HESTIA rule as good as sPESI score for triaging PE patients for home treatment

Triaging patients with pulmonary embolism (PE) using a strategy based on either the HESTIA criteria or the simplified Pulmonary Embolism Severity Index (sPESI) score guides decisions on whom to safely send home to receive outpatient care, according to the results of the HOME-PE* trial.

With respect to the primary composite endpoint of recurrent venous thromboembolism, major bleeding, or death at 30 days, the pragmatic HESTIA method was at least as safe as the sPESI score for triaging haemodynamically stable PE patients for outpatient management, said principal study author Dr Pierre-Marie Roy of the University Hospital of Angers, France.

Presented at this year’s virtual European Society of Cardiology (ESC) meeting, HOME-PE included 1,974 patients (average age, 60 years; 20 percent had cancer) with normal blood pressure presenting to the emergency department within 24 hours of acute PE. The study was conducted in 26 hospitals in France, Belgium, the Netherlands, and Switzerland.

Patients randomized to the sPESI arm were deemed low risk and eligible for PE treatment at home if the score was 0, while in the HESTIA arm, patients had to meet none of the exclusion criteria of the rule. Otherwise, they were hospitalized. The physician-in-charge could overrule the decision for medical or social reasons.

Initially, a greater proportion of patients in the sPESI arm were eligible for home care (48.4 percent vs 39.4 percent), but sPESI score-based decisions were more often overruled than those made according to the HESTIA rule (29 percent vs 3 percent). In the end, the proportion of patients discharged within 24 hours for home treatment were similar in the two arms (36.6 percent vs 38.4 percent; p=0.42).

Roy stressed that the applicability of the HESTIA rule was better, with less decisions being overruled by the physician-in-charge.

All patients managed at home had a low rate of complications, with the composite endpoint occurring similarly in the HESTIA and sPESI arms (3.8 percent and 3.6 percent of patients). This indicated that the HESTIA strategy was not inferior to the latter (p=0.005 for noninferiority).

The risk of adverse events was low with both strategies, Roy said. There were two cases of death, one in each study arm, both due to cancer.

“These results support outpatient management of acute PE patients using either the HESTIA method or the sPESI score with the option for physicians to override the decision,” he added. “In hospitals organized for outpatient management, both triaging strategies enable more than a third of PE patients to be managed at home with a low rate of complications.”

Currently, international recommendations cite that patients with low-risk PE should be considered for early discharge and continuation of treatment at home, so long as proper care and anticoagulant medication can be provided. European guidelines recommend using the sPESI score to assess the risk of all-cause mortality, whereas American guidelines do not require a predefined score and advise using a list of pragmatic criteria, such as the HESTIA rule. [Eur Heart J 2020;41:543-603; Chest 2016;149:315-352]

*HESTIA versus simplified PESI: an international multicentre randomized controlled study