The Hestia Score & Outpatient Treatment of Pulmonary Embolism

Washington University Emergency Medicine Journal Club– January 18th, 2023


You are moonlighting in a large community hospital ED one afternoon when you encounter Mr. X, a pleasant 68-year-old man with a history of non-small cell lung cancer on chemotherapy, hypertension, and diabetes mellitus. He complains of sudden-onset left-sided pleuritic chest pain and dyspnea. He is mildly tachycardic and somewhat tachypneic but has a normal oxygen saturation and blood pressure and appears overall well and non-toxic. You astutely suspect an acute pulmonary embolism (PE); because your pre-test probability is high, you forgo D-dimer testing and order a CT PE protocol. The CT demonstrates an acute segmental pulmonary embolism; the radiologist also comments that the right heart appears somewhat enlarged. The remainder of Mr. X’s workup is notable for a slightly elevated NT-proBNP, normal troponin, and mild RV dilation on point of care cardiac ultrasound. 

After you update Mr. X and his family on the results, they ask about next steps– will he need to stay in the hospital, or can he go home? You ponder this question, thinking about his malignancy, the evidence of mild right heart strain, and his age. You recall that one of your residency classmates had been talking about a scoring system to identify patients who could go home on oral anticoagulants after a PE diagnosis, so you open up MD Calc on your phone and start scrolling…

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Article 1: Roy PM, Penaloza A, Hugli O, Klok FA, Arnoux A, Elias A, Couturaud F, Joly LM, Lopez R, Faber LM, Daoud-Elias M, Planquette B, Bokobza J, Viglino D, Schmidt J, Juchet H, Mahe I, Mulder F, Bartiaux M, Cren R, Moumneh T, Quere I, Falvo N, Montaclair K, Douillet D, Steinier C, Hendriks SV, Benhamou Y, Szwebel TA, Pernod G, Dublanchet N, Lapebie FX, Javaud N, Ghuysen A, Sebbane M, Chatellier G, Meyer G, Jimenez D, Huisman MV, Sanchez O; HOME-PE Study Group. Triaging acute pulmonary embolism for home treatment by Hestia or simplified PESI criteria: the HOME-PE randomized trial. Eur Heart J. 2021 Aug 31;42(33):3146-3157. doi: 10.1093/eurheartj/ehab373. PMID: 34363386; PMCID: PMC8408662.

Article 2: Zondag W, Mos IC, Creemers-Schild D, Hoogerbrugge AD, Dekkers OM, Dolsma J, Eijsvogel M, Faber LM, Hofstee HM, Hovens MM, Jonkers GJ, van Kralingen KW, Kruip MJ, Vlasveld T, de Vreede MJ, Huisman MV; Hestia Study Investigators. Outpatient treatment in patients with acute pulmonary embolism: the Hestia Study. J Thromb Haemost. 2011 Aug;9(8):1500-7. doi: 10.1111/j.1538-7836.2011.04388.x. PMID: 21645235.

Article 3: Frank Peacock W, Coleman CI, Diercks DB, Francis S, Kabrhel C, Keay C, Kline JA, Manteuffel J, Wildgoose P, Xiang J, Singer AJ. Emergency Department Discharge of Pulmonary Embolus Patients. Acad Emerg Med. 2018 Sep;25(9):995-1003. doi: 10.1111/acem.13451. Epub 2018 Jun 11. PMID: 29757489; PMCID: PMC6175358.

Article 4: Vanni S, Becattini C, Nazerian P, Bova C, Stefanone VT, Cimini LA, Viviani G, Caviglioli C, Sanna M, Pepe G, Grifoni S. Early discharge of patients with pulmonary embolism in daily clinical practice: A prospective observational study comparing clinical gestalt and clinical rules. Thromb Res. 2018 Jul;167:37-43. doi: 10.1016/j.thromres.2018.05.008. Epub 2018 May 8. PMID: 29778034.

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