Low risk patients, identified by low clinical scores such as (s)PESI, should be considered for early discharge to home as their mortality on ambulatory anticoagulant treatment is <1%. Studies on new oral anticoagulants (dabigatran, rivaroxaban and apixaban) - as well as results of the Hokusai-VTE trial (edoxaban) revealed during this Congress offer a new quality of treatment, including lower bleeding risk, crucial in early discharged patients.
The optimal treatment strategy in patients at intermediate risk of early death, identified by more comprehensive laboratory cardiovascular assessment, is less clear.
New data from a large prospective randomized trial suggest that patients with RV dysfunction on imaging (echo or CT) and a positive troponin I or T test could benefit from treatment with thrombolysis to prevent early haemodynamic decompensation without, however, reducing all-cause mortality and at the cost of an increased risk of stroke.
Better stratification of bleeding risk, as well as safer thrombolytic regimens are necessary to implement such a strategy in clinical practice. The potential role of low dose and/or local thrombolysis, which could also be enhanced by application of therapeutic intravascular ultrasound, awaits further research.