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Hestia Criteria for Pulmonary Embolism Evaluation (In- vs. Out-patient Tx)

Evaluates candidacy for inpatient vs. outpatient PE treatment

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*SBP < 100 mmHg and HR > 100, needing ICU care, or by clinician judgement

Introduction
 

The Hestia Criteria risk assess patients with PE to guide decisions regarding inpatient vs. outpatient PE treatment.

 

The Hestia Criteria have been validated in several studies.  A 2011 validation study determined that patients who were negative for any of the Hestia Criteria:

  • Can be selected for outpatient PE treatment.

  • VTE recurred in 2% of patients (CI 0.8- 4.3.)  None of the recurrences were fatal.

  • None of the patients experienced a recurrent VTE within 7 days of the index event (a period equaling the average duration of hospital admission for PE.)


A 2013 validation study determined the Hestia Criteria can safely select patients with PE for outpatient treatment, irrespective of right ventricular function.

 

An additional 2013 validation study suggested a proportion of patients classified as high risk by sPESI score, for reasons such as malignant disease, advanced age, or cardiopulmonary comorbidities, can be safely treated at home under Hestia Criteria.

 

A 2015 study utilizing the Hestia Criteria suggested the safety of oral rivaroxaban for the treatment of outpatient PE (rivaroxaban dose: 15mg by mouth twice daily for 21 days, followed by 20mg once daily).

 

The predictive accuracy of the Hestia Criteria was confirmed in 2016 by den Exeter (3 month risk of recurrent VTE was 1.1%, CI 0.2-3.2%) and Weeda (acceptable predictive accuracy in patients with advanced age, active malignancy, or cardiopulmonary disease.)


Scoring 

If any of the following Hestia criteria is/are present, the patient is considered "Not Low Risk" and is recommended for inpatient PE treatment.

 

Patients receive +1 point for each present element (no points if absent).

  • Hemodynamically unstable

  • Thrombolysis or embolectomy indicated

  • Need for supplemental oxygen (> 24 hours)

  • PE diagnosed while actively anticoagulated

  • Need for IV pain medication (> 24 hours)

  • Presence of compelling indication or social reason for admission (> 24 hours)

  • Creatinine Clearance < 30 ml/min

  • Presence of severe liver impairment

  • Pregnancy

  • Documented history of Heparin-Induced Thrombocytopenia

Alle Fragen und möglichen Ergebnisse

GuidanceTitel nicht sichtbar
Is the patient hemodynamically unstable?

*SBP < 100 mmHg and HR > 100, needing ICU care, or by clinician judgement

Select one option:

  • No
  • Yes
Is thrombolysis or embolectomy indicated/needed?

*for reasons other than hemodynamic instability

Select one option:

  • No
  • Yes
Does the patient have active bleeding or is at high-risk for bleeding?

High-bleeding risk characteristics includes:

  • GI bleeding or surgery <= 2 weeks ago
  • Stoke <= 1 month ago
  • Bleeding disorder or platelet count < 75,000
  • Uncontrolled HTN (SBP > 180 or DBP < 110 mmHg)
  • High-risk by clinician judgement

Select one option:

  • No
  • Yes
Does the patient need supplemental oxygen for > 24 hours?

*required to maintain SaO2 > 90%

Select one option:

  • No
  • Yes
Was the PE diagnosed while actively anticoagulated?

*and fully compliant

Select one option:

  • No
  • Yes
Does the patient need IV pain medication for severe pain?

*required for > 24 hours

Select one option:

  • No
  • Yes
Is there a compelling medical or social reason for admission of > 24 hours?

*e.g., infection, malignancy, no support system

Select one option:

  • No
  • Yes
Is the patient's creatinine clearance < 30 mL/min?

*CrCl as calculated by Cockcroft-Gault formula

Select one option:

  • No
  • Yes
Does the patient have severe liver impairment?

*per clinician judgement

Select one option:

  • No
  • Yes
Is the patient pregnant?

Select one option:

  • No
  • Yes
Does the patient have a documented history of heparin-induced thrombocytopenia (HIT)?

Select one option:

  • No
  • Yes
Mögliche Ergebnisse
Low Risk: Patient a candidate for outpatient PE treatment

If no criteria are positive, studies indicate a 0% mortality and a 2% VTE recurrence.

Patient is a candidate for outpatient PE treatment.

 

*Note: No decision rule should trump clinical gestalt.*

 

If anticoagulated and treated as an outpatient, the patient must be counseled about the risks of outpatient treatment and should be given close return precautions.

 

The patient should be counseled regarding anticoagulation-related bleeding risks and standard safety precautions while on anticoagulant therapy.

 

The patient should have close outpatient follow-up with a primary care provider.

NOT Low Risk: Recommend admission for inpatient PE treatment

If any criteria are positive, the patient is not a candidate for outpatient PE treatment per the Hestia Criteria and requires initial inpatient admission.

Zitat

Zondag W, Mos IC, Creemers-Schild D, Hoogerbrugge AD, Dekkers OM, Dolsma J, Eijsvogel M, Faber LM, Hofstee HM, Hovens MM, Jonkers GJ, van Kralingen KW, Kruip MJ, Vlasveld T, de Vreede MJ, Huisman MV; Hestia Study Investigators. Outpatient treatment in patients with acute pulmonary embolism: the Hestia Study. J Thromb Haemost. 2011 Aug;9(8):1500-7.

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