Pulmonary Vascular Disease: PAH |

The Role of New Oral Anticoagulants in the Early Discharge of Acute Pulmonary Embolism Patients at Low and Intermediate Risk of Mortality FREE TO VIEW

Jason Filopei, MD; Aloke Chakravarti, MD; Navitha Ramesh, MD; David Steiger, MD
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Mount Sinai Beth Israel, New York, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):1151A. doi:10.1016/j.chest.2016.08.1261
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SESSION TYPE: Original Investigation Slide

PRESENTED ON: Sunday, October 23, 2016 at 01:30 PM - 03:00 PM

PURPOSE: With the advent of the new oral anti-coagulants (NOAC), early discharge of patients with acute pulmonary embolism (PE) at a low risk (LR) for mortality based on Pulmonary Embolism Severity Index (PESI) and/or HESTIA criteria has been described as potentially safe and effective. To our knowledge, there are no studies describing early discharge of intermediate low (ILR) or intermediate high risk (IHR) PE patients using NOAC’s. We hypothesized that acute PE patients with ILR and IHR for mortality can be safely and quickly discharged on NOAC’s with close outpatient follow-up.

METHODS: We performed a single center retrospective review of a QI database of consecutive PE patients from 6/2015 to 2/2016 (n=120) and analyzed 66 consecutive hemodynamically stable patients evaluated by the pulmonary consult service with an admitting diagnosis of acute PE. Risk classes were defined based on the 2014 European Society of Cardiology guidelines. LR patients were defined as a Pulmonary Embolism Severity Index (PESI) Class I or II with normal cardiac biomarkers. Intermediate risk patients were classified as low and high risk, defined as PESI > III and RVD on imaging. ILR had one or no cardiac biomarkers (troponin I or beta-naturietic peptide) and IHR had both cardiac biomarkers positive. The primary outcomes were survival, the recurrent symptomatic VTE, and major bleeding at discharge and 30 days. Secondary outcome was hospital length of stay.

RESULTS: All of the 66 patients, 20/23 LR, 17/21 ILR, and 14/22 IHR who received unfractionated heparin initially were discharged on a NOAC. The mean PESI scores were identical (31) in the LR NOAC and LR non-NOAC group. The mean PESI in the ILR NOAC vs. ILR non-NOAC was 63 and 79, respecitvely. The mean PESI in the IHR NOAC vs. IHR non NOAC was 67 and 59, respectively.For the ILR NOAC group (n=17), survival, recurrent VTE, and bleeding rate at discharge was100%, 0%, and 0% respectively. At 30 days, the ILR NOAC group (n=12), survival, recurrent VTE, and bleeding rate was 100%, 0%, and 0%, respectively. For the IHR NOAC group (n=14), survival, recurrent VTE, and bleeding rate at discharge was100%, 0%, and 0% respectively. At 30 days, the IHR NOAC group (n=10), survival, recurrent VTE, and bleeding rate was100%, 0%, and 10% respectively. Five and four patients were lost to follow-up in the ILR and IHR NOAC groups. Mean length of stay for LR, ILR, and IHR discharged on a NOAC was 1.5, 1.6, and 3.8 days respectively, compared to the mean length of stay for the ILR and IHR non-NOAC which was 3.8 and 9.3 days, respectively. Approximately 30% of the ILR and IHR patients were admitted to a respiratory step down unit or medical intensive care unit.

CONCLUSIONS: A significant number of patients admitted with acute PE at LR, ILR, and IHR can be safely discharged on a NOAC with close follow-up. Use of a NOAC was associated with a reduction in LOS compared to the patients discharged on non- NOACs.

CLINICAL IMPLICATIONS: It is possible that NOAC's can be used safely in intermediate risk patients with signs of right ventricular dysfunction. Large scale studies are needed to evaluate the efficacy of the new oral anti-coagulants in this population of patients. Close outpatient follow-up is imperative.

DISCLOSURE: The following authors have nothing to disclose: Jason Filopei, Aloke Chakravarti, Navitha Ramesh, David Steiger

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