title: Acute pulmonary embolism treatment with rivaroxaban results in a shorter duration of hospitalisation compared to standard therapy: an academic centre experience.
abstract: BACKGROUND
  Depending on the severity of clinical condition, acute pulmonary embolism (APE) is treated with unfraction-ated heparin (UFH), low-molecular weight heparin (LMWH), oral anticoagulants or, in the most severe form, with fibrinolytic agents. Following APE, patients require prolonged anticoagulant therapy for 3-6 months or in some cases indefinitely. Treatment options in this period include vitamin K antagonists (VKA) and non-VKA oral anticoagulants (NOAC) including rivaroxaban. The most recent European Society of Cardiology guidelines on the diagnosis and management of APE recommend use of NOAC in patients at a low-to-moderate risk of early mortality (a class I B recommendation). Rivaroxaban may be used in haemodynamically stable patients since the first day of therapy and was approved for this indication in Poland in December 2012.
  
  
  OBJECTIVE
  To evaluate the rate of rivaroxaban use, characterise patients with APE treated with rivaroxaban, and evaluate potential reduction of the duration of hospitalisation in patients treated with rivaroxaban compared to those receiving VKA.
  
  
  METHODS
  We evaluated hospital and postdischarge treatment in 215 consecutive APE patients (105 men, 110 women) at the mean age of 65.0 (range: 19.5-91.9) years. The study included patients hospitalised from January 2013 to November 2014, i.e. in the period immediately following approval of rivaroxaban for the treatment of APE in Poland. In the acute phase, patients were treated with LMWH, UFH, or rivaroxaban, and the treatment was continued with VKA, LMWH, or rivaroxaban. The timing of initiation of oral therapy depended on the haemodynamic stability of the patient.
  
  
  RESULTS
  Our study group of 215 APE patients included 157 (73%) moderate-risk patients, 51 (24%) low-risk, and 7 (3.3%) high-risk patients. Treatment was initiated with UFH or LMWH in 208 (96.7%) patients, and with rivaroxaban in 7 (3.3%) patients. In 33 (16.5%) patients, rivaroxaban was started after up to 3 days of heparin therapy. Chronic therapy prescribed at discharge in-cluded VKA in 64 (30.5%) patients, rivaroxaban in 82 (39%) patients, and LMWH in 64 (30.5%) patients. Five patients died during hospital, for the total mortality of 2.3%. Acute high-risk PE was diagnosed on admission in 2 of these patients, and moderate-risk PE in 3 patients. Treatment in this group included enoxaparin in 4 patients and UFH in 1 patient. Patients who were discharged on rivaroxaban stayed in hospital for a significantly shorter time compared to patients discharged on VKA (6 [2-22] vs. 8 [2-17] days, p = 0.0005). Duration of hospital stay was significantly shorter in APE patients with sPESI of 0 who were treated with rivaroxaban compared to those with sPESI of 0 treated with VKA (5 [2-11] vs. 6 [2-12] days, p = 0.002). A significant difference in the duration of hospital stay was also noted in patients with sPESI of ≥ 1 treated with rivaroxaban compared to those treated with VKA (7 [3-22] vs. 9 [3-17] days, p = 0.015). Patients with sPESI of ≥ 1 treated with rivaroxaban were hospitalised for a sig-nificantly longer time compared to those with sPESI of 0 treated with rivaroxaban (7 [3-22] vs. 5 [2-11] days, p = 0.00005).
  
  
  CONCLUSIONS
  Rivaroxaban therapy is a useful therapeutic option in patients with APE. Compared to standard therapy, use of rivaroxaban has been associated with a significant reduction of the duration of hospital stay.
authors.affiliation: Department of Internal Medicine and Cardiology and Centre for the Diagnosis and Management of Venous Thromboembolism, Medical University of Warsaw, Warsaw, Poland. marzenia513@interia.pl.
authors.forename: Marzanna
authors.initials: M
authors.lastname: Paczyńska
authors.forename: Katarzyna
authors.initials: K
authors.lastname: Kurnicka
authors.forename: Barbara
authors.initials: B
authors.lastname: Lichodziejewska
authors.forename: Sylwia
authors.initials: S
authors.lastname: Goliszek
authors.forename: Olga
authors.initials: O
authors.lastname: Dzikowska-Diduch
authors.forename: Piotr
authors.initials: P
authors.lastname: Sobieraj
authors.forename: Łukasz
authors.initials: Ł
authors.lastname: Burzyński
authors.forename: Maciej
authors.initials: M
authors.lastname: Kostrubiec
authors.forename: Piotr
authors.initials: P
authors.lastname: Pruszczyk
authors.forename: Michał
authors.initials: M
authors.lastname: Ciurzyński
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D065427:Factor Xa Inhibitors / Q000627:therapeutic use; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011655:Pulmonary Embolism / Q000188:drug therapy*; D000069552:Rivaroxaban / Q000627:therapeutic use*; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D065427:Factor Xa Inhibitors; D000069552:Rivaroxaban
keywords: acute pulmonary embolism; risk stratification; rivaroxaban; vitamin K antagonists