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Not low risk

Patient not eligible for outpatient treatment per the Hestia Criteria, which recommends admission and inpatient treatment.

ADVICE

Patients identified as candidates for outpatient management:

Must be counseled about risks of outpatient treatment and should be given close return precautions.
Should remain in the hospital if there is any evidence of hemodynamic instability.
Should be counseled on risks of bleeding once started on novel oral anticoagulant (NOAC) therapy.

MANAGEMENT

Most hospitals have particular DVT/PE order sets or guidelines for management.
Management typically includes the following:

Heparin drip or enoxaparin with bridging to warfarin.
Serial PT/PTT.
Telemetry and monitoring.

Alternative:

Treatment with a NOAC.

CRITICAL ACTIONS

Does not apply in patients with hemodynamic instability or those not being considered for outpatient management.
If the patient is being considered for outpatient management, this tool may be used to help justify avoiding inpatient hospitalization.
No decision rule should trump clinical gestalt.

FORMULA

If ≥1 present, patient is not eligible for outpatient management by Hestia Criteria.

Hestia Criteria

Hemodynamically unstable*

Thrombolysis or embolectomy needed

Active bleeding or high risk for bleeding**

>24 hrs on supplemental oxygen required to maintain SaO2 >90%

PE diagnosed while on anticoagulation

Severe pain needing IV pain medication required >24 hr

Medical or social reason for admission >24 hr (infection, malignancy, no support system)

Creatinine clearance <30 mL/min by Cockcroft-Gault formula

Severe liver impairment***

Pregnant

Documented history of heparin-induced thrombocytopenia (HIT)

*sBP <100 mmHg and HR >100, needing ICU care, or by clinician judgment.

**GI bleeding or surgery within 2 weeks, stroke within 1 month, bleeding disorder or thrombocytopenia (platelet count <75 × 109/L), uncontrolled HTN (sBP >180 or dBP >110), or by clinician judgment.

***By clinician judgment.

FACTS & FIGURES

Hestia Criteria	Risk
0 points	Low (0% mortality, 2% VTE recurrence)
>0 points	Not low

EVIDENCE APPRAISAL

The Hestia Criteria were first derived by Zondag et al in 2011 and have been validated in multiple additional studies.

Zondag 2011:

Patients with PE selected for outpatient treatment with predefined criteria can be treated with anticoagulants on an outpatient basis.
VTE recurred in 2% of patients, with the upper limit of the confidence interval (CI) reaching 4.3%, which is lower than the predefined limit of 7%. None of the recurrences was fatal.
None of the patients experienced a recurrent VTE event within seven days of the initial event, a period that equals the average duration of hospital admission for PE.

Zondag 2013, “Hestia Criteria can safely select patients with pulmonary embolism for outpatient treatment irrespective of right ventricular function”:

Study including 496 patients, found sensitivity 82% (95% CI 0.52–0.95) and specificity of 56% (95% CI 0.52–0.61).
A 3-month follow-up period revealed a mortality rate of approximately 1%, although no deaths were caused by PE. Recurrent VTE occurred in 2.0% of the outpatient treatment group. Major bleeding occurred in <1% of patients.
The Hestia Criteria have a greater predictive value of adverse clinical outcome when compared to the European Society of Cardiology guidelines (which use biomarkers and echocardiography).
Results suggest that a proportion of patients with right ventricular (RV) dysfunction who could be treated at home safely can be pre-identified. Clinical criteria, such as the Hestia Criteria, could be helpful in selecting patients with RV dysfunction who have a very low risk of an adverse clinical outcome and could be candidates for outpatient treatment.

Zondag 2013, “Comparison of two methods for selection of out of hospital treatment in patient with acute pulmonary embolism”:

This study suggests that a proportion of patients classified as high risk by sPESI for reasons such as malignant disease, cardiopulmonary comorbidities or old age, can be safely treated at home when the Hestia Criteria are applied.
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.
Of the 247 patients treated at home, 189 (77%) patients were classified as low risk according to sPESI and 58 patients (23%) as high risk.
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 sPESI, respectively.
This study demonstrated that 1/4 of patients treated at home safely in the Hestia study would have been classified as high risk by the sPESI and therefore would not have been eligible for outpatient treatment according to sPESI.

Beam 2015:

This study evaluated the use of rivaroxaban 15 mg by mouth twice daily for 21 days, followed by 20 mg once per day. Investigators used modified Hestia exclusion criteria* to identify patients at low risk for adverse outcome. In this cohort of 106 patients discharged with VTE, 28% had PE, 67% had DVT, and 5% had combined DVT and PE. No patients experienced a new VTE, while 3 patients experienced recurrent VTE after treatment discontinuation. No patients experienced major bleeding.
These results suggest safety of oral rivaroxaban for the outpatient treatment of low-risk VTE.

Den Exter 2016:

Among patients sent home on the basis of the Hestia clinical decision rule alone, the 3-month risk of recurrent VTE was 1.1% (95% CI: 0.2–3.2%). The upper limit of the CI was well within the predefined safety limit of 7%; hence, this study serves as an external validation of the Hestia clinical decision rule.
This trial confirms that outpatient treatment of acute PE, selected on the basis of the Hestia clinical decision rule alone, is feasible and associated with low risk of adverse events.

Weeda 2016:

The Hestia Criteria have an acceptable predictive accuracy to identify patients with PE at low risk for in-hospital or 30-day mortality, and the sensitivity and NPV of the Hestia Criteria remained high in advanced age patients and those concomitantly diagnosed with active cancer or cardiopulmonary disease.
The Hestia Criteria had excellent sensitivity (100%, 95% CI 79.1–100%) and NPV (100%, 95% CI 87.7–100%) for predicting in-hospital and 30-day mortality, but low specificity.
In hospital positive likelihood ratio = 1.36 (sensitivity 100%, specificity 26.7%).
30-day mortality positive likelihood ratio = 1.38 (sensitivity 100%, specificity 27.5%)

*Modified Hestia criteria used in Beam 2015:

Systolic hypotension (<100 mm Hg and no history of low BP at baseline).
Contraindication to low molecular weight heparin or warfarin treatment: active bleeding or high‐risk postoperative status, creatinine clearance <30 mL/min, history of heparin‐induced thrombocytopenia, or warfarin skin necrosis).
Other medical condition requiring hospital treatment (e.g. sepsis, new or decompensated existing organ failure, intractable pain).
Social condition requiring hospital treatment (e.g. homelessness with history of nonadherence to treatment, suspected neglect or abuse, untreated psychosis, severe alcohol or drug dependency).
Coagulopathy, any INR >1.7, or thrombocytopenia (platelet count <50 × 109/L).
Pregnancy.
Incarceration

Hestia Criteria for Outpatient Pulmonary Embolism Treatment