Risk Stratification PE
Among patients with PE, risk stratification with the HESTIA rule was noninferior to the PESI score on all-cause death, recurrent VTE, or major bleeding. The two strategies were similar regarding the proportion of patients treated at home - Anthony A. Bavry MD
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PE risk stratification: which tool is best?
Your patient with a newly diagnosed PE hates hospitals. He or she agrees to defer to your judgement about admission versus discharge home, but makes it clear they would prefer to go home if it is safe. Which tool should you use to help you decide? Up until recently, there were no prospective studies comparing sPESI (simplified pulmonary embolism severity index) and Hestia, the leading risk stratification tools for PE. Finally, in August 2018, a single center, prospective cohort study including 488 patients newly diagnosed with PE was published that compared the two scores head to head. Reassuringly, both scores identified similar numbers of low risk patients (sPESI 28%, Hestia 27%). Interestingly,…
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Outpatient PE – sPESI or Hestia?
ACEP and CHEST guidelines are encouraging us to send more patients home from the ED rather than admit. Until now, there has never been a prospective head-to-head comparison of the leading risk stratification scores— sPESI and Hestia.
Outpatient Treatment for Pulmonary Embolism
Patients who are classified as low risk by Hestia criteria or clinician judgment and sPESI score, have access to DOAC medication and outpatient follow-up, and have appropriate social support can be discharged home with outpatient therapy.
Two triaging strategies equally safe for facilitating outpatient care of acute PE
HOME-PE is the first prospective, randomized trial to compare the sPESI and Hestia triaging strategies for outpatient treatment of patients with acute PE. The trial was conducted from 2017 to 2019 at 26 hospitals in Belgium, France, Switzerland and the Netherlands that, prior to study initiation, had set up a thrombosis team for outpatient PE care.
When I treat a patient with acute pulmonary embolism at home
Home treatment is feasible and safe in selected patients with acute pulmonary embolism (PE) and is associated with a considerable reduction in health care costs. When establishing a PE outpatient pathway, 2 major decisions must be made. The first one concerns the selection of patients for home treatment. The second one involves dedicated outpatient follow-up including sufficient patient education and facilities for specialized follow-up visits. Current evidence points toward the use of either the Hestia criteria or Pulmonary Embolism Severity Index with/without assessment of the right ventricular function to select patients for home treatment, depending on local preferences.
Articles of Interest
Ambulatory Management of PE: A Comparison of Two Risk-Stratification Scores
The HOME-PE (HESTIA Rule vs. Simplified PESI for Home Treatment of Patients With Acute Pulmonary Embolism) study compared two risk-stratification strategies—the HESTIA rule and simplified Pulmonary Embolism Severity Index (sPESI)—to identify low-risk patients with pulmonary embolism (PE). The study showed that the HESTIA rule was non-inferior to sPESI in the primary outcome of all-cause mortality, recurrent venous thromboembolism (VTE), and major bleed and that about one-third of patients with PE presenting to emergency department can be effectively managed at home. Both the HESTIA rule and sPESI are acceptable strategies for screening potential candidates for ambulatory management of PE.
A clinical decision framework to guide the outpatient treatment of emergency department patients diagnosed with acute pulmonary embolism or deep vein thrombosis: Results from a multidisciplinary consensus panel
The outpatient treatment of select emergency department patients with acute pulmonary embolism (PE) or deep vein thrombosis (DVT) has been shown to be safe, cost effective and associated with high patient satisfaction. Despite this, outpatient PE and DVT treatment remains uncommon.
HESTIA Rule vs. Simplified PESI for Home Treatment of Patients With Acute Pulmonary Embolism - HOME-PE
Among patients with PE, risk stratification with the HESTIA rule was noninferior to the PESI score on all-cause death, recurrent VTE, or major bleeding. The two strategies were similar regarding the proportion of patients treated at home. By using risk stratification, approximately one-third of low-risk patients with PE could be safely managed at home.
HOME-PE trial clarifies which patients with acute PE can be managed at home
Patients with acute pulmonary embolism (PE) can be selected for home management using the sPESI score or the Hestia criteria, according to results of the HOME-PE trial presented in a Hot Line session at the European Society of Cardiology (ESC) Congress 2020.
HOME-PE: Comparison of U.S. and European-Recommended Outpatient Care Triaging Strategies For Acute Pulmonary Embolism
"These results support outpatient management of acute pulmonary embolism patients using either the HESTIA method or the sPESI score with the option for physicians to override the decision," Roy said. "In hospitals organized for outpatient management, both triaging strategies enable more than a third of pulmonary embolism patients to be managed at home with a low rate of complications."
Identify patients with PE who can be treated as outpatient or early discharge from hospital
Recently, there have been a number of clinical studies performed to define the subset of patients with PE at low risk for early mortality and adverse outcomes in order to systematically identify those individuals who can be treated as an outpatient or discharged early from the emergency room or after a short-stay hospitalization. A meta-analysis of patients with acute PE managed at home or early discharge from the hospital using the original Pulmonary Embolism Severity Index (PESI) that looked at 11 factors, simplified PESI (sPESI) 6 factors, or HESTIA rule (11 factors) (see tables below) developed criteria for this purpose. Using these criteria, early complication rates (1-3 months) including thromboembolic recurrences or major bleeding was <2% and early mortality (30-day) was < 3%.
Outpatient treatment of pulmonary embolism
The Hestia criteria were developed for application in haemodynamically stable patients with acute PE. They contain a number of clinical parameters concerning PE severity and comorbidity. If all parameters are absent, the Hestia result is negative and home management of PE can be considered. A negative Hestia result is associated with 0% mortality and 2% venous thromboembolism (VTE) recurrence.
Prognostic Performance of Hestia Criteria in Acute Pulmonary Embolism: A Systematic Review and Meta-Analysis
The result of our meta-analysis indicate that Hestia criteria can effectively identify PE patients at low risk of poor prognosis with high sensitivity and NPV, but its prognostic role in patients with higher risk class still need to be verified.
The Hestia Score & Outpatient Treatment of Pulmonary Embolism
After you update Mr. X and his family on the results, they ask about next steps– will he need to stay in the hospital, or can he go home? You ponder this question, thinking about his malignancy, the evidence of mild right heart strain, and his age. You recall that one of your residency classmates had been talking about a scoring system to identify patients who could go home on oral anticoagulants after a PE diagnosis, so you open up MD Calc on your phone and start scrolling…
Resources
Hestia Criteria
Identifies low-risk PE patients safe for outpatient treatment.
Simplified PESI (Pulmonary Embolism Severity Index)
Predicts 30-day outcome of patients with PE, with fewer criteria than the original PESI.
