Acute Pulmonary Embolism Clinical Practice Guidelines (ESC, 2019)

European Society of Cardiology (ESC)

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

December 03, 2019

Guidelines for the diagnosis and management of acute pulmonary embolism were published in 2019 by the European Society of Cardiology (ESC).[1]

Perform bedside transthoracic echocardiography as an immediate step to differentiate suspected high-risk pulmonary embolism (PE) from other acute life-threatening situations in patients presenting with hemodynamic instability.

If acute PE is suspected, institute anticoagulation therapy as soon as possible, unless the patient is bleeding or has absolute contraindications.

Use recommended, validated diagnostic algorithms for PE, including standardized assessment of (pre-test) clinical probability and D-dimer testing.

Consult a radiologist and/or seek a second opinion if the computed tomography pulmonary angiogram (CTPA) report suggests single subsegmental PE.

In a patient without hemodynamic instability, confirmation of PE must be followed by further risk assessment involving clinical findings and comorbidity along with evaluation of the size and/or function of the right ventricle (RV), and with laboratory biomarkers if appropriate.

As soon as you diagnose (or strongly suspect) high-risk PE, select the best reperfusion option (systemic thrombolysis, surgical embolectomy, or catheter-directed treatment), considering the resources and expertise available at your hospital.

Reperfusion is not a first-line treatment for patients with intermediate–high-risk PE.

When oral anticoagulation is started in a patient with PE who is eligible for a novel oral anticoagulant (NOAC) (apixaban, dabigatran, edoxaban, or rivaroxaban), a NOAC is recommended in preference to a vitamin K antagonist (VKA).

A reduced dose of the NOACs apixaban (2.5 mg b.i.d.) or rivaroxaban (10 mg o.d.) should be considered if extended oral anticoagulation is decided after PE in a patient without cancer.

There is a lifelong risk of venous thromboembolism (VTE) recurrence after the first episode of PE, therefore the patient should be re-examined after the first 3–6 months of anticoagulation.

If PE is suspected in a pregnant patient, utilize formal diagnostic pathways and algorithms, including CTPA or ventilation–perfusion lung scan if needed, which can be used safely during pregnancy.

Follow-up imaging is not routinely recommended in an asymptomatic patient, but it may be considered in patients with risk factors for the development of chronic thromboembolic pulmonary hypertension (CTEPH).

For more Clinical Practice Guidelines, go to Guidelines.

For more information, go to Acute Pulmonary Embolism.


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