Why use it

Approximately 40–50% of hemodynamically stable PE patients can safely be treated as outpatients, reducing healthcare costs and improving patient satisfaction without increasing adverse events. The Hestia criteria are bedside exclusion criteria — simple, rapidly applicable, and directly actionable — requiring no mathematical computation. They capture clinical and social factors that PESI-based scores do not address, including bleeding risk, oxygen requirements, and social support.

About

The Hestia criteria is a validated clinical decision rule developed to identify patients with acute pulmonary embolism (PE) who are safe for outpatient treatment with low molecular weight heparin (LMWH) or direct oral anticoagulants (DOACs). Developed by Zondag and colleagues in the Netherlands (2011), the rule consists of 11 yes/no exclusion criteria evaluated at presentation. If ANY criterion is positive, the patient should be admitted for in-hospital treatment. If ALL criteria are negative, the patient is eligible for outpatient treatment. The Hestia study demonstrated 30-day adverse event rates of less than 2% in Hestia-negative patients treated as outpatients. The rule is recommended by ESC 2019 PE Guidelines and ACCP guidelines as a validated tool for PE outpatient selection, and performs comparably to the simplified PESI score in prospective studies.

When to use

All hemodynamically stable patients with confirmed acute PE (CT pulmonary angiogram or V/Q scan)
Before deciding on admission vs. early discharge for low-risk PE patients in the emergency department
As part of a PE clinical pathway to standardize outpatient anticoagulation eligibility
In conjunction with simplified PESI or right heart strain assessment in borderline cases

Formula

Hestia Criteria — 11 Yes/No exclusion criteria: ANY "Yes" = Hospital admission required ALL "No" = Outpatient treatment eligible 1. Hemodynamically unstable (SBP <100 mmHg or HR >100 bpm or need for vasopressors/ICU) 2. Thrombolysis or surgical embolectomy necessary 3. Active bleeding or high risk of bleeding 4. >24h supplemental O₂ required to maintain SpO₂ >90% 5. PE diagnosed during anticoagulation treatment 6. Severe pain requiring IV analgesics >24h 7. Medical or social reason for in-hospital treatment >24h (clinician judgment) 8. Creatinine clearance <30 mL/min 9. Severe liver impairment 10. Pregnancy 11. Documented history of heparin-induced thrombocytopenia (HIT)

Pearls & pitfalls

The Hestia criteria are EXCLUSION criteria — if ANY single criterion is present, the patient must be admitted. There is no point accumulation or threshold.
Hemodynamic instability (Criterion 1) is paramount — SBP <100 mmHg or HR >100 bpm automatically requires admission regardless of other criteria.
Criterion 7 (medical or social reason for admission) is intentionally broad — it captures clinical judgment including poor social support, inability to self-administer LMWH, and lack of reliable follow-up.
Creatinine clearance <30 mL/min (Criterion 8) is important for DOAC dosing — rivaroxaban and apixaban are not recommended at CrCl <15 mL/min; check renal function in all PE patients.
Criterion 5 (PE on anticoagulation) implies therapeutic failure and requires reassessment of anticoagulation strategy, usually requiring admission for parenteral therapy.
DOACs (rivaroxaban, apixaban) are preferred over LMWH-bridged VKA for Hestia-eligible outpatient PE — fixed dosing, no INR monitoring, and single-agent approach reduce outpatient complexity.
Right ventricular dysfunction on echo or CT (RV/LV ratio >0.9) or elevated troponin are not Hestia criteria but should still inform shared decision-making in borderline cases.
The Hestia criteria have been validated in multiple European and North American cohorts with consistent results — 30-day adverse event rates of 1.5–3% in Hestia-negative patients.

Next steps

All criteria "No" (Hestia-Negative): Patient is eligible for outpatient treatment. Initiate rivaroxaban (15 mg twice daily × 21 days, then 20 mg once daily) or apixaban (10 mg twice daily × 7 days, then 5 mg twice daily) — preferred as single-agent DOACs. Alternatively use LMWH with transition to warfarin. Arrange follow-up within 1–3 days. Provide written emergency return instructions (worsening dyspnoea, haemoptysis, syncope, new chest pain). Any criterion "Yes" (Hestia-Positive): Admit for in-hospital anticoagulation. Address underlying positive criteria. Reassess for early discharge as criteria resolve.

Evidence

Zondag W et al. Outpatient treatment in patients with acute pulmonary embolism: the Hestia Study. J Thromb Haemost. 2011;9(8):1500-1507. PMID:21645235. Prospective cohort, n=297 Hestia-eligible patients treated as outpatients. 30-day adverse events: 3 recurrent VTE (1%), 1 major bleed (0.3%), 0 deaths. Validated in: den Exter PL et al. Thromb Haemost. 2013. ESC 2019 PE Guidelines endorse Hestia criteria as validated outpatient selection tool (Class IIa, Level B). Comparable performance to simplified PESI in head-to-head comparison.

References

Zondag W et al. Outpatient treatment in patients with acute pulmonary embolism: the Hestia Study. J Thromb Haemost. 2011;9(8):1500-1507. — link
Konstantinides SV et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2020;41(4):543-603. — link
den Exter PL et al. Validation and clinical implications of the Hestia criteria for outpatient treatment of acute pulmonary embolism. J Thromb Haemost. 2013;11(7):1206-1214. — link

Hestia Criteria for Outpatient PE Treatment

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