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............................................................................................................................................................................. slightly different criteria or combinations thereof were used to ensure the above three requirements.

The Hestia exclusion criteria (Supplementary Data Table 12) represent a checklist of clinical parameters or questions that can be obtained/answered at the bedside. They integrate aspects of PE severity, comorbidity, and the feasibility of home treatment. If the answer to one or more of the questions is ‘yes’, then the patient cannot be discharged early. In a single-arm management trial that used these criteria to select candidates for home treatment, the 3 month rate of recurrent VTE was 2.0% (0.84.3%) in patients with acute PE who were discharged within 24 h.317 In a subsequent non-inferiority trial that randomized 550 patients to direct discharge based on the Hestia criteria alone vs. additional NT-proBNP testing and discharge if levels were <_500 pg/mL, the primary outcome (30 day PE- or bleeding-related mortality, cardiopulmonary resuscitation, or admission to an intensive care unit) was very low in both arms. The results suggest no incremental value of natriuretic-peptide testing in patients who are eligible for home treatment based on the Hestia criteria, although the study was not powered to exclude this possibility.318 The PESI and its simplified form, the sPESI (Table 7), also integrate clinical parameters of PE severity and comorbidity to permit assessment of overall 30 day mortality. Compared with the Hestia criteria, the PESI is more standardized, but it contains a less-comprehensive list of aggravating conditions; moreover, the sPESI excludes all patients with cancer from the low-risk category (compare Table 7 with Supplementary Data Table 12). The PESI was not primarily developed as a tool to select candidates for home treatment, but it has been used—in combination with additional feasibility criteria—in a trial of 344 patients randomized to inpatient vs. outpatient treatment of PE.178 One (0.6%) patient in each treatment group died within 90 days.178 In patients who were included in prospective cohort studies and treated at home, with or without a short hospitalization period, the 3 month rates of thromboembolic recurrence, major bleeding, and death were 1.75, 1.43, and 2.83%, respectively.327 In summary, the currently available evidence indicates that both the Hestia rule and the PESI or sPESI appear capable of reliably identifying patients who are (i) at low PE-related risk, and (ii) free of serious comorbidity. Consequently, either may be used for clinical triage according to local experience and preference. If a PESI- or sPESIbased approach is chosen, it must be combined with assessment of the feasibility of early discharge and home treatment; this assessment is already integrated into the Hestia criteria. A more difficult decision related to immediate or early discharge is whether the exclusion of intermediate-risk PE on clinical grounds alone is adequate, or whether the assessment of RV dysfunction or myocardial injury (see section 5) by an imaging test or a laboratory biomarker is necessary to provide maximal safety for the patient in this ‘vulnerable’ early period. A systematic review and meta-analysis of cohort studies suggested that the prognostic sensitivity is increased further when clinical criteria (e.g. PESI or sPESI) are combined with imaging findings, or laboratory biomarker levels.234 A multicentre prospective management trial tested this hypothesis, investigating the efficacy and safety of early discharge, and ambulatory rivaroxaban treatment, in patients selected by clinical criteria and an absence of RV dysfunction. Overall, 20% of the screened unselected patients with PE were included. At the predefined interim analysis of 525 patients (50% of the planned population), the 3 month rate of symptomatic or fatal recurrent VTE was 0.6% (one-sided upper 99.6% CI 2.1%), permitting the early rejection of the null hypothesis and termination of the trial. Major bleeding occurred in six (1.2%) of the patients in the safety population. There were no PE-related deaths.319 In view of the existing evidence—and taking into consideration (i) the catastrophic scenario of early death if a patient with acute PE is falsely judged to be at low risk on clinical grounds alone and discharged ‘too early’ (as described in a prematurely terminated trial328), and (ii) the ease and minimal additional effort of assessing RV size and function at presentation by echocardiography, or on the CTPA performed to diagnose the PE event itself329 (section 5)—it is wise to exclude RV dysfunction and right heart thrombi if immediate or early (within the first 2448 h) discharge of the patient is planned.

8 Chronic treatment and

prevention of recurrence

The aim of anticoagulation after acute PE is to complete the treatment of the acute episode and prevent recurrence of VTE over the long-term. Current drugs and regimens for the initial phase, and the first months of anticoagulant treatment, are described insection 6. Most of the randomized studies focusing on long-term anticoagulation for VTE have included patients with DVT, with or without PE; only two randomized studies have specifically focused on patients with PE.330,331 The incidence of recurrent VTE does not appear to depend on the clinical manifestation of the first event (i.e. it is similar after PE and after proximal DVT). However, in patients who have had a PE, VTE more frequently recurs as PE, while in patients who have had a DVT, it tends to recur more frequently as DVT.332 As a consequence, the case fatality rate of recurrent VTE in patients who have previously had a PE is twice as high as that of VTE recurrence after DVT.333,334 Landmark clinical trials have evaluated various durations of anticoagulant treatment with VKAs for VTE.330,331,335337 The findings of these studies permit the following conclusions. First, all patients with PE should receive >_3 months of anticoagulant treatment. Second, after withdrawal of anticoagulant treatment, the risk of recurrence is expected to be similar if anticoagulants are stopped after 36 months compared with longer treatment periods (e.g. 1224 months). Third, extended oral anticoagulant treatment reduces the risk for recurrent VTE by <_90%, but this benefit is partially offset by the risk of bleeding. Oral anticoagulants are highly effective in preventing recurrent VTE during treatment, but they do not eliminate the risk of subsequent recurrence after the discontinuation of treatment.330,331 Based on this fact on the one hand, and considering the bleeding risk of anticoagulation treatment on the other, the clinically important question is how to best select candidates for extended or indefinite anticoagulation. Involvement of the patient in the decision-making process is crucial to optimize and maintain treatment adherence. Downloaded from academic.oup.com/eurheartj/article/41/4/543/5556136 by guest on 07 October 2026