Can Hestia criteria be used before PE diagnosis?

No. Hestia criteria are applied after pulmonary embolism is confirmed — typically after CT-PA results. They are not pre-test probability tools and cannot be used to decide whether to perform CT-PA. For pre-diagnosis PE probability assessment, use Wells PE score, Revised Geneva Score, YEARS algorithm, or PERC rule.

What follow-up is needed after outpatient PE treatment?

Patients discharged with outpatient PE management should have: follow-up within 48–72 hours (primary care, hematology, or anticoagulation clinic); telephone check-in at 24 hours for dose confirmation and symptom check; clear instructions on when to return to the ED (worsening dyspnea, chest pain, hemoptysis, signs of major bleeding); repeat imaging only if symptomatic recurrence occurs; and VTE duration decision at 3-month follow-up.

Is pregnancy always a contraindication to outpatient PE treatment (Hestia criterion 9)?

Yes, in the original Hestia criteria, pregnancy is an exclusion criterion for standard outpatient PE management. This reflects the complexity of anticoagulation in pregnancy (warfarin contraindicated due to teratogenicity; DOACs not validated; LMWH required), monitoring requirements, and the need for obstetric co-management. Pregnant patients with PE typically require inpatient admission and multidisciplinary care.

What is renal impairment's impact on DOAC dosing in outpatient PE?

Severe renal impairment (CrCl <30 mL/min) is a Hestia exclusion criterion because most DOACs require dose adjustment or are contraindicated at very low eGFR. Rivaroxaban and apixaban are renally cleared — rivaroxaban requires caution at CrCl <30 mL/min (generally not recommended for PE below this threshold); apixaban has less renal dependence and may be used with monitoring at CrCl 25–30 mL/min in selected patients. Always calculate actual CrCl (not eGFR) for anticoagulant dosing.

How does Hestia handle subsegmental or incidental PE?

Hestia criteria do not specifically address subsegmental PE (SSPE) or incidentally detected PE. In patients with SSPE found incidentally on CT-PA ordered for another indication, the decision to anticoagulate is itself uncertain and requires specialist consultation. If anticoagulation is decided upon, Hestia eligibility may still apply for outpatient vs inpatient management, but the uncertainty about treatment at all makes SSPE a specialist-level decision separate from routine Hestia application.

Online Medical Tools — HESTIA Criteria

Printed on 9/2/2026

For informational purposes only. This is not medical advice.

Emergency

HESTIA Criteria

The HESTIA approach is a practical bedside checklist used after confirmed pulmonary embolism to identify patients who should not be managed as outpatients. If no exclusion criteria are present, outpatient treatment may be considered in suitable systems with close follow-up.

Formula: HESTIA is a checklist: outpatient eligibility typically requires zero exclusion criteria.

Hemodynamic instability (shock, persistent hypotension)

Need for thrombolysis, embolectomy, or ICU-level intervention

Active bleeding or high risk of major bleeding

Need for oxygen to maintain SpO2 > 90% for over 24 hours

Need for IV pain treatment for over 24 hours

Severe renal impairment (e.g., CrCl <30 mL/min)

Severe liver impairment

Pregnancy

Other medical or social reason requiring admission

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How It Works

Apply Hestia after confirmed PE diagnosis

Hestia criteria are applied after pulmonary embolism has been confirmed (typically by CT pulmonary angiography). They are not used as a pre-test probability tool or for PE diagnosis. The checklist evaluates whether any clinical, safety, or social factor contraindicates outpatient management.

Check all 12 exclusion criteria

Systematically check each of the 12 Hestia criteria: hemodynamic instability (SBP <100 mmHg), need for thrombolysis/embolectomy/ICU, active bleeding or high major bleeding risk, need for supplemental O2 >24h to maintain SpO2 >90%, need for IV analgesia >24h, started anticoagulation on IV heparin and clinical concern about dosing, severe renal impairment (CrCl <30 mL/min), severe liver disease, pregnancy, thrombocytopenia <75,000/µL or documented HIT, medical/social reason for hospitalization.

Interpret: any positive = inpatient; all negative = outpatient eligible

If ANY single Hestia criterion is positive → inpatient treatment is required; do not proceed with outpatient discharge. If ALL criteria are negative → the patient is eligible for outpatient treatment. Arrange DOAC anticoagulation, discharge instructions, and close follow-up (within 48–72 hours). Final disposition still requires clinician judgment.

Who Uses the HESTIA Criteria

Emergency Department PE Disposition Decision

Emergency physicians, acute care providers

Hestia criteria are most commonly applied in the emergency department after PE confirmation to determine whether the patient can be safely discharged with oral anticoagulation. They provide a structured safety check that systematically identifies contraindications to outpatient PE management.

Reducing Unnecessary PE Hospitalization

Emergency physicians, hospitalists, PE programs

Approximately 30–50% of all diagnosed PE patients are Hestia-negative and potentially eligible for outpatient treatment. Systematic Hestia application enables evidence-based same-day or next-day discharge, avoiding unnecessary hospitalization without compromising safety.

Outpatient PE Treatment Program Management

PE management programs, anticoagulation clinics

Formal outpatient PE programs use Hestia criteria as part of the patient eligibility screen. Patients who pass Hestia screening are enrolled in structured outpatient pathways with DOAC prescriptions, patient education, and scheduled follow-up — often yielding equivalent outcomes to inpatient care at substantially lower cost.

Applying PE Care Pathway Consistently

All emergency and hospital providers

Hestia criteria standardize the outpatient PE decision across providers and shifts. By providing an explicit checklist rather than relying on individual clinical judgment, Hestia reduces variability in disposition decisions and ensures patients are neither over-admitted nor prematurely discharged.

Training Emergency Providers on PE Disposition

Medical educators, residency programs, nursing educators

Hestia criteria serve as an excellent teaching framework for PE outpatient disposition. The 12-item checklist covers hemodynamics, bleeding risk, medication administration, organ function, and social factors — systematically teaching trainees how to assess PE management complexity.

Pro Tips

Hestia was designed specifically for the outpatient decision — unlike PESI/sPESI

PESI and sPESI predict 30-day mortality risk. Hestia is designed specifically to identify contraindications to outpatient PE management. These tools answer different questions: sPESI answers 'How high is the 30-day mortality?' while Hestia answers 'Can this patient safely be treated at home?' Both are needed for a complete outpatient PE decision.

Hestia was prospectively validated with 2% 3-month failure rate

In the original Hestia study (Zondag et al., J Thromb Haemost 2011; n=297), only 2% of Hestia-negative patients experienced recurrent VTE or died within 3 months. This 2% failure rate is comparable to outcomes in low-risk inpatients, establishing that Hestia-guided outpatient PE is clinically safe.

The 12 criteria cover all major safety domains for outpatient anticoagulation

Hestia criteria comprehensively address: hemodynamic stability (criterion 1–2), bleeding safety (criterion 3), oxygen requirement (criterion 4), pain management (criterion 5), anticoagulation delivery method (criterion 6), renal/liver clearance of anticoagulants (criteria 7–8), pregnancy-specific anticoagulation complexity (criterion 9), platelet/HIT safety (criterion 10), and social adequacy (criteria 11–12).

DOAC preferred for outpatient PE — rivaroxaban or apixaban, no bridging needed

For Hestia-negative outpatient PE: rivaroxaban 15 mg BID with food for 21 days, then 20 mg daily (EINSTEIN-PE trial); or apixaban 10 mg BID for 7 days, then 5 mg BID (AMPLIFY trial). Both are approved for PE treatment without requiring parenteral anticoagulation bridging, making outpatient management logistically feasible.

Same-day follow-up or within 48–72 hours must be arranged before discharge

Outpatient PE management requires scheduled close follow-up — typically within 48–72 hours with a primary care provider, hematologist, or anticoagulation clinic. Telephone check-in at 24 hours and clear instructions on when to return to the ED (worsening dyspnea, chest pain, signs of bleeding) are essential components of safe discharge.

Subsegmental PE is controversial — no definitive guidance on anticoagulation

Subsegmental PE (PE limited to the most peripheral, small pulmonary arteries) is increasingly detected due to high-resolution CT-PA. Current guidelines lack strong evidence for or against anticoagulation in incidentally detected isolated subsegmental PE, particularly in patients with low DVT risk and no symptoms. Specialist consultation may be warranted.

HOME-PE trial confirmed Hestia equivalent to sPESI for outpatient selection

The HOME-PE randomized trial (Righini et al., NEJM 2021; n=1,974) compared Hestia criteria vs sPESI for outpatient PE selection. Both strategies resulted in equivalent 3-month outcomes, confirming that Hestia is non-inferior to sPESI for outpatient PE selection and can be used according to institutional preference.

When in doubt, hospitalize — Hestia is an inclusive decision, not exclusive

Hestia criteria identify patients who CANNOT safely be discharged. When any criterion is borderline or uncertain (e.g., uncertain about social support adequacy, borderline renal function), the default should be hospitalization. It is safer to over-admit borderline cases than to discharge a patient who subsequently decompensates.

Common Questions About Your Results

Both tools are used together for a complete outpatient PE evaluation. sPESI (or PESI) identifies mortality risk — sPESI 0 (or Class I–II) indicates low mortality risk. Hestia then confirms absence of specific contraindications to outpatient management. In the HOME-PE trial, both strategies performed equivalently. Many institutions use sPESI as the first screen and Hestia for safety confirmation, or use Hestia alone.

Social factors are explicitly part of Hestia criteria — 'other medical/social reason requiring admission' is one criterion. If a patient has inadequate home support, cannot reliably obtain medication, lacks access to follow-up, or cannot communicate worsening symptoms, this criterion should be marked positive and hospitalization arranged. Social adequacy is a medical safety issue in this context.

Evidence-Based Methodology

Hestia Criteria published by Zondag et al. (J Thromb Haemost 2011) from 297 PE patients — 3-month VTE recurrence/mortality 2%. Prospective validation Zondag et al. (J Thromb Haemost 2013). ESC 2019 PE Guidelines endorse Hestia criteria for outpatient treatment eligibility assessment. HOME-PE randomized trial (Righini et al., NEJM 2021) confirmed Hestia equivalent to sPESI/PESI for outpatient selection. Outpatient PE DOAC evidence: EINSTEIN-PE (rivaroxaban, NEJM 2012) and AMPLIFY (apixaban, NEJM 2013).

Clinical Content Trust

Last reviewed:: April 21, 2026
Guideline version:: General evidence framework v2026.04
Source set version:: Primary-source set v1

How to Interpret Your Result

If one or more HESTIA criteria are present, inpatient treatment is generally favored due to higher short-term risk or care complexity. If none are present, outpatient treatment may be considered in clinically stable patients with reliable follow-up.

HESTIA is a safety-oriented disposition screen, not a mortality score.

When to Use This Tool

Use HESTIA after confirming pulmonary embolism when deciding outpatient versus inpatient treatment pathways.

It is especially useful in ED pathways that include early discharge protocols for selected low-risk PE patients.

Limitations

HESTIA is a checklist and does not provide graded mortality risk. It should be integrated with prognostic tools, imaging/biomarker findings, and local resources.

Thresholds and definitions can vary slightly by institution, so align use with your local PE pathway.

Disclaimer: This tool is for educational and informational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider with questions about your health.

Sources

Zondag W, et al. Outpatient treatment in patients with acute pulmonary embolism: the Hestia Study. J Thromb Haemost. 2011;9(8):1500-1507.

Changelog

April 21, 2026 · trust-baseline
Clinical trust metadata enabled for this tool page with structured review/version fields.

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Frequently Asked Questions

The Hestia criteria are a 12-item safety checklist used after confirmed pulmonary embolism to determine eligibility for outpatient treatment. If ALL 12 criteria are absent, the patient is considered safe for outpatient management with oral anticoagulation. Any single positive criterion indicates hospitalization is needed. Criteria cover hemodynamics, bleeding risk, oxygen requirement, pain management, renal/liver function, pregnancy, platelet count, HIT history, anticoagulation delivery method, and social factors.

The 12 Hestia criteria are: (1) Hemodynamic instability — SBP <100 mmHg or HR >100 bpm with SBP <100; (2) Need for thrombolysis, embolectomy, or ICU admission; (3) Active bleeding or high major bleeding risk; (4) Need for supplemental O2 >24h to maintain SpO2 >90%; (5) Need for IV analgesia >24h; (6) On IV heparin with clinical uncertainty; (7) Severe renal impairment (CrCl <30 mL/min); (8) Severe liver disease; (9) Pregnancy; (10) Platelet count <75,000/µL or history of HIT; (11) Documented or suspected HIT; (12) Medical/social reason for hospitalization.

Yes. In the original Hestia study (Zondag et al., J Thromb Haemost 2011; n=297), only 2% of Hestia-negative patients experienced recurrent VTE or died within 3 months. The HOME-PE randomized trial (Righini et al., NEJM 2021; n=1,974) confirmed Hestia non-inferior to sPESI for outpatient PE selection, with equivalent 3-month outcomes. Outpatient PE treatment in appropriately selected patients is safe and evidence-based.

PESI and sPESI are prognostic tools estimating 30-day mortality. Hestia is a safety exclusion checklist identifying contraindications to outpatient management. They serve complementary roles: sPESI identifies low-mortality-risk patients; Hestia confirms no safety contraindications to discharge. The HOME-PE trial found Hestia and sPESI performed equivalently as outpatient selection strategies, validating both as standalone approaches.

For Hestia-negative outpatient PE, direct oral anticoagulants (DOACs) are preferred: Rivaroxaban 15 mg twice daily with food for 21 days, then 20 mg once daily — validated in EINSTEIN-PE (NEJM 2012). Apixaban 10 mg twice daily for 7 days, then 5 mg twice daily — validated in AMPLIFY (NEJM 2013). Both DOACs require no parenteral bridging, making outpatient PE treatment logistically straightforward. Treatment duration is typically 3 months for provoked PE; longer for unprovoked or cancer-associated PE.

Clinical judgment can override Hestia eligibility. Consider hospitalization when: patient or family requests it, there is patient inability to understand anticoagulation instructions, patient is unreliable for follow-up, there are significant comorbidities not captured by Hestia, you have strong clinical concern about the patient's trajectory, or when borderline criteria exist. Hestia informs but does not replace physician judgment about individual patient safety.

Online Medical Tools — HESTIA Criteria

HESTIA Criteria

How It Works

Apply Hestia after confirmed PE diagnosis

Check all 12 exclusion criteria

Interpret: any positive = inpatient; all negative = outpatient eligible

Who Uses the HESTIA Criteria

Emergency Department PE Disposition Decision

Reducing Unnecessary PE Hospitalization

Outpatient PE Treatment Program Management

Applying PE Care Pathway Consistently

Training Emergency Providers on PE Disposition

Pro Tips

Hestia was designed specifically for the outpatient decision — unlike PESI/sPESI

Hestia was prospectively validated with 2% 3-month failure rate

The 12 criteria cover all major safety domains for outpatient anticoagulation

DOAC preferred for outpatient PE — rivaroxaban or apixaban, no bridging needed

Same-day follow-up or within 48–72 hours must be arranged before discharge

Subsegmental PE is controversial — no definitive guidance on anticoagulation

HOME-PE trial confirmed Hestia equivalent to sPESI for outpatient selection

When in doubt, hospitalize — Hestia is an inclusive decision, not exclusive

Common Questions About Your Results

Evidence-Based Methodology

Clinical Content Trust

How to Interpret Your Result

When to Use This Tool

Limitations

Sources

Changelog

Related Tools

PESI Score

sPESI Score

Wells Score (PE)

PERC Rule

Further Reading

A Complete Guide to Emergency Medicine: Decision Tools, Scoring Systems, and Clinical Protocols

Frequently Asked Questions