This calculator is for general information and education. It is not medical advice and does not replace the judgment of a doctor, nurse or pharmacist who knows the full clinical picture.
Treating pulmonary embolism at home
Pulmonary embolism, a blood clot that blocks an artery in the lungs, used to mean a hospital stay of a week or more. Since oral anticoagulants that work immediately became available, many stable patients can safely go home within 24 hours. The Hestia criteria, developed in the Netherlands and published by Zondag and colleagues in 2011, are a pragmatic checklist to identify them.
The 11 criteria
The patient should stay in hospital if any answer is yes:
- Hemodynamically unstable (systolic pressure below 100 mmHg with a heart rate above 100, or needing intensive care)
- Thrombolysis or embolectomy needed
- Active bleeding or high risk of bleeding
- Oxygen needed for more than 24 hours to keep saturation above 90%
- Pulmonary embolism diagnosed while already on anticoagulants
- Severe pain needing intravenous pain medication for more than 24 hours
- A medical or social reason to stay more than 24 hours, such as infection, cancer or no support at home
- Creatinine clearance below 30 mL/min
- Severe liver impairment
- Pregnancy
- A history of heparin-induced thrombocytopenia
Evidence
In the Hestia study, 297 patients with no criteria were treated at home. At 3 months, recurrent venous thromboembolism occurred in 2.0%, major bleeding in 0.7% and death in 1.0%, none due to the embolism. The randomized HOME-PE trial in 2021 found that the Hestia strategy was as safe as the sPESI score while allowing a similar share of patients to go home.
Worked example
A 48-year-old woman is diagnosed with pulmonary embolism after a long flight. Her blood pressure is 124/78 mmHg, heart rate 92, oxygen saturation 96% on room air, and her pain is controlled with acetaminophen. Her kidney and liver tests are normal, she is not pregnant, has no bleeding risk and lives with her partner. All 11 answers are no: she can start an oral anticoagulant and go home, with a follow-up appointment.
Before going home
- Start anticoagulation right away, usually apixaban or rivaroxaban.
- Know the warning signs: worsening breathlessness, chest pain, fainting, coughing blood or any bleeding.
- Arrange a follow-up visit within a few days and decide the treatment duration, usually at least 3 months.
Hestia and sPESI
The simplified Pulmonary Embolism Severity Index scores age, cancer, heart or lung disease, heart rate, blood pressure and oxygen saturation. A score of 0 suggests low mortality. Hestia covers more practical reasons to stay. The European Society of Cardiology accepts either, and an elevated troponin or right ventricular strain on imaging generally argues for a short admission.