Withholding treatment in patients with acute pulmonary embolism who have ahigh risk of bleeding and negative serial noninvasive leg tests

PURPOSE: Patients who have nonmassive acute pulmonary embolism and a high r isk of bleeding or contraindication to anticoagulants, such recent surgery or gastrointestinal bleeding, present a clinical dilemma. We sought to esti mate whether such patients could be safely left untreated if serial compres sion ultrasound or serial impedance plethysmography were negative and cardi orespiratory reserve was adequate. SUBJECTS AND METHODS: The frequency of recurrent pulmonary embolism among p atients with nonmassive acute pulmonary embolism and negative serial noninv asive leg tests who were not treated was estimated from two prospective stu dies of the noninvasive management of patients with suspected pulmonary emb olism. One of the studies used serial impedance plethysmography of the lowe r extremities; the other used serial compression ultrasound. The prevalence of pulmonary embolism in patients with nondiagnostic ventilation/perfusion lung scans was determined from the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED). RESULTS: The estimated frequency of fatal recurrent pulmonary embolism was 1% [95% confidence interval (CI), 0% to 5%) among untreated patients with n onmassive pulmonary embolism who had negative serial impedance plethysmogra ms and 0% (95% CI, 0% to 4%) among those with negative serial compression u ltrasonograms. The frequency of nonfatal recurrent pulmonary embolism among untreated patients was 3%, regardless of whether they had negative serial impedance plethysmograms or negative serial compression ultrasonograms. The se results were comparable with the frequency of recurrent pulmonary emboli sm among patients treated with anticoagulants or with inferior vena cava fi lters. CONCLUSION: Withholding treatment of nonmassive acute pulmonary embolism, i f serial impedance plethysmograms or serial venous ultrasonograms are negat ive and cardiopulmonary reserve is adequate, is a possible strategy for the management of patients with a high risk of bleeding or other contraindicat ion to anticoagulants. This strategy may be associated with fewer adverse e vents than treatment with anticoagulants or an inferior vena cava filter. P rospective trials comparing alternative treatments are needed. Am J Med. 20 00;109:301-306. (C) 2000 by Excerpta Medica, Inc.