Hestia Criteria for Outpatient Pulmonary Embolism Treatment

Hestia Criteria for Outpatient PE Treatment
Hemodynamically unstable
Thrombolysis or embolectomy needed
Active bleeding or high bleeding risk
>24h supplemental O₂ needed to maintain SpO₂ >90%
PE diagnosed while on anticoagulation
Severe pain needing IV pain medication >24h
Medical or social reason for admission
CrCl <30 mL/min
Severe liver impairment
Pregnant
History of HIT
Positive Criteria: –
Awaiting input
Select all criteria to compute the score.
Identifies low-risk PE patients safe for outpatient treatment.

Why Use

Safely triages patients for outpatient management. Easily applied in a clinical setting at the bedside. Associated with decreased length of stay and lower costs. Associated with fewer in-hospital complications.

When to Use

Hemodynamically stable patients with acute PE.

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 SaO 2 >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 × 10 9 /L), uncontrolled HTN (sBP >180 or dBP >110), or by clinician judgment. ***By clinician judgment.

Pearls / Pitfalls

Acute PE is associated with potentially life-threatening complications in the short term; therefore, careful risk stratification must be used when attempting to identify candidates for outpatient management. Not all patients deemed low-risk will have acute life threatening complications, and not all necessitate inpatient management. This tool only helps identify those who are low risk, and does not necessarily predict those who are high risk.

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.

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.

More Information

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

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