Outpatient treatment of patients with deep-vein thrombosis or pulmonary embolism.
There have been a large number of randomized trials comparing standard unfractionated intravenous heparin with low-molecular-weight heparin for the treatment of deep-vein thrombosis, but only two of these have looked at outpatient therapy. There have been only two randomized trials including patients with symptomatic pulmonary embolism, and neither of these provided outpatient therapy. Postmortem and clinical studies have shown a strong association between pulmonary embolism and the presence of venous thrombosis in the lower limbs. Based on similar rates of venous thromboembolic recurrence and death, these studies suggest that initial treatment should be the same for deep-vein thrombosis and pulmonary embolism. The feasibility of providing outpatient care to many patients seeking treatment for deep-vein thrombosis or acute pulmonary embolism at certain tertiary care hospitals has become evident, but the data suggest that the proportion of eligible patients is institution dependent and may vary from 18% to 91%. In the author's institution, approximately 50% of patients with pulmonary embolism could be treated as outpatients, but there have been no other reports on outpatient therapy for patients with pulmonary embolism. If patients with pulmonary embolism meet criteria demonstrated to result in a higher risk of death, it is, of course, reasonable to not treat such patients on an outpatient basis. Low-molecular-weight heparin followed by oral anticoagulant therapy provides adequate therapy in most patients with deep-vein thrombosis or pulmonary embolism, and many patients can be treated as outpatients.
Wells
P S
PS
Department of Medicine, Ottawa Health Research Institute, 737 Parkdale Avenue, Ottawa, Ontario K1Y 1J8, Canada. pwells@ottawahospital.on.ca
D000284:Administration, Oral; D000553:Ambulatory Care / Q000592:standards; D000925:Anticoagulants / Q000627:therapeutic use*; D017985:Dalteparin / Q000627:therapeutic use; D005240:Feasibility Studies; D006495:Heparin, Low-Molecular-Weight / Q000627:therapeutic use*; D006801:Humans; D011379:Prognosis; D011655:Pulmonary Embolism / Q000188:drug therapy* / Q000453:epidemiology; D020246:Venous Thrombosis / Q000188:drug therapy* / Q000453:epidemiology
D000925:Anticoagulants; D006495:Heparin, Low-Molecular-Weight; D017985:Dalteparin