Triaging acute pulmonary embolism for home treatment by Hestia or simplified PESI criteria: the HOME-PE randomized trial

Abstract

Aims The aim of this study is to compare the Hestia rule vs. the simplified Pulmonary Embolism Severity Index (sPESI) for triaging patients with acute pulmonary embolism (PE) for home treatment. Methods and results Normotensive patients with PE of 26 hospitals from France, Belgium, the Netherlands, and Switzerland were randomized to either triaging with Hestia or sPESI. They were designated for home treatment if the triaging tool was negative and if the physician-in-charge, taking into account the patient’s opinion, did not consider that hospitalization was required. The main outcomes were the 30-day composite of recurrent venous thrombo-embolism, major bleeding or all-cause death (non-inferiority analysis with 2.5% absolute risk difference as margin), and the rate of patients discharged home within 24 h after randomization (NCT02811237). From January 2017 through July 2019, 1975 patients were included. In the per-protocol population, the primary outcome occurred in 3.82% (34/891) in the Hestia arm and 3.57% (32/896) in the sPESI arm (P = 0.004 for non-inferiority). In the intention-to-treat population, 38.4% of the Hestia patients (378/984) were treated at home vs. 36.6% (361/986) of the sPESI patients (P = 0.41 for superiority), with a 30-day composite outcome rate of 1.33% (5/375) and 1.11% (4/359), respectively. No recurrent or fatal PE occurred in either home treatment arm. Conclusions For triaging PE patients, the strategy based on the Hestia rule and the strategy based on sPESI had similar safety and effectiveness. With either tool complemented by the overruling of the physician-in-charge, more than a third of patients were treated at home with a low incidence of complications.

Development and validation of a prognostic tool: Pulmonary embolism short-term clinical outcomes risk estimation (PE-SCORE)

“…The absence of advanced age or cancer as discrete variables in the PE-SCORE does not prevent these features from being considered by provider’s discretion for social or medical reasons for hospitalization or an increased level of monitoring—an important component of PE-SCORE. Original clinical scores or guidelines, which were developed for outcomes of death, recurrent VTE, or major bleeding 30 days or later, tend to be pragmatically modified or adapted to consider other social/medical conditions or laboratory or imaging findings instead of being used in isolation during clinical practice [ 7 , 13 , 15 , 66 ]. With PE-SCORE, variables for provider discretion on social or medical reasons for hospitalization for increased monitoring and RV imaging assessment are built in.…”

Diagnostik und Therapie der Lungenembolie

“…4 ) integrieren klinische Parameter zum einen des Schweregrads des akuten LE-Ereignisses und zum anderen der Grunderkrankung und/oder der Komorbidität der Patientin/des Patienten [ 15 , 16 ]. Diese Scores ermöglichen eine zuverlässige Prognoseabschätzung und haben ihren Stellenwert insbesondere bei der Identifizierung von Patienten mit niedrigem Risiko, welche für eine Frühentlassung und ambulante Therapie in Frage kommen [ 17 ].…”

The Use of Point-of-Care Ultrasound (POCUS) in the Diagnosis of Deep Vein Thrombosis

“…Unfortunately, these patients would be considered false negative while performing a standard POCUS protocol instead of a full CUS performed by a radiologist [52,53]. POCUS can also have false positives around 4% as reported by Fischer et al, which can lead to unnecessary anticoagulation treatment and risk of bleeding or other complications [11,54]. There are several potential causes of a false positive POCUS evaluation for DVT worth noting.…”