Better guidelines required for early-discharge acute PE patients
MedWire News: Dutch researchers have called for new guidelines for anticoagulation in patients with acute pulmonary embolism (PE) who are discharged from hospital before they reach an adequate international normalized ratio (INR).
Esther van Bladel (University Medical Centre Utrecht) and colleagues found that half of all patients admitted for acute PE were discharged early. This led to a prolonged time needed to reach adequate INR (2.0-3.5), probably as a consequence of a lower intensity of monitoring at home after early discharge, they say.
In total, 86 patients with acute PE received low-molecular-weight-heparin (LMWH) transitioning therapy plus the vitamin K antagonist acenocoumarol at two large regional teaching hospitals between January 2005 and July 2007.
The researchers report that 44 (51.2%) of the patients were discharged early, before reaching an adequate INR on two consecutive measurements during hospitalization, as recommended by current guidelines. The remaining 42 (48.8%) patients were discharged after reaching an adequate INR.
The time to reach an adequate INR was significantly longer among the early-discharge patients, at 13 days, compared with 6 days in the normal-discharge group. However, the INR values were only measured every 2.8 days until reaching an adequate INR in the early-discharge group, compared with every 1.5 days in the normal-discharge group.
LMWH transitioning therapy was stopped before reaching an adequate INR in 28 (32.6%) of the 86 patients. Of note, inadequate transitioning was significantly higher among the early-discharge patients, at 47.7%, compared with 16.7% among the normal-discharge patients.
In spite of the differences observed, the mean individual times below, within, and above the INR range were equal between the two groups during the first 3 months of treatment.
van Bladel and team say that, in their opinion, hospitalization just to obtain an adequate INR is not strictly necessary, provided that INR monitoring after discharge is intensified.
They add: "Enhanced compliance to existing guidelines… and further development of guidelines, with focus on intensification of monitoring of INR values in an outpatient setting and preventing premature discontinuation of transitioning therapy, are warranted for a safe and early discharge of stable patients with PE."
The study findings are reported in the Journal of Thrombosis Research.
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By Laura Dean