Patients with acute pulmonary embolism (PE) can be selected for home management using the sPESI score or the Hestia criteria, according to results of the HOME-PE trial presented in a Hot Line session at the European Society of Cardiology (ESC) Congress 2020.
Principal investigator Pierre-Marie Roy (University Hospital of Angers, Angers, France) said: “The pragmatic Hestia method was at least as safe as the sPESI score for triaging haemodynamically stable PE patients for outpatient care.”
European guidelines recommend the Pulmonary Embolism Severity Index (PESI) score or the simplified PESI score (sPESI) to assess the risk of all-cause mortality. Patients with an sPESI score of 0 can be treated at home, providing that proper follow-up and anticoagulant therapy can be provided. American guidelines do not require a predefined score, and advise using pragmatic criteria such as those in the Hestia study.
The HOME-PE trial examined whether a strategy based on the Hestia criteria was at least as safe as a strategy based on the sPESI score to select patients for home treatment. In addition, it evaluated whether the Hestia method was more efficient compared to the sPESI score.
This was a randomised, open-label non-inferiority trial comparing the two triaging strategies. It was conducted in 26 hospitals in France, Belgium, the Netherlands, and Switzerland, which had set up, prior to study initiation, a thrombosis team for outpatient care of patients with acute PE.
In the period 2017–2019, 1,974 patients with normal blood pressure presenting to the emergency department with acute PE were included. Patients randomised to the sPESI group were eligible for outpatient care if the score was 0; otherwise they were hospitalised. Patients randomised to the Hestia group were eligible for outpatient care if all 11 criteria were negative; otherwise they were hospitalised. In both groups, the physician in charge could overrule the decision on treatment location for medical or social reasons.
The primary outcome was a composite of recurrent venous thromboembolism (VTE), major bleeding, and all-cause death within 30 days. The Hestia strategy was non-inferior to the sPESI strategy: the primary outcome occurred in 3.8% of the Hestia group and 3.6% of the sPESI group (p=0.005).
A greater proportion of patients were eligible for home care using sPESI (48.4%) compared to Hestia (39.4%). However, the doctor in charge of the patient overruled sPESI more often than Hestia. Consequently, a similar proportion of patients were discharged within 24 hours for home treatment: 38.4% in the Hestia group and 36.6% in the sPESI group (p=0.42). All patients managed at home had a low rate of complications.
Roy said: “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. In hospitals organised 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.”