Two triaging strategies equally safe for facilitating outpatient care of acute PE
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New data from the HOME-PE trial support outpatient management of patients with acute pulmonary embolism using two different triaging strategies.
The trial examined whether a strategy based on the Hestia criteria was at least as safe as a strategy based on the simplified Pulmonary Embolism Severity Index (sPESI) score to select patients for home treatment.
Several studies have demonstrated the possibility of home treatment for selected patients with low-risk PE; however, controversy persists about triaging strategy and eligibility criteria for outpatient care, Pierre-Marie Roy, MD, PhD, from the University Hospital of Angers, France, said during a presentation at the virtual European Society of Cardiology Congress. European guidelines recommend the sPESI score to assess risk for all-cause mortality; patients with an sPESI score of 0 can be treated at home, with proper follow-up and anticoagulant therapy. U.S. guidelines do not require a predefined score and advise using pragmatic criteria such as those in the Hestia study, Roy said.
The HOME-PE trial compared the two triaging strategies in a randomized controlled trial of 1,974 patients with normal BP who presented to the ED with acute PE. Patients were enrolled within 24 hours of diagnosis of PE, randomly assigned to the sPESI or Hestia triaging strategy and then prospectively followed by a thrombosis team organized for outpatient care.
The Hestia strategy was noninferior to the sPESI strategy for the primary outcome of recurrent venous thromboembolism, major bleeding or all-cause death within 30 days, Roy reported. The primary outcome occurred in 3.8% of the Hestia group vs. 3.6% of the sPESI group (P for noninferiority = .005).
In other results, 48.4% of patients were eligible for home care using sPESI compared with 39.4% using Hestia.
The physician in charge of the patient overruled sPESI more often than Hestia, according to Roy. Thus, a similar proportion of patients were discharged within 24 hours for home treatment (38.4% in Hestia group vs. 36.6% in sPESI group; P = .42).
All patients managed at home had a low rate of complications during 30 days of follow-up. One death occurred in each group. The researchers observed no recurrent or fatal PE.
“The two strategies do not significantly differ with respect to the proportion of patients managed at home or early discharged. Compared with sPESI, Hestia identified less patients eligible for outpatient care, but its applicability was better, [with] less patients being overruled by the physician in charge,” Roy said during the presentation.
HOME-PE is the first prospective, randomized trial to compare the sPESI and Hestia triaging strategies for outpatient treatment of patients with acute PE. The trial was conducted from 2017 to 2019 at 26 hospitals in Belgium, France, Switzerland and the Netherlands that, prior to study initiation, had set up a thrombosis team for outpatient PE care.
Patients randomly assigned to the sPESI group were eligible for outpatient care if the score was 0; otherwise, they were hospitalized. Those randomly assigned to the Hestia group were eligible for outpatient care if all 11 criteria were negative; otherwise, they were hospitalized. In both groups, the physician in charge could overrule the decision on treatment location for medical or social reasons, according to a press release.
“In hospitals organized for outpatient management, with both triaging strategies, more than one-third of patients could be managed as outpatient with a low rate of complications,” Roy said.
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Roy PM. Hot Line: HOME-PE. Presented at: European Society of Cardiology Congress; Aug. 29-Sept. 1, 2020 (virtual meeting).
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