Out-patient treatment of acute pulmonary embolism and fresh proximal deep vein thrombosis with low molecular weight heparin

History and clinical findings: A 39 year-old man presented with dyspnoe and calf pain. Aside from two long-distance flights there were no triggering e vents for deep vein thrombosis (DVT). 6 years before the patient had had a spontaneous DVT. Family history concerning DVT was negative. Investigations: The patient presented with tachypnoe but no significant dys pnoe at rest. Color-coded duplex scan revealed a free floating thrombus in the left femoral vein, lung perfusion scan exhibited perfusion defects on t he right side with a high probability for pulmonary embolism (PE). Echocard iography showed no signs of right ventricular failure. Thrombophilia screen ing was normal including prothrombin and factor V gene analysis. Treatment and course: As the patient refused hospital admission, after info rmed consent he was treated on an out-patient basis with low molecular weig ht heparin (LMWH) with the dosage adjusted to body weight, despite of the p ending licensing of most LMWH for PE. Compression therapy was initiated and patient education on self-injection was performed. On the second day, oral anticoagulation was initiated. The further course was uneventful and long- term oral anticoagulation was continued. Conclusion: LMWH is at least as sa fe and effective as unfractionated heparin for the treatment of DVT, and it had been demonstrated that out-patient treatment of patients with DVT is s afe. For PE however, most LMWHs are not yet licensed in Germany, even thoug h recent studies show that they are safe and effective in the same dosis re gimen. As data on out-patient treatment of PE are sparse, out-patient treat ment of symptomatic PE seems not generally advisible at present, although - as shown in the present case - it is feasible under particular circumstanc es.