Acad Emerg Med. 2026 Jun;33(6):e70360. doi: 10.1111/acem.70360.
ABSTRACT
BACKGROUND: Although guidelines support outpatient management for low-risk pulmonary embolism, U.S. emergency department (ED) adoption remains low, partly due to limited contemporary evidence. Direct oral anticoagulant (DOAC) era studies are small or European and typically classify all sPESI > 0 as high risk. More granular U.S. outcomes are needed to inform which patients can be safely discharged.
OBJECTIVES: To characterize 30-day all-cause mortality by sPESI in patients with an acute PE treated with a DOAC.
DESIGN: Retrospective cohort study.
SETTING: United States Veterans Affairs (VA) Health System, 2015 to 2024.
PARTICIPANTS: Adult patients diagnosed with an acute PE in a VA ED were prescribed a DOAC within one day.
EXPOSURE: Hospital admission.
MAIN OUTCOMES: 30-day all-cause mortality.
RESULTS: A total of 6,427 first-time acute PEs were treated with a DOAC. Thirty-day mortality rates by sPESI were: sPESI 0: 0.0%, sPESI 1: 0.4%, sPESI 2: 1.8%, sPESI 3: 3.8%, sPESI 4: 8.8%, sPESI 5: 21.1%, and sPESI 6: 25.0%. Of 3,799 patients with sPESI < 2, 2,578 (67.9%) were hospitalized with a median length of stay of 24 h. After adjusting for covariates, odds of 30-day all-cause mortality were similar regardless of admission vs. ED discharge (OR 1.32, 95% CI 0.40, 4.36, p = 0.65).
CONCLUSIONS: In this large U.S. DOAC-era cohort, patients with sPESI 0 or 1 had very low 30-day mortality, and hospitalization did not appear to improve outcomes. Despite this, two-thirds were admitted. These findings support expanding outpatient management of acute PE and reducing short-stay, low-value hospitalizations if no other indication for admission exists.
PMID:42313763 | DOI:10.1111/acem.70360