The British Thoracic Society (BTS) has published a new guideline for the initial outpatient management of pulmonary embolism (PE). The guideline provides recommendations on the risk-stratification and subsequent management of patients with suspected and confirmed PE in an outpatient or ambulatory care setting.
The BTS advises that patients in Pulmonary Embolism Severity Index (PESI) Class I/II, simplified PESI (sPESI) 0 or meeting the Hestia criteria should be considered for outpatient management of PE. Where PESI or sPESI indicates a low risk, a set of exclusion criteria should be applied to patients being considered for outpatient management.
The exclusion criteria set out in the guideline are as follows:
- Haemodynamic instability.
- Oxygen saturations <90% on air.
- Active bleeding or risk for major bleeding.
- On full-dose anticoagulation at the time of PE.
- Severe pain.
- Other medical comorbidities requiring hospital admission.
- Chronic kidney disease stages IV or V (estimated glomerular filtration rate, <30 mL/min) or severe liver disease.
- Heparin-induced thrombocytopenia within the last year and where there is no alternative to repeating heparin treatment.
- Social circumstances.
It is advised that no specific assessment of bleeding risk is required in patients who are deemed low risk by PESI/sPESI/ Hestia criteria. Also, measurement of right ventricular:left ventricular ratio on CT or echocardiography is not obligatory for the identification of low-risk patients for outpatient management.
The guideline also addresses the management of patients prior to receiving a confirmed diagnosis and the outpatient management of PE in specific circumstances such as cancer, pregnancy and intravenous drug misuse.
