MDCalc

Hestia Criteria for Outpatient Pulmonary Embolism Treatment

Identifies low-risk PE patients safe for outpatient treatment.

Use in hemodynamically stable patients with acute pulmonary embolism (PE).

Hemodynamically unstable
sBP <100 mmHg and HR >100, needing ICU care, or by clinician judgment
Thrombolysis or embolectomy needed
For reasons other than hemodynamic instability
Active bleeding or high risk for bleeding
GI bleeding or surgery ≤2 weeks ago, stroke ≤1 month ago, bleeding disorder or platelet count <75 × 10⁹/L, uncontrolled HTN (sBP >180 or dBP >110), or by clinician judgment
>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
Severe liver impairment
By clinician judgment
Pregnant
Documented history of heparin-induced thrombocytopenia (HIT)

Result:

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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.
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