2019 ESC Guidelines for Acute Pulmonary Embolism

Authors:
Konstantinides SV, Meyer G, Becattini C, et al.
Citation:
2019 ESC Guidelines for the Diagnosis and Management of Acute Pulmonary Embolism Developed in Collaboration With the European Respiratory Society (ERS): The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J 2019;Aug 31:[Epub ahead of print].

The following are key points to remember from the 2019 European Society of Cardiology (ESC) and European Respiratory Society (ERS) Guidelines for the Diagnosis and Management of Acute Pulmonary Embolism (PE):

  1. D-dimer cut-offs should be adjusted to age and pretest probability rather than fixed values.
  2. Terminology such as “provoked” vs. “unprovoked” PE/venous thromboembolism (VTE) is no longer supported by the guidelines; instead they propose using terms like “reversible risk factor,” “any persistent risk factor,” or “no identifiable risk factor.”
  3. A revised risk-adjusted management algorithm is proposed accounting for clinical severity, right ventricular dysfunction, and other comorbidities with emphasis on multidisciplinary teams (Class IIa) and early PE risk stratification.
  4. Hemodynamic instability is now clearly defined as presence of cardiac arrest needing resuscitation or obstructive shock or persistent hypotension not caused by other pathologies.
  5. Rescue intravenous (IV) thrombolysis is now a Class I recommendation (previously Class IIa), and interventional thrombus removing therapy (catheter-based or surgical) is now a Class IIa (previously Class IIb) recommendation in hemodynamically deteriorating PE.
  6. Direct oral anticoagulants (DOACs) are now recommended as first choice anticoagulants over warfarin even in those who are warfarin eligible.
  7. A reduced dose of apixaban or rivaroxaban for extended anticoagulation should be considered after the first 6 months of treatment.
  8. Edoxaban or rivaroxaban should be considered as an alternative to low molecular weight heparin in patients with cancer, with caution in gastrointestinal cancer due to the increased bleeding risk with DOACs.
  9. A dedicated diagnostic algorithm is proposed for suspected PE in pregnancy. Using D-dimer and other clinical prediction rules to rule out PE during pregnancy is now Class IIa recommendation (previously Class IIb). DOACs are not recommended in pregnancy (Class III).
  10. Routine follow-up with an integrated inpatient-outpatient care delivery model 3-6 months after as well as referring symptomatic patients with mismatched perfusion defects (on V/Q scan) >3 months post-PE to an expert chronic thromboembolic pulmonary hypertension center is a Class I recommendation.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Implantable Devices, SCD/Ventricular Arrhythmias, Acute Heart Failure, Pulmonary Hypertension

Keywords: Anticoagulants, Gastrointestinal Neoplasms, Heart Arrest, Heart Failure, Hemodynamics, Hemorrhage, Heparin, Low-Molecular-Weight, Hypertension, Pulmonary, Hypotension, Neoplasms, Patient Care Team, Pregnancy, Pulmonary Embolism, Risk Factors, Secondary Prevention, Thrombosis, Vascular Diseases, Venous Thrombosis, Ventricular Dysfunction, Right, Warfarin


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