Comprehensive Management of Acute Pulmonary Embolism in Primary Care Using Telemedicine During the COVID-19 Pandemic

Background: During the COVID-19 pandemic, there has been increasing reliance on telemedicine to provide timely, low-risk, and accessible care. This may include triage, diagnosis, and management of acute pulmonary embolism (PE). While major society guidelines recommend outpatient management of low-risk PE, little research has evaluated primary care-based management. We present a case of comprehensive clinic-based outpatient PE management using telemedicine, including video visit, telephone follow-up, and secure messaging in a system with an integrated electronic health record. Case Presentation: A healthy, active woman in her 70s with a remote history of provoked PE presented to her primary care physician (PCP) with 2-3 months of dyspnea on exertion during the COVID-19 pandemic. She denied chest pain, cough, fevers, and dyspnea at rest. There was no recent surgery, reduced mobility, or history of malignancy. The initial visit was conducted through secure video interface due to pandemic restrictions on in-person visits. The PCP noted that the patient appeared in stable condition without respiratory distress. Outpatient laboratory work-up showed normal complete blood count and elevated D-dimer of 2.41 mcg/mL (normal <0.5 mcg/mL). Results and next steps were discussed with the patient via secure messaging, at which time the patient reported mild improvement in symptoms. Outpatient computed tomography pulmonary angiography demonstrated new partial filling defects in the right segmental arteries. The presentation was categorized as low-risk with a probable Class II PE Severity Index score and no apparent Hestia criteria. The PCP obtained same-day telephone consult with hematology, who advised indefinite anticoagulation therapy. Rivaroxaban was promptly initiated. The pharmacy-led anticoagulation management service provided next-day patient education by telephone and supplemental instructions by secure messaging. The patient had a follow-up secure video visit with hematology one week after her PE diagnosis. After completing one month of rivaroxaban treatment, the patient requested to switch to dabigatran, with which she has continued. She has experienced no bleeding complications nor recurrence of venous thromboembolism. Discussion: Our patient's low-risk PE presentation was appropriate for outpatient management and was particularly well-suited for telemedicine given her familiarity with technology, established PCP relationship, access to diagnostic testing, and prior PE as well as anticoagulation experience. This case demonstrates that telemedicine may be used safely and effectively in the diagnosis and management of acute PE without the need for transfer to a higher level of care, given an eligible patient in the right care setting supported by adequate resources and infrastructure.