Outpatient Management of Pulmonary Embolism Patients with Direct Oral Anticoagulants: A Systematic Review

Background: Pulmonary embolism (PE) patients are generally admitted to the hospital, which leads to significant burden on healthcare systems. Many PE patients are hemodynamically stable and can be ambulated safely. Direct oral anticoagulants (DOACs) do not need routine laboratory monitoring, which makes them a convenient option for outpatient care. Data on the outpatient management of PE patients using DOACs are scarce. Methods: We conducted a systematic search of MECENTRAL databases to identify randomized controlled trials (RCTs), non-randomized studies (non-RCTs), retrospective studies, reviews, systematic reviews, meta-analyses, and clinical guidelines evaluating the use of DOACs for outpatient treatment of PE patients. Results: A total of 833 publications were identified, and eight studies—two RCTs and six non-RCTs (two retrospective and four prospective)—were finally included. These studies reported rates of bleeding events, recurrent venous thromboembolism (VTE), PE-related mortality, and all-cause mortality among outpatients who received DOACs. No PE-related deaths were reported in any of the included studies. Bleeding events were reported in five studies, and recurrent VTE rates were reported in two studies. Study findings showed that the sPESI score has some disadvantages in selecting patients for home treatment. The quality of the studies varied considerably. A meta-analysis could not be performed due to heterogeneity in the study designs, patient populations, and outcome reporting. While the treatment results favored outpatient management of selected PE patients, no robust conclusions could be drawn from the published data. Conclusions: Outpatient treatment of PE with DOACs has some potential as an approach for managing selected patients. Hestia, POMPE-C and RESI scores are preferable for selecting PE patients for home treatment, but utilizing sPESI as the only tool has to be avoided. Apixaban and rivaroxaban are both safe, with a low bleeding risk. Large-scale prospective studies are required to establish the efficacy and safety of outpatient PE management using DOACs.