Key result
PE risk models identify up to ~48% of hospitalized patients as eligible for outpatient care.
Why the study?
Many low-risk acute pulmonary embolism patients continue to be hospitalized despite guideline recommendations for outpatient management, and real data evaluating hospitalization appropriateness and agreement among contemporary PE risk stratification models remain limited.
How accurately do contemporary risk stratification models (Hestia, PESI, sPESI, Bova, 2019 ESC, and 2026 AHA/ACC categories) assess hospitalization precision and predict all-cause mortality in hospitalized patients with acute pulmonary embolism?
Cohort (n=150)
No
How accurately do contemporary risk stratification models (Hestia, PESI, sPESI, Bova, 2019 ESC, and 2026 AHA/ACC categories) assess hospitalization precision and predict all-cause mortality in hospitalized patients with acute pulmonary embolism?
Nearly one-quarter to two-fifths of patients hospitalized with acute pulmonary embolism met validated low-risk criteria for outpatient care, and because contemporary risk scores show only fair-to-moderate agreement, combining Hestia with multidimensional prognostic tools (such as 2026 AHA/ACC or PESI) is needed to optimize safe triage.
Answers are grounded in this paper and cite their sources.
May support shifting select acute PE patients to outpatient care; leaves open optimal model integration for safe triage.
Background and aim Although current pulmonary embolism guidelines recommend outpatient management for carefully selected patients with acute pulmonary embolism, many patients at low risk continue to be hospitalized. Real data evaluating the appropriateness of hospitalization decisions and agreement among contemporary PE risk stratification models remain limited. The primary aim of this study was to evaluate the appropriateness of hospitalization decisions in patients with APE using contemporary risk stratification models. The secondary aim was to compare agreement among these models and their prognostic performance in relation to hospitalization precision. Methods We retrospectively analyzed a prospectively maintained cohort of 150 consecutive patients hospitalized with APE between January 2022 and January 2024. APE was confirmed by computed tomography pulmonary angiography. Hospitalization decisions were evaluated using the Hestia criteria, PESI, simplified PESI, the Bova score, the 2019 ESC risk classification, and the 2026 AHA/ACC PE categories. Cohen’s kappa and McNemar’s tests were used to assess agreement and differences in paired classifications between Hestia and the other models. Prognostic performance for all-cause mortality was evaluated using ROC curve analysis. Results The mean age was 52 ± 17.0 years, and 34 patients (22.7%) died during follow-up. According to the Hestia rule, 35 patients (23.3%) fulfilled the criteria for outpatient management despite having been hospitalized. Low-risk classification was assigned to 35.3% of patients by the ESC algorithm, 30.7% by sPESI, 38.0% by PESI, and 42.7% by the AHA/ACC categories. Combining Hestia with additional clinical or imaging criteria reduced outpatient eligibility to 16.7%–22.7%. Agreement between Hestia and the other risk models ranged from fair to moderate (κ = 0.35–0.58). The 2026 AHA/ACC classification showed the highest discrimination for mortality (AUC, 0.889), followed by PESI (0.870), ESC (0.865), and Bova (0.810). Hospitalization precision ranged from 52.0% to 76.7% across the evaluated strategies. Conclusions A substantial proportion of hospitalized patients with APE fulfilled validated low risk criteria for outpatient management, suggesting that potentially avoidable hospitalization persists in routine practice. Contemporary risk stratification models showed fair to moderate agreement and should be considered complementary rather than interchangeable. Integrating outpatient eligibility criteria with multidimensional risk assessment may improve hospitalization decisions and optimize healthcare resource utilization. Clinical trial number and affiliation approval number Approval No. AU17101855 (Ethics Committee, Faculty of Medicine, Assiut University); ClinicalTrials.gov Identifier: NCT05469724.
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Ahmed et al. (2026) conducted a cohort in Acute pulmonary embolism (APE) (n=150). Hestia criteria for outpatient management eligibility vs. PESI, sPESI, Bova score, 2019 ESC risk classification, and 2026 AHA/ACC PE categories was evaluated on Appropriateness of hospitalization decisions (hospitalization precision and outpatient management eligibility). Contemporary PE risk models identified 23.3% (Hestia) to 48.0% (Bova) of hospitalized acute PE patients as low-risk candidates eligible for outpatient care, with hospitalization precision of 52.0%–76.7%.
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