Which Patients With Pulmonary Embolism Can Be Treated at Home?

Zosia Chustecka

December 05, 2010

December 5, 2010 (Orlando, Florida) — Patients with pulmonary embolism (PE) are usually treated in the hospital, but the Hestia study out of Europe suggests that about half of these patients could be treated at home, which would reduce costs, inconvenience, and the risk for infection.

The new study also identifies which patients would be suitable for outpatient treatment, commented lead author Menno Huisman MD, PhD, associate professor of medicine at Leiden University, in the Netherlands. He was speaking at a press conference here at American Society of Hematology 52nd Annual Meeting, ahead of the scheduled presentation of the data in a late-breaking abstract on December 7.

"This is a very important issue," commented Harry Buller MD, PhD, professor of medicine at the Academic Medical Center at the University of Amsterdam, in the Netherlands.

Dr. Menno Huisman

Patients with PE are usually treated in hospital and stay for an average of 10 days; this study suggests that half could be treated at home with similar results, which would reduce costs and improve their quality of life, said Dr. Buller, who was not involved in the study.

"This is the best evidence yet that some patients with [PE] can be treated as outpatients," commented American Society of Hematology Secretary Charles Abrams, MD, associate chief of the Division of Hematology/Oncology at the University of Pennsylvania in Philadelphia. He was also not involved in the study. Treatment at home is more convenient for the patient, he commented, and potentially safer, because being admitted to a hospital always exposes patients to potential infections and complications.

Which Patients Can Go Home?

Previous studies have suggested that PE could be treated at home instead of in the hospital, and this is done sometimes in practice, but not on a formal basis, Dr. Huisman explained. He noted that the 2008 guidelines from the American College of Chest Physicians concluded that home treatment is not generally recommended.

Dr. Harry Buller

One of the problems is deciding which patients would be suitable for treatment at home, and which are at higher risk and need to be treated in the hospital, he said. To address this issue, his team developed the Hestia criteria, an 11-point questionnaire that evaluates patients for risk. In their study, only patients who met all 11 criteria were allowed to be treated at home; the rest of the patients were treated as inpatients.

Results Similar to Historical Controls

For their study, Dr. Huisman and colleagues screened 581 patients with acute PE and found that 297 patients (51%) met the Hestia criteria and were treated at home.

These patients were sent home within 24 hours of being diagnosed with PE and all received weight-adjusted therapeutic doses of low–molecular weight heparin, followed by vitamin K antagonists.

After 3 months, 6 patients had recurrent venous thromboembolism (2%).

This was not a randomized trial, so there is no direct comparison between these patients and those who were treated in hospital, Dr. Huisman said, but historical controls show a recurrence rate of 1% to 3% among inpatients, so the 2% seen in the patients treated at home is in the same range, he said.

There were 3 deaths in the 3 months after treatment: 2 from cancer and 1 from an intracranial hemorrhage, but the latter occurred in a patient with uncontrolled hypertension, Dr. Huisman said. In addition, 2 patients experienced major bleeding (0.7%). This also compares favorably with historical controls of patients treated in hospital, he commented.

"Results from this study show that the Hestia criteria are efficacious and safe in helping doctors determine which acute PE patients can receive outpatient anticoagulant treatment safely," Dr. Huisman concluded.

Not yet, but we are coming close to closing the gap.

However, when asked whether clinicians should go ahead and use the Hestia criteria in practice, he was hesitant: "Not yet, but we are coming close to closing the gap," he told Medscape Medical News.

The next step will be validation in a randomized trial, which is already planned. Known as Vesta, the trial will take about 1 to 2 years to carry out, so results should be available in about 2.5 years' time, he said.

The names of both trials are taken from mythology, "because I hate acronyms," Dr. Huisman told Medscape Medical News. Hestia is the Greek goddess of the home, and Vesta is the Roman equivalent.

The Hestia Criteria

Triaging for outpatient treatment of PE was carried out using the 11-point questionnaire reproduced here. Only patients for whom the answer was no to each question were allowed to be treated at home; if even 1 question was answered with a yes, the patient had to remain in the hospital.

Hestia criteria:
  • Is the patient hemodynamically unstable?

  • Is thrombolysis or embolectomy necessary?

  • Is there active bleeding or high risk for bleeding?

  • Are more than 24 hours of oxygen supply needed to maintain oxygen saturation greater than 90%?

  • Is PE diagnosed during anticoagulant treatment?

  • Is there severe pain needing intravenous pain medication for more than 24 hours?

  • Is there a medical or social reason for treatment in the hospital for more than 24 hours (infection, malignancy, no support system, etc)?

  • Does the patient have a creatinine clearance of less than 30 mL/minute?

  • Does the patient have severe liver impairment?

  • Is the patient pregnant?

  • Does the patient have a documented history of heparin-induced thrombocytopenia?

American Society of Hematology 52nd Annual Meeting: Abstract LBA-1. To be presented December 7, 2010.

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.

processing....