Hospitalization or Outpatient Management of Patients with Pulmonary Embolism: HESTIA versus simplified PESI

Presented at the ESC congress 2020 by Pierre-Marie Roy (Angers, France)

Introduction and methods

Several studies have demonstrated the possibility of home treatment for low risk pulmonary embolism (PE) patients, if proper outpatient care and anticoagulant therapy can be provided. However, controversy persists on triage strategy on eligibility criteria for outpatient management. The ESC recommends to use an all-cause mortality risk assessment, using the simplified PESI score, but ACC does not recommend a predefined scoring system and suggests to use a list of pragmatic criteria, such as the HESTIA rule.

Therefore, two triage strategies for outpatient treatment of PE patients were compared in a controlled randomized trial, the HOME-PE study, with blind adjudication of end points. 1974 Patients were enrolled in the emergency department within 24 hours following diagnosis. Patients were randomized to triage based on the HESTIA rule (containing 11 criteria, with 0 criteria the patient is negative and eligible to go home) or the sPESI rule (containing 6 criteria, with sPESI=0 patient is eligible to go home). Non-inferiority was tested for strategy based on the HESTIA rule vs. strategy based on sPESI. Outcome was a composite of recurrent VTE, major bleeding or death after 30 days.

*IMain results *I

• Triage strategy based on HESTIA scoring was non-inferior to sPESI scoring for the outcome of adverse events (3.8% for the HESTIA group vs. 3.6% for the sPESI group, adjusted absolute difference: -.20% [-1.03 to 1.43], Pnon-inferiority=0.005).
• Based on the HESTIA score, there were less low-risk patients who could be referred to outpatient management compared to sPESI score (39% of patients in the HESTIA group were negative vs. 48% of patients in the sPESI group had sPESI=0).
• There was less overruling the physician-in-charge in the HESTIA negative group compared to the sPESI=0 group (3% in the HESTIA group vs. 29% in the sPESI group).
• There was no significant difference in the rate of patients managed at home.

Conclusion

The HOME-PE study demonstrated that triage strategy based on the pragmatic rule, HESTIA, was non-inferior to the strategy based on the severity risk assessment score, sPESI, with regard to a composite end point of recurrent venous thromboembolism, major bleeding and death in patients with acute PE. The authors conclude that outpatients care can be safely performed for patients with acute PE, using either the HESTIA rule or the sPESI score with overruling by the physician-in-charge.

- Our reporting is based on the information provided at the ESC congress -

Watch a video by prof. Huisman on the HOME-PE trial