Hestia criteria can safely select patients with pulmonary embolism for outpatient treatment irrespective of right ventricular function

Abstract

Summary. Background: There has been debate over how patients with pulmonary embolism (PE) can be safely selected for outpatient treatment. Objectives: To compare the Hestia criteria with the European Society of Cardiology (ESC) criteria for selecting low-risk patients with PE for outpatient treatment. Methods: From 2008 to 2010, 496 patients with acute, symptomatic PE were screened and 275 treated at home and 221 treated in the hospital according to the Hestia Study protocol. The Hestia criteria were used to select patients for outpatient treatment. Right and left ventricular (RV and LV) diameters were measured on computed tomography images. RV dysfunction was defined as an RV/LV ratio > 1.0. Patients were classified according to the ESC criteria into low, intermediate and high-risk groups, based on blood pressure and RV dysfunction. During 3 months follow-up adverse events were scored. Results: Adverse events occurred in 22 patients (4.5%) treated in the hospital vs. none of the patients treated at home (P < 0.001). Sensitivity and negative predictive value for adverse outcome were 100% for the Hestia criteria and 96% and 99% for the ESC criteria, respectively. Of the patients treated at home according to the Hestia criteria, 35% were normotensive but had RV dysfunction and were classified as intermediate risk according to the ESC criteria. No adverse events happened in these patients treated at home. Conclusions: Clinical criteria, such as the Hestia criteria, could be helpful in selecting patients, including those with RV dysfunction who have a low risk of adverse clinical outcome and could be candidates for outpatient treatment.

Computed tomography to assess risk of death in acute pulmonary embolism: a meta-analysis

“…The association between death at 30 days and right ventricle dilation was confirmed in a separate analyses for right-to-left ventricle diameter ratio assessed either in transverse images ( Six studies (2254 patients) reported on right-to-left ventricle diameter ratio (all measuring transverse images) in haemodynamically stable patients [11,32,34,44,49,53]. The meta-analysis of these studies revealed an increased risk of death at 30 days in patients with right-to-left ventricle diameter ratio, the OR was 1.64 (95% CI 1.06-2.52; p50.03, I 2 0%) ( fig.…”

“…Eight studies (2925 patients) reported on death due to pulmonary embolism at 30 days [11,32,36,38,39,44,49,53]. Analysing these studies an association was found between right-to-left ventricle ratio and death due to pulmonary embolism (OR 7.35 (95% CI 3.59-15.09); p,0.00001, I 2 16%) ( fig.…”

The role of computed tomography in the diagnosis of acute and chronic pulmonary embolism

“…By ESC consensus criteria, RV/LV diameter ratio <1 in combination with advantageous clinical parameters may be used as to help select patients who may be treated at home instead of hospital (21). However, the recent Hestia Study has suggested that hemodynamically stable patients with asymptomatic RV dysfunction as assessed by RV/LV diameter ratio >1.0 may also be treated safely at home when appropriately selected based on the Hestia criteria risk checklist (75). Many other secondary CT signs of RV dysfunction such as interventricular septum bowing, inferior vena cava reflux, and pulmonary artery diameter exceeding that of the aorta have been recognized, although without direct association with short-term mortality in acute PE (76).…”

Pulmonary embolism: whom to discharge and whom to thrombolyze?

“…In addition, this was not confirmed in all studies [25,26]. These results suggest that biomarkers and imaging data have probably a limited role in the selection of low-risk patients for outpatient treatment.…”

“…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.…”