Comparison of two methods for selection of out of hospital treatment in patients with acute pulmonary embolism

Abstract

The aim of this study is to compare the performance of two clinical decision rules to select patients with acute pulmonary embolism (PE) for outpatient treatment: the Hestia criteria and the simplified Pulmonary Embolism Severity Index (sPESI). From 2008 to 2010, 468 patients with PE were triaged with the Hestia criteria for outpatient treatment: 247 PE patients were treated at home and 221 were treated as inpatients. The outcome of interest was all-cause 30-day mortality. In a post-hoc fashion, the sPESI items were scored and patients were classified according to the sPESI in low and high risk groups. Of the 247 patients treated at home, 189 (77%) patients were classified as low risk according to the sPESI and 58 patients (23%) as high risk. In total, 11 patients died during the first month; two patients treated at home and nine patients treated in-hospital. None of the patients treated at home died of fatal PE. Both the Hestia criteria and sPESI selected >50% of patients as low risk, with good sensitivity and negative predictive values for 30-day mortality: 82% and 99% for the Hestia criteria and 91% and 100% for the sPESI, respectively. The Hestia criteria and the sPESI classified different patients eligible for outpatient treatment, with similar low risks for 30-day mortality. This study suggests that the Hestia criteria may identify a proportion of high risk sPESI patiennts who can be safely treated at home, this however requires further validation.

Outpatient or inpatient treatment for acute pulmonary embolism: a retrospective cohort study of 439 consecutive patients

“…In these patients, the authors found low complication rates (1.0 % mortality, 2.0 % recurrent VTE and 0.7 % major bleeding). Later studies of the same group confirmed the value of HESTIA criteria [1][2][3][13][14][15].…”

Pulmonary embolism: whom to discharge and whom to thrombolyze?

“…The FAST score combines heart-type fatty acid binding protein (H-FABP) (≥ 6 ng mL À1 ), heart rate (> 110 bpm), and syncope [18]. In normotensive patients with PE, the positive predictive value of the FAST score and sPESI for PE-related complications were 22% (95% CI, [14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33] and 11% (95% CI, [8][9][10][11][12][13][14][15][16][17], respectively [18]. Combining patient data from six studies involving 2874 normotensive patients with PE, Bova et al developed a prognostic model for intermediate-risk PE.…”

“…Conversely, among patients treated at hospital according to the Hestia criteria, 86 patients (39%) had a sPESI = 0. The Hestia criteria and the sPESI classified different patients eligible for outpatient treatment, with similar and low mortality rates [22]. Of note, HESTIA and the criteria described by Erkens et al lack external validation yet, whereas PESI and sPESI have been assessed in several independent studies [11].…”

Risk stratification of pulmonary embolism: clinical evaluation, biomarkers or both?

“…Implementing PESI enables the identification of ∼45% of patients with acute PE as low-risk patients and reduces the length of hospitalisation without significantly increasing the risk of death, recurrent PE or major bleeding [4,6]. Patients with normal blood pressure, but higher values of PESI or sPESI, have a mortality risk of ∼5-7% and should be treated at hospital according to ESC guidelines [1,7,8]. The goal of further risk stratification is to select the patients with the highest risk of an adverse event among those with normal blood pressure.…”