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Prof. Menno Huisman,
Traditionally, patients with acute pulmonary embolism (PE) are hospitalised for initial treatment with LMWH, in analogy with successful home treatment of patients with deep-vein thrombosis (DVT). Thus, the question arises whether patients with acute PE could initially be treated out of hospital. Dr Jimenez discussed various clinical scores helping to triage patients with acute PE. As of today, the PE severity score (PESI) (Aujesky AJRCCM 2005) and its simplified form sPESI (Jimenez Arch Int Med 2010) seem to be the best validated scores to select patients for home treatment. With negative predictive value (NPV) for three months, mortality is > 98-99 % in patients with a low-risk PESI score, the latter which occurred in 30-50% of patients. As this NPV is already very high for clinical scores alone, it remains to be seen whether biomarkers for right ventricle dysfunction or ischemia will improve this triage process. It may be that combining clinical score and biomarkers will not gain in sensitivity but will lose in efficiency, i.e. the number of patients with low risk to be sent home will decrease. Dr Konstantinides commented on the recent HOME- study (Agterof JTH 2010), in which patients with a NT-proBNP < 500 pg/l were successfully treated at home – they had no recurrent VTE, no major bleeding, and no mortality during three months follow-up. Dr Aujesky discussed three recent home treatment studies, of which HOME was one. In the Hestia Cohort Study (Zondag JTH 2010), of the 297 patients without any clinician oriented exclusion criteria, 2.0 % had recurrent VTE, 1.0 % had major bleed and 1% died. In the randomised OTPE study ( Aujesky Lancet 2011) , patients treated at home had 0.6 % recurrent VTE versus 0 % hospitalised patients; major bleed occurred in 1.2 % in home treated patients vs 0% in hospitalised patients. Finally, Dr Schellong informed us on trials evaluating new oral anticoagulants in the treatment of PE, some of which are still under way. His main message was that, as initial treatment is so vital in treating patients with acute PE, the doctor should be sure that the patient takes the oral medication during the first week and he foresaw reluctance by doctors to send these patients home directly before prospective trials have demonstrated the safety of home treatment of VTE with new oral anticoagulants. In my view, this session was very relevant, given the current discussion on home treatment of patients with acute PE and the data recently published in the literature. The quality of the presentations was very high. The meeting was reasonably well attended and discussions were lively, despite the early morning start time.
Is it time for home treatment of pulmonary embolism?
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