Letters

RAPID RESPONSE FROM BMJ.COM

How many patients are candidates for home treatment of DVT?

This article originally appeared in BMJ USA

EDITORSchwarz et al demonstrate the feasibility of home treatment (HT) for most patients with acute deep vein thrombosis (DVT). These data, along with those reported previously,¹ mainly regard patients investigated at vascular units where uncomplicated DVT is usually seen. This population may be different from that evaluated in the emergency department (ED), where most of the patients clinically suspected of having acute venous thromboembolism (VTE) are firstly investigated.² In this respect, the ED can be an appropriate setting not only for detecting acute DVT but also for fully investigating and identifying patients who may be suitable for HT.

In the past 23 months, we applied a HT program for acute VTE in 121 consecutive patients with objectively confirmed acute VTE: 84 with DVT (69.4%) and 37 with pulmonary embolism (PE) (30.5%).³ During a short hospitalization (mean 2 hours, SD 1 hour) in the ED, patients were screened as potentially eligible for HT (absence of concomitant disorders) or for standard in-hospital care.⁴ Low-risk patients (n=46, 38%) and those at high risk who refused hospitalization (n=15, 12%) were treated at home (enoxaparine 100 IU antiFXa/Kg/12h plus warfarin according to the international normalized ratio (INR)); the remaining high-risk patients (n=68, 56.1%) received standard in-hospital care. In a table published on the Internet (http://bmj.com/cgi/eletters/322/7296/1212), we report the results concerning the initial period of anticoagulation (heparin plus warfarin) (mean 10 days, SD 3 days) between the two groups of patients. There was no difference between hospitalized and HT patients in terms of major outcomes. This lack of difference is even more evident if one takes into account that a subgroup of high-risk patients was treated at home. At three months follow-up, two patients in standard in-hospital care died for causes other than VTE, and one HT patient developed a non-fatal intra-cranial hemorrhage (his INR was in the therapeutic range).

Although we also considered for HT patients with symptomatic, hemodynamically stable PE and massive DVT, the proportion of patients treated at home was lower (50.4%, 95% confidence interval (CI) 41.5-58.3) than that reported by Schwarz et al (78.6%, 95% CI 70.1-85.7). As reported above, our data are derived from a population with a rate of concomitant medical disorders (62.8%, 95% CI 54.2-71.4) higher than that seen in the study by Schwarz et al (2.6%, 95% CI 0.9-7.1); such patients are representative of the population usually referred to an ED.

Our preliminary results suggest that a careful HT program for high-risk patients performed in an appropriate setting is as feasible and safe as standard in-hospital management or HT for uncomplicated DVT. In addition, these data show that the proportion of patients potentially eligible for HT varies according to the clinical setting where they are first evaluated.

Sergio Siragusa, hematologist. 
Francesco Falaschi. 
Paola Tatoni. 
Servizio Pronto Soccorso Accettazione, Emergency Department IRCCS Policlinico, San Matteo, Pavia, Italy sergiosiragusa{at}yahoo.com

1.	Levine M, Gent M, Hirsh J, Leclerc J, et al. A comparison of low-molecular-weight heparin administered primarily at home with unfractionated heparin administered in the hospital for proximal deep-vein thrombosis. N Engl J Med 1996; 334: 677-681[Abstract/Free Full Text].
2.	Siragusa S, Barone M, Serafini S, Beltrametti C, Piovella F. Do patients admitted to the Emergency Department for suspected deep vein thrombosis have signs and symptoms different from those presented by patients admitted to the outpatients clinic? Thromb Haemostas 1999; 82(suppl. 2): 2660.
3.	Hirsh J, Hoak J. Management of deep vein thrombosis and pulmonary embolism. Circulation 1996; 93: 2212-2245[Free Full Text].
4.	Siragusa S, Porta C, Tatoni P, et al. The Home Treatment Program for deep vein thrombosis at the Emergency Department: preliminary results. Haematologica 2000; 85(suppl. 5): 191.