Trends in length of hospital stay in acute pulmonary embolism over the years. What is changing in the era of direct oral anticoagulants?

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The optimal management of acute pulmonary embolism remains a compelling challenge. In recent years, with the improvement of prognostic stratification, it has become clear that entire home treatment or early hospital discharge could be a possible option for managing pulmonary embolism.1 Actually, international recommendations suggest considering home treatment or early hospital discharge in low risk mortality pulmonary embolism, which is defined as hemodynamically stable condition without echocardiographic or laboratory biomarkers of right heart dysfunction (RHD) and absence of comorbidity such as cardiopulmonary diseases or cancer.2
Based on their pharmacological profiles, direct oral anticoagulants (DOACs), inhibitors of thrombin (dabigatran) or activated factor X (apixaban, edoxaban and rivaroxaban) may offer several advantages in management of acute pulmonary embolism.3 In fact, compared with vitamin K antagonist (VKAs), DOACs have a prompt and predictive anticoagulant effect and do not require overlapping with parenteral anticoagulants and periodical coagulation monitoring. Therefore, it is not surprising that over the coming years the percentage of patients with acute pulmonary embolism treated at home or early discharged from hospital may increase, reducing the length of stay (LOS) and costs for hospitalization. Despite phase III randomized clinical trials (RCTs) having shown that DOACs are effective and well tolerated as well as conventional treatment in acute phase of pulmonary embolism,4 available real-life data on usefulness of this pharmacological class on the pulmonary embolism management and on the potential benefit to reduce LOS are lacking. Therefore, we retrospectively analyzed data of patients discharged from five hospitals of Florence district, Italy, with diagnosis of acute pulmonary embolism with the aim to focus on trends in LOS over the years and on the burden of rivaroxaban, which was the first DOAC marketed in Italy for this purpose since September 2013, apixaban and dabigatran, marketed in Italy in the second half of 2015, on this endpoint. In the survivors from one of the five hospitals, we also focused on anticoagulants prescribed at hospital discharge according to early mortality risk assessment by using the new 2014 European Society of Cardiology (ESC) prognostic model for analyzing which kind of patients received DOACs.2 Briefly, the new ESC prognostic model categorizes four early mortality risk classes (high, intermediate-high, intermediate-low and low), based on integrated clinical signs, echocardiography, biomarkers and original or simplified PESI (Pulmonary Embolism Severity Index) score.5,6 In the new ESC guidelines, original or simplified PESI scores are the initial prognostic tool for categories in low or non-low risk patients. Class I and II of original PESI score and simplified PESI score 0 identifies low risk patients (early mortality risk <1%). In this kind of patients, further prognostic investigations, such as transthoracic echocardiography and/or biomarkers assessment are considered redundant and not mandatory for this purpose. In contrast, patients with class III–V in the original PESI score or simplified PESI score of at least 1 identifies non-low risk patients who require further prognostic assessment aimed to identify echocardiographic RHD and/or myocardial damage signs and better stratify in intermediate-low risk (presence of only one of RHD, increased natriuretic peptides and troponins) and intermediate-high risk (contemporary presence of RHD, increased natriuretic peptides and troponins). High risk pulmonary embolism patients are those presenting shock or hemodynamic instability. Of interest, ESC recommendations suggest in their note that patients with signs of RHD and/or elevated biomarkers should be considered at intermediate risk, irrespective of PESI score.2
We searched for patients discharged with International Classification of Disease 9th revision Clinical Modification (ICD-9CM) codes 415.11 or 415.19 as first or second diseases reported in hospital discharge schedule in the years 2010, 2012 and from 2014 January 1st to 2015 August 31st.

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