Reasons for Hospitalization of Patients with Acute Pulmonary Embolism Based on the Hestia Decision Rule
23 March 2020
05 May 2020
28 June 2020 (online)
Background The Hestia criteria can be used to select pulmonary embolism (PE) patients for outpatient treatment. The subjective Hestia criterion “medical/social reason for admission” allows the treating physician to consider any patient-specific circumstances in the final management decision. It is unknown how often and why this criterion is scored.
Methods This is a patient-level post hoc analysis of the combined Hestia and Vesta studies. The main outcomes were the frequency of all scored Hestia items in hospitalized patients and the explicit reason for scoring the subjective criterion. Hemodynamic parameters and computed tomography-assessed right ventricular (RV)/left ventricular (LV) ratio of those only awarded with the subjective criterion were compared with patients treated at home.
Results From the 1,166 patients screened, data were available for all 600 who were hospitalized. Most were hospitalized to receive oxygen therapy (45%); 227 (38%) were only awarded with the subjective criterion, of whom 51 because of “intermediate to intermediate-high risk PE.” Compared with patients with intermediate risk PE (RV/LV ratio > 1.0) treated at home (179/566, 32%), hospitalized patients with only the subjective criterion had a higher mean RV/LV ratio (mean difference +0.30, 95% confidence interval [CI] 0.19–0.41) and a higher heart rate (+18/min, 95% CI 10–25). No relevant differences were observed for other hemodynamic parameters.
Conclusion The most frequent reason for hospital admission was oxygen therapy. In the decision to award the subjective criterion as sole argument for admission, the severity of the RV overload and resulting hemodynamic response of the patient was taken into account rather than just abnormal RV/LV ratio.
All authors contributed significantly to this manuscript and take responsibility for the analyses. S.H. and F.K. designed the study, interpreted the data, and drafted the manuscript. M.H. designed the study, interpreted the data, and critically revised the manuscript for important intellectual content.
- 1 Konstantinides SV, Meyer G, Becattini C. , et al; ESC Scientific Document Group. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2020; 41 (04) 543-603
- 2 van der Wall SJ, Hendriks SV, Huisman MV, Klok FA. Home treatment of acute pulmonary embolism: state of the art in 2018. Curr Opin Pulm Med 2018; 24 (05) 425-431
- 3 Zondag W, Mos IC, Creemers-Schild D. , et al; Hestia Study Investigators. Outpatient treatment in patients with acute pulmonary embolism: the Hestia Study. J Thromb Haemost 2011; 9 (08) 1500-1507
- 4 den Exter PL, Zondag W, Klok FA. , et al; Vesta Study Investigators *. 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. Am J Respir Crit Care Med 2016; 194 (08) 998-1006
- 5 Vanni S, Becattini C, Nazerian P. , et al. Early discharge of patients with pulmonary embolism in daily clinical practice: a prospective observational study comparing clinical gestalt and clinical rules. Thromb Res 2018; 167: 37-43
- 6 Dentali F, Di Micco G, Giorgi Pierfranceschi M. , et al. Rate and duration of hospitalization for deep vein thrombosis and pulmonary embolism in real-world clinical practice. Ann Med 2015; 47 (07) 546-554
- 7 Wang L, Baser O, Wells P. , et al. Benefit of early discharge among patients with low-risk pulmonary embolism. PLoS One 2017; 12 (10) e0185022
- 8 Zondag W, Kooiman J, Klok FA, Dekkers OM, Huisman MV. Outpatient versus inpatient treatment in patients with pulmonary embolism: a meta-analysis. Eur Respir J 2013; 42 (01) 134-144
- 9 Huisman MV, Barco S, Cannegieter SC. , et al. Pulmonary embolism. Nat Rev Dis Primers 2018; 4: 18028
- 10 Hendriks SV, Huisman MV, Eikenboom JCJ. , et al. Home treatment of patients with cancer-associated venous thromboembolism - an evaluation of daily practice. Thromb Res 2019; 184: 122-128
- 11 Zondag W, Vingerhoets LMA, Durian MF. , et al; Hestia Study Investigators. Hestia criteria can safely select patients with pulmonary embolism for outpatient treatment irrespective of right ventricular function. J Thromb Haemost 2013; 11 (04) 686-692