Category-specific clinical pathway
Symptomatic, low severity — non-subsegmental
Low clinical severity can support early discharge when structured eligibility, treatment access, and follow-up are all satisfied.
For eligible low-risk patients with reliable follow-up.
- Outpatient
- Med-surg
- Intermediate
- ICU
01Anticoagulation
First-lineDOAC first line when eligible.
Anticoagulation
First-lineDOAC first line when eligible.
- DOACs are preferred over warfarin when eligible; apixaban and rivaroxaban need no heparin lead-in.
- Apixaban may be favored in older patients or those with higher bleeding risk or stable kidney disease; the randomized COBRRA trial found less clinically relevant bleeding with similar recurrent VTE.
- Rivaroxaban may be favored for once-daily maintenance after day 21 but must be taken with food.
- Apixaban: 10 mg PO twice daily ×7 days, then 5 mg twice daily.
- Rivaroxaban: 15 mg PO twice daily with food ×21 days, then 20 mg daily with food.
02Outpatient treatment
Consider discharge only after a structured low-risk review.
Outpatient treatment
Consider discharge only after a structured low-risk review.
- Confirm stable vitals, controlled symptoms, low bleeding risk, medication access, and reliable follow-up.
- Use Hestia/PESI plus clinical judgment; for isolated subsegmental PE, exclude proximal DVT before surveillance.
Outpatient eligibility
Hestia criteria calculator
Check every exclusion criterion that is present. Hestia is a binary safety checklist—not a weighted risk score.
Confirm that all criteria have been reviewed.
Use only for adults with objectively confirmed, hemodynamically stable PE being considered for home treatment. Any positive criterion excludes outpatient treatment under Hestia; zero criteria supports consideration but does not guarantee safe discharge or replace clinician judgment. Original Hestia study ↗
Transition of care
Discharge and follow-up
- Follow up within 1 week to review symptoms, adherence, access, and bleeding.
- Reassess anticoagulation duration and risk–benefit by 3 months.
- Screen for persistent dyspnea or exercise limitation for at least 1 year.
Management priorities are summarized from the 2026 AHA/ACC multisociety acute PE guideline. Adult medication doses are drawn from current FDA prescribing information and the referenced clinical trials, including PEITHO for off-label tenecteplase dosing in PE. Local protocols and patient-specific contraindications govern treatment.