Hestia Criteria for Pulmonary Embolism Evaluation (In- vs. Out-patient Tx)
Evaluates candidacy for inpatient vs. outpatient PE treatment
Kelly Rudd
Provided by
OSU Center for Health Sciences*SBP < 100 mmHg and HR > 100, needing ICU care, or by clinician judgement
*for reasons other than hemodynamic instability
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
*required to maintain SaO2 > 90%
*and fully compliant
*required for > 24 hours
*e.g., infection, malignancy, no support system
*CrCl as calculated by Cockcroft-Gault formula
*per clinician judgement
Usage
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.)
Summary
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
All questions & possible results
GuidanceTitle not visible
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?
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
Possible results
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.
Literature
- Outpatient treatment in patients with acute pulmonary embolism: the Hestia Study (2011) — Zondag W, et al.
- Hestia criteria can safely select patients with pulmonary embolism for outpatient treatment irrespective of right ventricular function (2013) — Zondag W, et al.
- Comparison of two methods for selection of out of hospital treatment in patients with acute pulmonary embolism (2013) — Zondg W, et al.
- Immediate Discharge and Home Treatment With Rivaroxaban of Low-risk Venous Thromboembolism Diagnosed in Two U.S. Emergency Departments: A One-year Preplanned Analysis (2015) — Beam D, Kahler Z, Kline J
- Efficacy and Safety of Outpatient Treatment Based on the Hestia Clinical Decision Rule with or without N-Terminal Pro-Brain Natriuretic Peptide Testing in Patients with Acute Pulmonary Embolism. A Randomized Clinical Trial (2016) — den Exeter PL, et al.
- External Validation of the Hestia Criteria for Identifying Acute Pulmonary Embolism Patients at Low Risk of Early Mortality (2016) — Weeda E, et al.
- 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS) — European Society of Cardiology
- Antithrombotic Therapy for VTE Disease (2021) — American College of CHEST Physicians
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