Welcome to the September 2015 REBELCast, where Swami, Matt, and I are going to tackle a couple of topics in the world of Venous Thromboembolism (VTE). Seems like we are hearing more and more about VTE in terms of workup, management, etc. Lets face it, diagnosing someone with a pulmonary embolism (PE) is no longer as simple as checking a d-dimer or just doing a CT Pulmonary Angiogram. There is so much more to it and to frustrate physicians even more there is so much research coming out on this topic alone, even I am having a hard time keeping up. Swami, Matt, and I thought it might be good to tackle a couple of articles from he world of VTE that have implications for clinical practice and patient care. So with that introduction today we are going to specifically tackle:
- Topic #1: Home Treatment of Low Risk Venous Thromboembolism with Rivaroxaban
- Topic #2: RV Dilation on Bedside Echo Performed by ED Physicians
September 2015 REBELCast Podcast
Topic #1: Home Treatment of Low Risk Venous Thromboembolism with Rivaroxaban
Question #1: Can patients with VTE, deemed to be low risk, be safely and effectively be treated as outpatients with Rivaroxaban?
Article #1: Beam DM et al. Immediate Discharge and Home Treatment with Rivaroxaban of Low-risk Venous Thromboembolism Diagnosed in Two U.S. emergency Departments: A One-year Preplanned Analysis. Acad Emerg Med 2015; 22(7): 788 – 95. [cite source=”pubmed”]26113241[/cite]
Background #1: Thus far systematic reviews and meta-analyses of literature on treatment of low risk venous thromboembolism (VTE) have pointed towards a low failure rate associated with outpatient treatment. Many of us work in health care systems where inability to arrange follow-up and probably more importantly medicolegal concerns negates this from occurring in real everyday practice. Well just recently Beam DM et al (and this does include Jeff Kline) published a study on the initial results of a Rivaroxaban-based outpatient treatment protocol of low risk VTE in Academic Emergency Medicine 2015.
What They Did #1:
- Prospective Observational Study from 2 Academic EDs in Indiana
- Test the safety and effectiveness of a clinical pathway that allowed immediate discharge of low-risk VTE from the ED using Rivaroxaban
- Pts selected for discharge given 1mg/kg enoxaparin, and one 15 mg Rivaroxaban dose by mouth prior to discharge, then continued on 15mg of Rivaroxaban BID for 21 days followed by 20mg daily until therapy finished
Bottom Line #1: This study provides us with more evidence that in a appropriately selected low risk patient population with VTE, and close follow up, outpatient anticoagulation with Rivaroxaban is feasible with very low rate of recurrence of VTE and risk of bleeding while on therapy.
Topic #2: RV Dilation on Bedside Echo Performed by ED Physicians
Question #2: What is the diagnostic performance of RV dilatation identified by POCUS, by EM physicians in patients with suspected or confirmed PEs?
Article #2: Dresden S et al. Right Ventricular Dilatation on Bedside Echocardiography Performed by Emergency Physicians Aids in the Diagnosis of Pulmonary Embolism. Ann Emerg Med 2014; 63: 16 – 24. [cite source=”pubmed”]24075286[/cite]
Background #2: Lets face it, diagnosing someone with a pulmonary embolism is a serious diagnosis, that carries a lot of stress both for the physician and the patient. We know that the range of mortality is anywhere from 2.5% up to 33% depending on what source you read and typically the treatment is anticoagulation for 3 – 6 months, but if that is not enough to stress you out, what about missing a submassive PE? And even if you do diagnose it, does this patient now get half dose lytics? If you are out in the community and not ultrasound trained, how comfortable do you feel putting the echo on the patients chest from the bedside and diagnosing right ventricular dysfunction? To be more specific right ventricular dilatation, right ventricular hypokinesis, paradoxical septal wall motion, McConnell’s sign (i.e. right ventricular wall hypokinesis with apical sparing), or maybe even tricuspid regurgitation? Well what is known is that patients with right ventricular dysfunction on echo, have a worse prognosis in the setting of PE, but that worsened prognosis can be decreased with acute treatment. So what if all you had to do was recognize right ventricular dilatation on echo? Would that be easy enough? It certainly could help expedite decisions about treatment and disposition ultimately reducing morbidity and mortality in patients. And I am here to tell you, that is exactly what the authors of this study did: Determine the diagnostic performance of RV dilatation identified by POCUS, by EM physicians in patients with suspected or confirmed PEs.
What They Did #2:
- Prospective, Observational study of a convenience sample of ED patients with suspected or confirmed PE
- Single Center study at Boston Medical Center (A large urban academic ED)
Bottom Line #2: With appropriate ultrasound training, ED physicians can perform POCUS echocardiography with visualization of RV dilatation, in patients without other causes/explanations of RV strain. And this finding would be a valuable tool that should increase clinical suspicion for PE.
For More Details of the above Studies Checkout the September 2015 REBELCast Show Notes
For more on what others thought on these topics checkout:
- Ken Milne at The SGEM: SGEM #126 – Take me to the Rivaroxaban – Outpatient Treatment of VTE
- Anton Helman at EM Cases: Best Case Ever 44 – Low Risk Pulmonary Embolism
Post Peer Reviewed By: Anand Swaminathan (Twitter: @EMSwami)