1,814 patients were included in this systematic review and they pretty much all did fine. Rates of mortality, recurrent VTE, and major bleeding was all below 1%.
“There was a single instance of PE related mortality within 90 days among the 1,814 outpatients in high quality studies.”
The authors state they have three main findings.
First, there are few controlled studies. But to answer the question, I don’t think we need a control arm. A well conducted cohort study should be fine.
Second, there were low rates of major adverse outcomes.
Third, there was no difference in patient outcomes with warfarin or with DOACs. For what it’s worth, 97% of the DOACs chosen were rivaroxaban.
It appears that the preponderance of evidence shows that sending low-risk patients home with oral rivaroxaban is safe.
However, there is a currently a large study by Jeff Kline enrolling patients in 33 hospitals in the USA to look at a protocol for outpatient management of VTE. So of course, our thoughts could all change.
Maughan B, Frueh L, McDonagh MS, et al. Outpatient Treatment of Low-risk Pulmonary Embolism in the Era of Direct Oral Anticoagulants: A Systematic Review. Acad Emerg Med 2021;28:226-239. [Link to article]
Dr Brian Doyle is an emergency physician originally from the United States but now very much calls Tasmania his home. Unfortunately, it will now be a bit more difficult to deport him from the country as he passed his Australian citizenship test a few years ago. (He was able to answer that Phar Lap won the Melbourne rather than the Davis Cup). His main interests are mostly the clinical aspects of emergency medicine but also in education, ultrasound and critical appraisal of the literature. He spends much of his time annoying people to help out with conferences.