Management of acute pulmonary embolism 2019: what is new in the updated European guidelines?

Abstract

Pulmonary embolism (PE) is the third most frequent acute cardiovascular syndrome. Annual PE incidence and PE-related mortality rates rise exponentially with age, and consequently, the disease burden imposed by PE on the society continues to rise as the population ages worldwide. Recently published landmark trials provided the basis for new or changed recommendations included in the 2019 update of the European Society of Cardiology Guidelines (developed in cooperation with the European Respiratory Society). Refinements in diagnostic algorithms were proposed and validated, increasing the specificity of pre-test clinical probability and D-dimer testing, and thus helping to avoid unnecessary pulmonary angiograms. Improved diagnostic strategies were also successfully tested in pregnant women with suspected PE. Non-vitamin K antagonist oral anticoagulants (NOACs) are now the preferred agents for treating the majority of patients with PE, both in the acute phase (with or without a brief lead-in period of parenteral heparin or fondaparinux) and over the long term. Primary reperfusion is reserved for haemodynamically unstable patients. Besides, the 2019 Guidelines endorse multidisciplinary teams for coordinating the acute-phase management of high-risk and (in selected cases) intermediate-risk PE. For normotensive patients, physicians are advised to include the assessment of the right ventricle on top of clinical severity scores in further risk stratification, especially if early discharge of the patient is envisaged. Further important updates include guidance (1) on extended anticoagulation after PE, taking into account the improved safety profile of NOACs; and (2) on the overall care and follow-up of patients who have suffered PE, with the aim to prevent, detect and treat late sequelae of venous thromboembolism.

Keywords: Anticoagulation; Diagnosis; Guidelines; Pulmonary embolism; Treatment.

Fig. 1

Risk-adjusted management strategies in acute PE ([8]). CTPA computed tomography pulmonary angiography/angiogram, PE pulmonary embolism, PESI Pulmonary Embolism Severity Index, RV right ventricular, sPESI simplified Pulmonary Embolism Severity Index, TTE transthoracic echocardiogram. ¹Cancer, heart failure and chronic lung disease are the comorbidities included in the PESI and sPESI. ²A cardiac troponin test may already have been performed during the initial diagnostic work-up (e.g., in the chest pain unit). Troponin is proposed as the preferred biomarker, because it is the only one to have been used in an interventional trial [24]. ³Included in the Hestia criteria adapted from the 2019 European Society of Cardiology Guidelines