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Original Research |

Usefulness of Preemptive Anticoagulation in Patients With Suspected Pulmonary EmbolismPreemptive Anticoagulation for Pulmonary Embolism: A Decision Analysis

Marc Blondon, MD; Marc Righini, MD; Drahomir Aujesky, MD; Grégoire Le Gal, MD, PhD; Arnaud Perrier, MD
Author and Funding Information

From the Division of General Internal Medicine (Drs Blondon and Perrier) and the Division of Angiology and Hemostasis (Dr Righini), Department of Internal Medicine, University Hospitals of Geneva, Geneva, Switzerland; the Division of General Internal Medicine (Dr Aujesky), Bern University Hospital, Bern, Switzerland; and Department of Internal Medicine and Chest Diseases and EA 3878 (Dr Le Gal), Brest University Hospital, Brest, France.

Correspondence to: Marc Blondon, MD, Department of Internal Medicine, University Hospitals of Geneva, 4 rue Gabrielle-Perret-Gentil, 1211 Geneva 14, Switzerland; e-mail: marc.blondon@hcuge.ch


Funding/Support: Although no funding was allocated for this study, the management study (from which some data were used) was supported by a grant from the Swiss National Research Foundation [Grant 3200B0-105988], from the Projets Hospitaliers de Recherche Clinique [PHRC 2005-08-08], and from Pneumologie Développement.

This study was presented as a poster at the XXIII Congress of the International Society on Thrombosis and Haemostasis, July 26, 2011, in Kyoto, Japan and published in abstract form (Blondon M, Gal GL, Aujesky D, Righini M, Perrier A. J Thromb Haemost. 2011;9[suppl S2]:403.)

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2012;142(3):697-703. doi:10.1378/chest.11-2694
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Background:  The diagnostic workup of pulmonary embolism (PE) may take several hours. The usefulness of anticoagulant treatment while awaiting the results of diagnostic tests has not been assessed. The objective of this study was to compare the risks and benefits of bid low-molecular-weight heparin vs no treatment in patients with suspected PE.

Methods:  We developed a decision tree with the following outcomes: mortality related to untreated and treated PE, mortality due to major hemorrhage, and intracranial bleeding. The timeframe extended from the suspicion of PE to its confirmation or exclusion. Most probabilities were derived from data from the Computerized Registry of Patients with VTE (RIETE). We estimated the incidence of bleeding by categories of clinical prediction rules of PE from a recent diagnostic management study of PE. Uncertainty was assessed through one-way and probabilistic sensitivity analyses.

Results:  The model favored preemptive anticoagulation if the diagnostic delay was . 6.3 h, . 2.3 h, and . 0.3 h (Revised Geneva low, intermediate, and high probability) and . 8.1 h and . 1.7 h (Wells unlikely and likely). With a diagnostic delay of 6 h, the absolute mortality reduction with anticoagulation was 0%, 0.02%, and 0.1% for low, intermediate, and high clinical probability, respectively. In one-way sensitivity analyses, the mortality of untreated PE was the most critical variable. Probabilistic analyses reinforced the superiority of anticoagulation in intermediate- and high-probability patients and suggested that low-probability patients might not benefit from treatment after diagnostic delays of < 6 to 8 h.

Conclusions:  Our model suggests that patients with intermediate and high/likely probabilities of PE benefit from preemptive anticoagulation. With a low probability, the decision to treat may rely on the expected diagnostic delay.

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