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2019 Guidelines on Acute Pulmonary Embolism (Diagnosis and Management of)

ESC Clinical Practice Guidelines

This document follows the previous ESC Guidelines focusing on the clinical management of pulmonary embolism (PE), published in 2000, 2008, and 2014. Many recommendations have been retained or their validity has been reinforced; however, new data have extended or modified our knowledge in respect of the optimal diagnosis, assessment, and treatment of patients with PE.

These new aspects have been integrated into previous knowledge to suggest optimal and—whenever possible—objectively validated management strategies for patients with suspected or confirmed PE.

Clinical
Pulmonary Embolism
Acute Cardiac Care
Valvular, Myocardial, Pericardial, Pulmonary, Congenital Heart Disease
Pulmonary Hypertension
Venous Thromboembolism
Pulmonary Circulation, Pulmonary Embolism, Right Heart Failure
Guidelines version available to download
Published in 2019
Reference Acute PE
Published in 2019
Reference APE
Published in 2019
Reference ESC Pocket Guidelines on Acute Pulmonary Embolism
Published in 2019
Reference 2019 Slide-set
Published in 2019
Reference CME-APE
App
Published in 2019
Reference Acute PE Mobile App with interactive tools
Table of contents: Full Text (ESC Clinical Practice Guidelines)

Abbreviations and acronyms

Preamble

Introduction

  • Why do we need new Guidelines on the diagnosis and management of pulmonary embolism?
  • What is new in the 2019 Guidelines?
  • New/revised concepts in 2019
  • Changes in recommendations 2014_19
  • Main new recommendations 2019

General considerations

  • Epidemiology
  • Predisposing factors
  • Pathophysiology and determinants of outcomes

Diagnosis

  • Clinical presentation
  • Assessment of clinical (pre-test) probability
  • Avoiding overuse of diagnostic tests for pulmonary embolism
  • D-dimer testing
    • Age-adjusted D-dimer cut-offs
    • D-dimer cut-offs adapted to clinical probability
    • Point-of-care
    • D-dimer assays
  • Computed tomographic pulmonary angiography
  • Lung scintigraphy
  • Pulmonary angiography
  • Magnetic resonance angiography
  • Echocardiography
  • Compression ultrasonography
  • Computed tomography venography

Assessment of pulmonary embolism severity and the risk of early death

  • Clinical parameters of pulmonary embolism severity
  • Imaging of right ventricular size and function
    • Echocardiography
    • Computed tomographic pulmonary angiography
  • Laboratory biomarkers
  • Markers of myocardial injury
  • Markers of right ventricular dysfunction
  • Other laboratory biomarkers
  • Combined parameters and scores for assessment of pulmonary embolism severity
  • Integration of aggravating conditions and comorbidity into risk assessment of acute pulmonary embolism
  • Prognostic assessment strategy

Treatment in acute phase

  • Haemodynamic and respiratory support
    • Oxygen therapy and ventilation
    • Pharmacological treatment of acute right ventricular failure
    • Mechanical circulatory support and oxygenation
    • Advanced life support in cardiac arrest
  • Initial anticoagulation
    • Parenteral anticoagulation
    • Non-vitamin K antagonist oral anticoagulants
    • Vitamin K antagonists
  • Reperfusion
    • Systemic thrombolysis
    • Percutaneous catheter-directed treatment
    • Surgical embolectomy
  • Multidisciplinary pulmonary embolism teams
  • Vena cava filters

Integrated risk-adapted diagnosis and management

  • Diagnostic strategies
    • Suspected pulmonary embolism with haemodynamic instability
    • Suspected pulmonary embolism without haemodynamic instability
    • Strategy based on computed tomographic pulmonary angiography
    • Strategy based on ventilation/perfusion scintigraphy
  • Treatment
    • Emergency treatment of high-risk pulmonary embolism
    • Treatment of intermediate-risk pulmonary embolism
    • Management of low-risk pulmonary embolism: triage for early discharge and home treatment

Chronic treatment and prevention of recurrence

  • Assessment of venous thromboembolism recurrence risk
  • Anticoagulant-related bleeding risk
  • Regimens and treatment durations with non-vitamin
  • K antagonist oral anticoagulants, and with other non-vitamin K antagonist antithrombotic drugs
  • Management of pulmonary embolism in patients with cancer

Pulmonary embolism and pregnancy

  • Epidemiology and risk factors for pulmonary embolism in pregnancy
  • Diagnosis of pulmonary embolism in pregnancy
    • Clinical prediction rules and D-dimers
    • Imaging tests
  • Treatment of pulmonary embolism in pregnancy
    • Role of a multidisciplinary pregnancy heart team
  • Amniotic fluid embolism

Long-term sequelae of pulmonary embolism

  • Persisting symptoms and functional limitation after pulmonary embolism
  • Chronic thromboembolic pulmonary hypertension
    • Epidemiology, pathophysiology, and natural history
    • Clinical presentation and diagnosis
    • Surgical treatment
    • Balloon pulmonary angioplasty
    • Pharmacological treatment
  • Strategies for patient follow-up after pulmonary embolism

Non-thrombotic pulmonary embolism 12Keymessages

Gaps in the evidence

‘What to do’ and ‘what not to do’ messages from the Guidelines

Supplementary data

Appendix

References

Supplementary data

Previous version available to download
Published in 2014
Reference Eur Heart J doi:10.1093/eurheartj/ehu283
Published in 2015
Reference doi.10.1093/eurheartj/ehu479
Published in 2015
Reference APE
Published in 2014
Reference Web Addenda
Published in 2014
Reference 40 Slides on Acute PE