title: Best Clinical Practice: Controversies in Outpatient Management of Acute Pulmonary Embolism.
abstract: BACKGROUND
  Pulmonary embolism (PE) is a common condition managed in the emergency department (ED), with a wide range of morbidity and mortality. Patients are classically admitted for treatment and monitoring of anticoagulation.
  
  
  OBJECTIVE
  We sought to evaluate the controversy concerning outpatient therapy for patients with acute PE and investigate the feasibility, safety, and efficacy of outpatient management.
  
  
  CONCLUSIONS
  Patients with venous thromboembolism have historically been admitted for treatment and monitoring for concern of worsening disease or side effects of anticoagulation (bleeding). More than 90% of EDs admit patients with PE in the United States. However, close to 50% of patients may be appropriate for discharge and outpatient therapy. The published literature suggests that outpatient treatment is safe, feasible, and efficacious, with similar rates of recurrent venous thromboembolism and all-cause mortality, especially with novel oral anticoagulants. Multiple scoring criteria can be used, including the Pulmonary Embolism Severity Index (PESI), simplified PESI, Hestia criteria, Geneva Prognostic Score, European Society of Cardiology guidelines, Global Registry of Acute Coronary Events, and Aujesky score. Simplified PESI and the European Society of Cardiology guidelines have high-quality evidence, sufficient sensitivity, and ease of use for the ED. Patients considered for outpatient therapy should possess low hemorrhage risk, adequate social situation, negative biomarkers, ability to comply, and no alternate need for admission.
  
  
  CONCLUSIONS
  Patients with acute PE are often admitted in the United States, but a significant proportion may be appropriate for discharge. Patients with low risk for adverse events according to clinical scoring criteria, adequate follow-up, ability to comply, and no other need for admission can be discharged with novel oral anticoagulant therapy.
authors.affiliation: Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston.
authors.forename: Brit
authors.initials: B
authors.lastname: Long
authors.affiliation: Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas.
authors.forename: Alex
authors.initials: A
authors.lastname: Koyfman
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000553:Ambulatory Care / Q000379:methods* / Q000639:trends; D000925:Anticoagulants / Q000009:adverse effects / Q000494:pharmacology / Q000627:therapeutic use; D019468:Disease Management; D004636:Emergency Service, Hospital / Q000458:organization & administration; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011655:Pulmonary Embolism / Q000628:therapy*; D018570:Risk Assessment / Q000379:methods / Q000592:standards; D012720:Severity of Illness Index; D015912:Thrombolytic Therapy / Q000009:adverse effects / Q000379:methods; D054556:Venous Thromboembolism / Q000628:therapy
chemical_list: D000925:Anticoagulants
keywords: anticoagulation; novel oral anticoagulant; outpatient; pulmonary embolism; risk stratify; score