Optimal Follow-Up After Acute Pulmonary Embolism: Key Points

Klok FA, Ageno W, Ay C, et al
Optimal Follow-Up After Acute Pulmonary Embolism: A Position Paper of the European Society of Cardiology Working Group on Pulmonary Circulation and Right Ventricular Function, in Collaboration With the European Society of Cardiology Working Group on Atherosclerosis and Vascular Biology, Endorsed by the European Respiratory Society. Eur Heart J 2022;43:183-189.

The following are key points to remember from this position paper on optimal follow-up after acute pulmonary embolism (PE):

  1. At the time of acute PE diagnosis, clinicians should rule out any absolute contraindications to anticoagulation, identify optimal anticoagulant strategies, and avoid unnecessary interventions.
  2. At the time of acute PE diagnosis, only a limited age-appropriate screen for cancer is recommended.
  3. Hormonal contraceptives can be continued to help prevent pregnancy and mitigate the risk of abnormal uterine bleeding as long as anticoagulation therapy is being given. If the hormonal contraceptive is discontinued, then a limited course of anticoagulation is generally recommended. These women should receive thromboprophylaxis in the antepartum and post-partum period for any future pregnancies.
  4. After the diagnosis of acute PE, patients should be encouraged to resume regular exercise and sporting activities in a stepwise manner. Ensure that the right ventricle has recovered size and function before resuming strenuous exercise or air travel. Encourage the use of compression stockings or prophylactic-dose anticoagulation during long-haul air flights (>4 hours).
  5. In the first weeks after acute PE diagnosis, consider anti-phospholipid antibody syndrome screening for patients with unprovoked PE, especially if prior arterial or small-vessel thrombosis, pregnancy complications, autoimmune disease, or acute PE diagnosis at age <50 years. Do NOT routinely screen for genetic thrombophilia.
  6. In the first few weeks after acute PE diagnosis, ensure anticoagulant adherence and avoid relevant drug–drug interactions. Screen for and address any modifiable risk factors for bleeding (e.g., concurrent use of aspirin, nonsteroidal anti-inflammatory drugs).
  7. At 3 months following acute PE diagnosis, estimate the bleeding risk in all patients for whom long-term anticoagulation is considered. If anticoagulation is extended beyond the initial 3-6 months, periodically reassess bleeding risk and determine of continued anticoagulation is appropriate.
  8. At 3 months following acute PE diagnosis, perform cardiopulmonary exercise testing in patients with post-PE syndrome (including persistent symptoms of dyspnea). Rule out chronic thromboembolic pulmonary hypertension in all patients with persistent symptoms of dyspnea or right heart failure. Consider psychological support for patients with incomplete functional recovery due to anxiety or depression.
  9. At 3 months (and periodically thereafter), apply validated risk calculators to systematically assess general cardiovascular risk, especially in cases of unprovoked PE and/or obesity.
  10. Over the long-term, limit periods of overlap between antiplatelet and anticoagulant medications for patients who continue to take anticoagulation beyond the initial 3 months.

Clinical Topics: Anticoagulation Management, Congenital Heart Disease and Pediatric Cardiology, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Anticoagulation Management and Venothromboembolism, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Prevention, CHD and Pediatrics and Quality Improvement, Acute Heart Failure, Pulmonary Hypertension, Exercise, Hypertension

Keywords: Anticoagulants, Anti-Inflammatory Agents, Non-Steroidal, Antiphospholipid Syndrome, Anxiety, Aspirin, Atherosclerosis, Depression, Drug Interactions, Dyspnea, Exercise, Exercise Test, Heart Failure, Hypertension, Pulmonary, Infant, Neoplasms, Obesity, Postpartum Period, Pregnancy, Primary Prevention, Pulmonary Embolism, Risk Factors, Stockings, Compression, Thrombophilia, Thrombosis, Uterine Hemorrhage, Venous Thromboembolism, Ventricular Function, Right

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