Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial Lancet 2011; 378: 41–48

Aujesky D et al. Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial. Lancet 2011 Jul.;378(9785):41–48. PMID 21703676

Most of you are probably treating PEs as out patients, we’ve been doing it for years now.

METHODS

• These guys (the key name is Aujesky here) used their own previously published score the Pulmonary Embolism Severity Criteria (which I have very limited familiarity with but I note that having a temp<36 gets you points which just sounds bonkers to me…) to select low risk PEs who they thought might be suitable for OP management.
• randomised to either heparin and warfarin as an OP or heparin and warfarin as an in-patient
• doctors on the wards decided when to discharge them

and this is a bit weird as they don’t really tell us how the docs on the wards decided this, was it just on the basis of warfarinisation or some other factor? Did they just stare at them for 4 days and then get bored and kick them out?

RESULTS

• 170 each group
• the IP group stayed about 4 days in the hospital
• INR were in range 52% of the time in both groups. But remember that this is worked out over 90 days and both groups got exactly the same OP management for this most of the time
• there was one recurrence of PE, it’s not even important which group it was in
• there was one death in each group, one from pneumonia and cancer, one from trauma

and that’s worth comment. These people do really well whether in hospital or not, and it seems we should definitely be treating as an OP for the majority.

I would have been interested to know what the risk stratification was prior to diagnosis and whether that correlated with their PE severity score, or indeed with something meaningful like clinical outcomes.

the question still stands – if everyone does this well then maybe we have a fantastic miracle treatment for VTE?

Or maybe (as mentioned before) they would do really well without any treatment.

Or maybe mortality in a low-risk group is 1% with no treatment and 0.5% with treatment?

Or anywhere in between…