Comparison of two methods for selection of out of hospital treatment in patients with acute pulmonary embolismFinancial support: This study was funded by an unrestricted research grant from Glaxo Smith Klein, The Netherlands BV.
06 July 2012
Accepted after major revision: 08 October 2012
27 November 2017 (online)
The aim of this study is to compare the performance of two clinical decision rules to select patients with acute pulmonary embolism (PE) for outpatient treatment: the Hestia criteria and the simplified Pulmonary Embolism Severity Index (sPESI). From 2008 to 2010, 468 patients with PE were triaged with the Hestia criteria for outpatient treatment: 247 PE patients were treated at home and 221 were treated as inpatients. The outcome of interest was all-cause 30-day mortality. In a post-hoc fashion, the sPESI items were scored and patients were classified according to the sPESI in low and high risk groups. Of the 247 patients treated at home, 189 (77%) patients were classified as low risk according to the sPESI and 58 patients (23%) as high risk. In total, 11 patients died during the first month; two patients treated at home and nine patients treated in-hospital. None of the patients treated at home died of fatal PE. Both the Hestia criteria and sPESI selected >50% of patients as low risk, with good sensitivity and negative predictive values for 30-day mortality: 82% and 99% for the Hestia criteria and 91% and 100% for the sPESI, respectively. The Hestia criteria and the sPESI classified different patients eligible for out-patient treatment, with similar low risks for 30-day mortality. This study suggests that the Hestia criteria may identify a proportion of high risk sPESI patiennts who can be safely treated at home, this however requires further validation.
* Both authors contributed equally to the manuscript.
- 1 Kearon C, Akl EA, Comerota AJ. et al. Antithrombotic Therapy for VTE Disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141: e419S-e494S. DOI:10.1378/chest.11-2301.
- 2 Torbicki A, Perrier A, Konstantinides S. et al. Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J 2008; 29: 2276-2315. DOI:10.1093/eurheartj/ehn475.
- 3 Kovacs MJ, Anderson D, Morrow B. et al. Outpatient treatment of pulmonary embolism with dalteparin. Thromb Haemost 2000; 83: 209-211.
- 4 Zondag W, Mos IC, Creemers-Schild D. et al. Outpatient treatment in patients with acute pulmonary embolism: the Hestia Study. J Thromb Haemost 2011; 09: 1500-1507. DOI:10.1111/j.1538-7836.2011.04388.x.
- 5 Agterof MJ, Schutgens RE, Snijder RJ. et al. Out of hospital treatment of acute pulmonary embolism in patients with a low NT-proBNP level. J Thromb Haemost 2010; 08: 1235-1241. DOI:10.1111/j.1538-7836.2010.03831.x.
- 6 Otero R, Uresandi F, Jimenez D. et al. Home treatment in pulmonary embolism. Thromb Res 2010; 126: e1-e5. DOI:10.1016/j.thromres.2009.09.026.
- 7 Aujesky D, Obrosky DS, Stone RA. et al. Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med 2005; 172: 1041-1046. DOI:10.1164/rccm.200506-862OC.
- 8 Donze J, Le Gal G, Fine MJ. et al. Prospective validation of the Pulmonary Embolism Severity Index. A clinical prognostic model for pulmonary embolism. Thromb Haemost 2008; 100: 943-948.
- 9 Aujesky D, Roy PM, Verschuren F. et al. Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial. Lancet 2011; 378: 41-48. DOI:10.1016/S0140-6736(11)60824-6.
- 10 Jimenez D, Aujesky D, Moores L. et al. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med 2010; 170: 1383-1389. DOI:10.1001/archinternmed.2010.199.
- 11 Howard L, Salooja N. Outpatient management of pulmonary embolism. Lancet 2011; 378: 5-6. DOI:10.1016/S0140-6736(11)60932-X.
- 12 Erkens PM, Gandara E, Wells PS. et al. Does the Pulmonary Embolism Severity Index accurately identify low-risk patients eligible for outpatient treatment?. Thromb Res 2011; 129: 710-714. DOI:10.1016/j.thromres.2011.08.025.
- 13 Righini M, Roy PM, Meyer G. et al. The Simplified Pulmonary Embolism Severity Index (PESI): validation of a clinical prognostic model for pulmonary embolism. J Thromb Haemost 2011; 09: 2115-2117. DOI:10.1111/j.1538-7836.2011.04469.x.
- 14 Sam A, Sanchez D, Gomez V. et al. The shock index and the simplified PESI for identification of low-risk patients with acute pulmonary embolism. Eur Respir J 2011; 37: 762-766. DOI:10.1183/09031936.00070110.
- 15 Sorensen HT, Mellemkjaer L, Olsen JH. et al. Prognosis of cancers associated with venous thromboembolism. N Engl J Med 2000; 343: 1846-1850. DOI:10.1056/NEJM200012213432504.