Abstract
Patients with pulmonary embolism (PE) can be stratified into two different prognostic categories, based on the presence or absence of shock or sustained arterial hypotension. Some patients with normotensive PE have a low risk of early mortality, defined as <1% at 30 days or during hospital stay. In this paper, we will discuss the new prospective for the optimal management of low-risk PE: prognostic assessment, early discharge, and single-drug therapy with new oral anticoagulants. Several parameters have been proposed and investigated to identify low-risk PE: clinical prediction rules, imaging tests, and laboratory markers of right ventricular dysfunction or injury. Moreover, outpatient management has been suggested for low-risk PE: it may lead to a decrease in unnecessary hospitalizations, acquired infections, death, and costs and to an improvement in health-related quality of life. Finally, the main characteristics of new oral anticoagulant drugs and the most recent published data on phase III trials on PE suggest that the single-drug therapy is a possible suitable option. Oral administration, predictable anticoagulant responses, and few drug-drug interactions of direct thrombin and factor Xa inhibitors may further simplify PE home therapy avoiding administration of low-molecular-weight heparin.
Highlights
Prognostic assessment is central in the initial management of patients with acute pulmonary embolism (PE) [1,2,3]. e latest guidelines of the European Society of Cardiology (ESC), and of the American College of Chest Physicians (ACCP), American Heart Association (AHA) scienti c statement on PE strongly suggest to stratify PE patients into two categories, which are patients at high risk of early mortality, that is, massive PE, and patients who are not at high risk of early mortality, that is, submassive and low-risk PE, based on the presence or absence of shock or sustained arterial hypotension, respectively, [1,2,3]
Two recent meta-analyses have reported an estimated 30% relative risk increase for acute coronary events with the use of dabigatran in patients with venous thromboembolism (VTE) and AF [121, 122]. is effect has not been reported with factor Xa inhibitors: it is not clear whether this can be due to an intrinsic property of dabigatran or to a protective effect of the comparator antithrombotic drugs. efore de nite data will be provided, it seems wise to prefer other drug options instead of dabigatran in AF patients with known cardiac ischemic disease or at high risk of acute coronary events
A correct prognostic strati cation is the rst step for early discharge or a complete home treatment, but a dedicated well-organised 24-h outpatient programme should be provided to each patient, to those already existing for deep vein thrombosis (DVT) patients all over the world
Summary
Prognostic assessment is central in the initial management of patients with acute pulmonary embolism (PE) [1,2,3]. e latest guidelines of the European Society of Cardiology (ESC), and of the American College of Chest Physicians (ACCP), American Heart Association (AHA) scienti c statement on PE strongly suggest to stratify PE patients into two categories, which are patients at high risk of early mortality, that is, massive PE, and patients who are not at high risk of early mortality, that is, submassive and low-risk PE, based on the presence or absence of shock or sustained arterial hypotension, respectively, [1,2,3]. Prognostic assessment is central in the initial management of patients with acute pulmonary embolism (PE) [1,2,3]. Prognostic strati cation is required to identify those patients who may be theoretically eligible for outpatient treatment or early discharge [4,5,6] and those patients who may require more aggressive therapeutic strategies [1,2,3]. Aim of this paper is to summarize current evidence on the best management of PE patients at low risk of adverse outcomes. Available prognostic tools, hometreatment and early discharge, and new drug options will be discussed
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