safely managed with early discharge and quality of life remains good for most individuals, clinicians need to keep quality of life and post-PE symptom recovery on their radar. Multiple factors can influence quality of life after PE and personalisation of follow-up is important. Primary care physicians and multidisciplinary thrombosis follow-up clinics should include an objective assessment of HRQoL when re-assessing PE patients. Extrapolating from the HoT-PE study results, they should also assess the adequacy of social supports, especially for patients who are working, for women, and those with obesity or cardiopulmonary comorbidities.

Shareable PDF

Supplementary Material

This one-page PDF can be shared freely online.

Shareable PDF ERJ-03811-2020.Shareable

Footnotes

  • Conflict of interest: K. Solverson has nothing to disclose.

  • Conflict of interest: L. Skeith reports grants from CSL Behring, non-financial support from LEO Pharma, outside the submitted work.

  • Conflict of interest: J. Weatherald reports grants, personal fees and non-financial support from Janssen Inc. and from Actelion, personal fees and non-financial support from Bayer, personal fees from Novartis, outside the submitted work.

  • Received October 12, 2020.
  • Accepted October 13, 2020.
  • Copyright ©ERS 2021
https://www.ersjournals.com/user-licence

References

  1. ↵
    1. Konstantinides SV,
    2. Meyer G,
    3. Becattini C, et al.
    2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). Eur Respir J 2019; 54: 1901647. doi:10.1183/13993003.01647-2019
    OpenUrlFREE Full Text
  2. ↵
    1. Janjua M,
    2. Badshah A,
    3. Matta F, et al.
    Treatment of acute pulmonary embolism as outpatients or following early discharge. A systematic review. Thromb Haemost 2008; 100: 756–761. doi:10.1160/TH08-05-0319
    OpenUrlPubMedWeb of Science
  3. ↵
    1. Aujesky D,
    2. Roy P-M,
    3. Verschuren F, et al.
    Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial. Lancet 2011; 378: 41–48. doi:10.1016/S0140-6736(11)60824-6
    OpenUrlCrossRefPubMedWeb of Science
    1. den Exter PL,
    2. Zondag W,
    3. Klok FA, et al.
    Efficacy and safety of outpatient treatment based on the Hestia clinical decision rule with or without N-terminal pro-brain natriuretic peptide testing in patients with acute pulmonary embolism. A randomized clinical trial. Am J Respir Crit Care Med 2016; 194: 998–1006. doi:10.1164/rccm.201512-2494OC
    OpenUrlCrossRefPubMed
  4. ↵
    1. Bledsoe JR,
    2. Woller SC,
    3. Stevens SM, et al.
    Management of low-risk pulmonary embolism patients without hospitalization: the Low-Risk Pulmonary Embolism Prospective Management Study. Chest 2018; 154: 249–256. doi:10.1016/j.chest.2018.01.035
    OpenUrlCrossRefPubMed
  5. ↵
    1. Roy P-M,
    2. Moumneh T,
    3. Penaloza A, et al.
    Outpatient management of pulmonary embolism. Thromb Res 2017; 155: 92–100. doi:10.1016/j.thromres.2017.05.001
    OpenUrl
  6. ↵
    1. Peacock WF,
    2. Singer AJ
    . Reducing the hospital burden associated with the treatment of pulmonary embolism. J Thromb Haemost 2019; 17: 720–736. doi:10.1111/jth.14423
    OpenUrl
  7. ↵
    1. Klok FA,
    2. van Kralingen KW,
    3. van Dijk APJ, et al.
    Quality of life in long-term survivors of acute pulmonary embolism. Chest 2010; 138: 1432–1440. doi:10.1378/chest.09-2482
    OpenUrlCrossRefPubMedWeb of Science
  8. ↵
    1. Kahn SR,
    2. Hirsch AM,
    3. Akaberi A, et al.
    Functional and exercise limitations after a first episode of pulmonary embolism: results of the ELOPE prospective cohort study. Chest 2017; 151: 1058–1068. doi:10.1016/j.chest.2016.11.030
    OpenUrlCrossRefPubMed
  9. ↵
    1. Barco S,
    2. Schmidtmann I,
    3. Ageno W, et al.
    Survival and quality of life after early discharge in low-risk pulmonary embolism. Eur Respir J 2021; 57: 2002368. doi: 10.1183/13993003.02368-2020. doi:10.1183/13993003.02368-2020
    OpenUrlAbstract/FREE Full Text
  10. ↵
    1. Barco S,
    2. Schmidtmann I,
    3. Ageno W, et al.
    Early discharge and home treatment of patients with low-risk pulmonary embolism with the oral factor Xa inhibitor rivaroxaban: an international multicentre single-arm clinical trial. Eur Heart J 2020; 41: 509–518.
    OpenUrlPubMed
  11. ↵
    1. Chuang L-H,
    2. Gumbs P,
    3. van Hout B, et al.
    Health-related quality of life and mortality in patients with pulmonary embolism: a prospective cohort study in seven European countries. Qual Life Res 2019; 28: 2111–2124. doi:10.1007/s11136-019-02175-z
    OpenUrl
  12. ↵
    1. Boon GJA M,
    2. Barco S,
    3. Bertoletti L, et al.
    Measuring functional limitations after venous thromboembolism: Optimization of the Post-VTE Functional Status (PVFS) Scale. Thromb Res 2020; 190: 45–51. doi:10.1016/j.thromres.2020.03.020
    OpenUrlPubMed
  13. ↵
    1. Hunter R,
    2. Lewis S,
    3. Noble S, et al.
    “Post-thrombotic panic syndrome”: a thematic analysis of the experience of venous thromboembolism. Br J Health Psychol 2017; 22: 8–25. doi:10.1111/bjhp.12213
    OpenUrlPubMed
  14. ↵
    1. Hunter R,
    2. Noble S,
    3. Lewis S, et al.
    Long-term psychosocial impact of venous thromboembolism: a qualitative study in the community. BMJ Open 2019; 9: e024805. doi:10.1136/bmjopen-2018-024805
    OpenUrlAbstract/FREE Full Text
PreviousNext
Back to top
View this article with LENS
Vol 57 Issue 2 Table of Contents
European Respiratory Journal: 57 (2)
  • Table of Contents
  • Index by author
Email

Thank you for your interest in spreading the word on European Respiratory Society .

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Early discharge after acute pulmonary embolism: keep quality of life on the radar
(Your Name) has sent you a message from European Respiratory Society
(Your Name) thought you would like to see the European Respiratory Society web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Print
Citation Tools
Early discharge after acute pulmonary embolism: keep quality of life on the radar
Kevin Solverson, Leslie Skeith, Jason Weatherald
European Respiratory Journal Feb 2021, 57 (2) 2003811; DOI: 10.1183/13993003.03811-2020

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero

Share
Early discharge after acute pulmonary embolism: keep quality of life on the radar
Kevin Solverson, Leslie Skeith, Jason Weatherald
European Respiratory Journal Feb 2021, 57 (2) 2003811; DOI: 10.1183/13993003.03811-2020
del.icio.us logo Digg logo Reddit logo Technorati logo Twitter logo CiteULike logo Connotea logo Facebook logo Google logo Mendeley logo
Full Text (PDF)

Jump To

  • Article
    • Abstract
    • Shareable PDF
    • Footnotes
    • References
  • Figures & Data
  • Info & Metrics
  • PDF
  • Tweet Widget
  • Facebook Like
  • Google Plus One

More in this TOC Section

  • CPAP for prevention of cardiovascular events and mortality
  • Disease-modifying effects of elexacaftor/ezacaftor/ivacaftor
  • An attack of asthma is not an attack of the heart
Show more Editorials

Related Articles

Navigate

  • Home
  • Current issue
  • Archive

About the ERJ

  • Journal information
  • Editorial board
  • Press
  • Permissions and reprints
  • Advertising

The European Respiratory Society

  • Society home
  • myERS
  • Privacy policy
  • Accessibility

ERS publications

  • European Respiratory Journal
  • ERJ Open Research
  • European Respiratory Review
  • Breathe
  • ERS books online
  • ERS Bookshop

Help

  • Feedback

For authors

  • Instructions for authors
  • Publication ethics and malpractice
  • Submit a manuscript

For readers

  • Alerts
  • Subjects
  • Podcasts
  • RSS

Subscriptions

  • Accessing the ERS publications

Contact us

European Respiratory Society
442 Glossop Road
Sheffield S10 2PX
United Kingdom
Tel: +44 114 2672860
Email: journals@ersnet.org

ISSN

Print ISSN:  0903-1936
Online ISSN: 1399-3003

Copyright © 2023 by the European Respiratory Society