Thromb Haemost 2013; 109(01): 47-52
DOI: 10.1160/TH12-07-0466
Blood Coagulation, Fibrinolysis and Cellular Haemostasis
Schattauer GmbH

Comparison of two methods for selection of out of hospital treatment in patients with acute pulmonary embolism

Wendy Zondag*
1   Department of Thrombosis and Hemostasis, Leiden University Medical Center (LUMC), Leiden, The Netherlands
,
Paul L. den Exter*
1   Department of Thrombosis and Hemostasis, Leiden University Medical Center (LUMC), Leiden, The Netherlands
,
Monique J. T. Crobach
2   Department of General Internal Medicine, Bronovo Hospital, The Hague, The Netherlands
,
Anneke Dolsma
3   Department of Pulmonology, Diaconessenhuis, Leiden, The Netherlands
,
Marjolein L. Donker
4   Department of General Internal Medicine, Rijnland Hospital, Leiderdorp, The Netherlands
,
Michiel Eijsvogel
5   Department of Pulmonology, Medical Spectrum Twente, Enschede, The Netherlands
,
Laura M. Faber
6   Department of General Internal Medicine, Rode Kruis Hospital, Beverwijk, The Netherlands
,
Herman M. A. Hofstee
7   Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
,
Karin A. H. Kaasjager
8   Department of General Internal Medicine, Rijnstate Hospital, Arnhem, The Netherlands
,
Marieke J. H. A. Kruip
9   Department of Hematology, Erasmus Medical Centre, Rotterdam, The Netherlands
,
Geert Labots
10   Department of General Internal Medicine, Haga Hospital, The Hague, The Netherlands
,
Christian F. Melissant
11   Department of Pulmonology, Spaarne Hospital, Hoofddorp, The Netherlands
,
Michelle S. G. Sikkens
12   Department of Internal Medicine, Haaglanden Medical Centre, The Hague, The Netherlands
,
Menno V. Huisman
1   Department of Thrombosis and Hemostasis, Leiden University Medical Center (LUMC), Leiden, The Netherlands
› Author Affiliations
Financial support: This study was funded by an unrestricted research grant from Glaxo Smith Klein, The Netherlands BV.
Further Information

Publication History

Received: 06 July 2012

Accepted after major revision: 08 October 2012

Publication Date:
27 November 2017 (online)

Summary

The aim of this study is to compare the performance of two clinical decision rules to select patients with acute pulmonary embolism (PE) for outpatient treatment: the Hestia criteria and the simplified Pulmonary Embolism Severity Index (sPESI). From 2008 to 2010, 468 patients with PE were triaged with the Hestia criteria for outpatient treatment: 247 PE patients were treated at home and 221 were treated as inpatients. The outcome of interest was all-cause 30-day mortality. In a post-hoc fashion, the sPESI items were scored and patients were classified according to the sPESI in low and high risk groups. Of the 247 patients treated at home, 189 (77%) patients were classified as low risk according to the sPESI and 58 patients (23%) as high risk. In total, 11 patients died during the first month; two patients treated at home and nine patients treated in-hospital. None of the patients treated at home died of fatal PE. Both the Hestia criteria and sPESI selected >50% of patients as low risk, with good sensitivity and negative predictive values for 30-day mortality: 82% and 99% for the Hestia criteria and 91% and 100% for the sPESI, respectively. The Hestia criteria and the sPESI classified different patients eligible for out-patient treatment, with similar low risks for 30-day mortality. This study suggests that the Hestia criteria may identify a proportion of high risk sPESI patiennts who can be safely treated at home, this however requires further validation.

* Both authors contributed equally to the manuscript.


 
  • References

  • 1 Kearon C, Akl EA, Comerota AJ. et al. Antithrombotic Therapy for VTE Disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141: e419S-e494S. DOI:10.1378/chest.11-2301.
  • 2 Torbicki A, Perrier A, Konstantinides S. et al. Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J 2008; 29: 2276-2315. DOI:10.1093/eurheartj/ehn475.
  • 3 Kovacs MJ, Anderson D, Morrow B. et al. Outpatient treatment of pulmonary embolism with dalteparin. Thromb Haemost 2000; 83: 209-211.
  • 4 Zondag W, Mos IC, Creemers-Schild D. et al. Outpatient treatment in patients with acute pulmonary embolism: the Hestia Study. J Thromb Haemost 2011; 09: 1500-1507. DOI:10.1111/j.1538-7836.2011.04388.x.
  • 5 Agterof MJ, Schutgens RE, Snijder RJ. et al. Out of hospital treatment of acute pulmonary embolism in patients with a low NT-proBNP level. J Thromb Haemost 2010; 08: 1235-1241. DOI:10.1111/j.1538-7836.2010.03831.x.
  • 6 Otero R, Uresandi F, Jimenez D. et al. Home treatment in pulmonary embolism. Thromb Res 2010; 126: e1-e5. DOI:10.1016/j.thromres.2009.09.026.
  • 7 Aujesky D, Obrosky DS, Stone RA. et al. Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med 2005; 172: 1041-1046. DOI:10.1164/rccm.200506-862OC.
  • 8 Donze J, Le Gal G, Fine MJ. et al. Prospective validation of the Pulmonary Embolism Severity Index. A clinical prognostic model for pulmonary embolism. Thromb Haemost 2008; 100: 943-948.
  • 9 Aujesky D, Roy PM, Verschuren F. et al. Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial. Lancet 2011; 378: 41-48. DOI:10.1016/S0140-6736(11)60824-6.
  • 10 Jimenez D, Aujesky D, Moores L. et al. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med 2010; 170: 1383-1389. DOI:10.1001/archinternmed.2010.199.
  • 11 Howard L, Salooja N. Outpatient management of pulmonary embolism. Lancet 2011; 378: 5-6. DOI:10.1016/S0140-6736(11)60932-X.
  • 12 Erkens PM, Gandara E, Wells PS. et al. Does the Pulmonary Embolism Severity Index accurately identify low-risk patients eligible for outpatient treatment?. Thromb Res 2011; 129: 710-714. DOI:10.1016/j.thromres.2011.08.025.
  • 13 Righini M, Roy PM, Meyer G. et al. The Simplified Pulmonary Embolism Severity Index (PESI): validation of a clinical prognostic model for pulmonary embolism. J Thromb Haemost 2011; 09: 2115-2117. DOI:10.1111/j.1538-7836.2011.04469.x.
  • 14 Sam A, Sanchez D, Gomez V. et al. The shock index and the simplified PESI for identification of low-risk patients with acute pulmonary embolism. Eur Respir J 2011; 37: 762-766. DOI:10.1183/09031936.00070110.
  • 15 Sorensen HT, Mellemkjaer L, Olsen JH. et al. Prognosis of cancers associated with venous thromboembolism. N Engl J Med 2000; 343: 1846-1850. DOI:10.1056/NEJM200012213432504.