History and clinical findings: A 39 year-old man presented with dyspnoea and calf pain. Aside from two long-distance flights there were no triggering events for deep vein thrombosis (DVT). 6 years before the patient had had a spontaneous DVT. Family history concerning DVT was negative.
Investigations: The patient presented with tachypnoea but no significant dyspnoea at rest. Color-coded duplex scan revealed a free floating thrombus in the left femoral vein, lung perfusion scan exhibited perfusion defects on the right side with a high probability for pulmonary embolism (PE). Echocardiography showed no signs of right ventricular failure. Thrombophilia screening was normal including prothrombin and factor V gene analysis.
Treatment and course: As the patient refused hospital admission, after informed consent he was treated on an out-patient basis with low molecular weight heparin (LMWH) with the dosage adjusted to body weight, despite of the pending licensing of most LMWH for PE. Compression therapy was initiated and patient education on self-injection was performed. On the second day, oral anticoagulation was initiated. The further course was uneventful and long-term oral anticoagulation was continued.
Conclusion: LMWH is at least as safe and effective as unfractionated heparin for the treatment of DVT, and it had been demonstrated that out-patient treatment of patients with DVT is safe. For PE however, most LMWHs are not yet licensed in Germany, even though recent studies show that they are safe and effective in the same doses regimen. As data on out-patient treatment of PE are sparse, out-patient treatment of symptomatic PE seems not generally advisable at present, although--as shown in the present case--it is feasible under particular circumstances.