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

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