Материал: 2019 ESC acute pulmonaryembolism

(2)If you suspect acute PE, institute anticoagulation therapy as soon as possible, while the diagnostic workup is ongoing, unless the patient is bleeding or has absolute contraindications to this therapy.

(3)Use recommended, validated diagnostic algorithms for PE, including standardized assessment of (pre-test) clinical probability and D-dimer testing. They help to avoid unnecessary, expensive, and potentially harmful imaging tests and exposure to ionizing radiation.

(4)If the CTPA report suggests single subsegmental PE, consider the possibility of a false-positive finding. Discuss the findings again with the radiologist and/or seek a second opinion to avoid misdiagnosis, and unnecessary, potentially harmful anticoagulation treatment.

(5)Confirmation of PE in a patient, without haemodynamic instability, must be followed by further risk assessment involving clinical findings, evaluation of the size and/or function of the RV, and laboratory biomarkers as appropriate. This information will help you to decide on the need for reperfusion treatment or monitoring for patients at elevated risk, or consider the option of early discharge and continuation of anticoagulation on an ambulatory basis for patients at low risk.

(6)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 patient’s risk profile, and the resources and expertise available at your hospital. For patients with intermediate-high-risk PE, reperfusion is not first-line treatment, but you should prospectively plan the management strategy with your team to have a contingency plan ready if the situation deteriorates.

(7)Prefer anticoagulation with a NOAC over the ‘traditional’ LMWH-VKA regimen unless the patient has contraindication(s) to this type of drug.

(8)Always remember that, with the exception of acute PE provoked by a strong transient/reversible risk factor, there is a lifelong risk of VTE recurrence after a first episode of PE. Consequently, reexamine the patient after the first 3 - 6 months of anticoagulation, weigh the benefits vs. risks of continuing treatment, and decide on the extension and dose of anticoagulant therapy, also considering the patient’s preference. Remember to recommend regular follow-up examinations, e.g. at yearly intervals.

(9)If you suspect PE in a pregnant patient, consider diagnostic pathways and algorithms including CTPA or V/Q lung scan, which can be used safely during pregnancy.

(10)After acute PE, patients should not be lost to follow-up. Apart from checking for possible signs of VTE recurrence, cancer, or bleeding complications of anticoagulation, ask the patient if there is persisting or new-onset dyspnoea or functional limitation. If yes, implement a staged diagnostic workup to exclude CTEPH or chronic thromboembolic disease, and to detect/treat comorbidity or ‘simple’ deconditioning. Follow-up imaging is not routinely recommended in an asymptomatic patient, but it may be considered in patients with risk factors for development of CTEPH.

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13 Gaps in the evidence

Diagnosis

•The optimal method to adjust (based on the patient’s age or in combination with clinical probability) the D-dimer threshold, permitting the exclusion of PE while reducing the number of unnecessary imaging tests to a minimum, remains to be determined.

•The diagnostic value and clinical significance of isolated subsegmental contrast-filling defects in the modern CTPA era remain controversial.

•No robust data exist to guide the decision on whether to treat incidental PE with anticoagulants compared with a strategy of watchful waiting.

•For patients presenting with non-traumatic chest pain, the benefits vs. risks of ‘triple rule-out’ (for coronary artery disease, PE, and aortic dissection) CT angiography need further evaluation before such an approach can be routinely recommended.

Assessment of pulmonary embolism severity and the risk of early death

•The optimal, clinically most relevant combination (and cut-off levels) of clinical and biochemical predictors of early PE-related death remain to be determined, particularly with regard to identifying possible candidates for reperfusion treatment among patients with intermediate-risk PE.

•The need for assessment of the RV status in addition to clinical parameters, to classify a patient with acute symptomatic PE as being at low vs. intermediate risk, needs to be confirmed by further prospective management (cohort) studies.

Treatment in the acute phase

•The clinical benefits vs. risks of reduced-dose thrombolysis and catheter-based reperfusion modalities in patients with intermedia- te-high-risk PE should be evaluated in prospective randomized trials.

•The place of ECMO in the management of acute high-risk PE awaits support by additional evidence from prospective management (cohort) studies.

•The optimal anticoagulant drug(s) and regimen in patients with renal insufficiency and CrCl <30 mL/min remain unclear.

•The criteria for selecting patients for early discharge and

outpatient treatment of PE, and particularly the need for assessment of the RV status with imaging methods and/or laboratory markers in addition to calculating a clinical score, need to be further validated in prospective cohort studies.

Chronic treatment and prevention of recurrence

•The clinical value and the possible therapeutic implications of models or scores assessing the risk of VTE recurrence, and the risk of bleeding under anticoagulation, need to be revisited in the NOAC era.

•The effectiveness of extended treatment with a reduced dose, or apixaban or rivaroxaban, should be confirmed in patients with a high risk of recurrent PE.

•The evidence supporting the efficacy and safety of NOACs for the treatment of PE in patients with cancer needs to be extended by further studies.

•In patients with cancer, the anticoagulant regimen and dose after the first 6 months should be clarified and prospectively tested.

•The optimal time for discontinuing anticoagulant treatment after an episode of acute PE in patients with cancer is yet to be determined.

Pulmonary embolism and pregnancy

•Diagnostic algorithms for PE in pregnancy, using modern radiological imaging techniques and low radiation doses, need to be prospectively tested in adequately powered cohort studies.

•Controversy persists on the optimal LMWH dose and regimen for the treatment of PE during pregnancy.

•NOACs are not allowed in pregnancy. However, if exposure to these drugs occurs during pregnancy despite this warning, any possible effects on the foetus should be recorded to provide

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more precise information on the risks and complications of these drugs, and adapt the instructions to physicians in the future.

Long-term sequelae of pulmonary embolism

•The optimal follow-up strategy, including the spectrum of diagnostic tests that may be necessary, in patients with persisting symptoms and functional limitation after acute PE needs to be defined and prospectively validated.

•In the absence of persisting symptoms or functional limitation after acute PE, the criteria for identifying patients whose risk of developing CTEPH may be sufficiently high to justify further diagnostic workup require further elaboration and validation in prospective cohort studies.

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

15 Supplementary data

Supplementary Data with additional Web Supplementary Tables complementing the full text, as well as section 11 on non-thrombotic PE, are available on the European Heart Journal website and via the ESC website at www.escardio.org/guidelines.

16 Appendix

Author/Task Force Member Affiliations:

Cecilia Becattini, Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy; He´ctor Bueno, Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain; and Cardiology, Hospital Universitario 12 de Octubre & iþ12 Research Institute, Madrid, Spain; CIBERCV, Madrid, Spain; Geert-Jan Geersing, Julius Center for Health Sciences and Primary Care, University Medical

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Center Utrecht, Utrecht University, Utrecht, Netherlands; VeliPekka Harjola, Emergency Medicine, Department of Emergency Medicine and Services, Helsinki University, Helsinki University Hospital, Helsinki, Finland; Menno V. Huisman, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands; Marc Humbert, Service de Pneumologie, Hoˆpital Bic^etre, Assistance Publique-Hoˆpitaux de Paris, Univ. Paris-Sud, Universite´ Paris-Saclay, Le Kremlin-Bic^etre, France; Catriona Sian Jennings, National Heart and Lung Institute (NHLI), Imperial College London, London, United Kingdom; David Jime´nez, Respiratory Department, Ramon y Cajal Hospital and Alcala University, IRYCIS, Madrid, Spain; Nils Kucher, Angiology, University Hospital, Zurich, Switzerland; Irene Marthe Lang, Cardiology, Medical University of Vienna, Vienna, Austria; Mareike Lankeit, Department of Internal Medicine and Cardiology, Campus Virchow Klinikum, Charite´ University Medicine Berlin, Berlin, Germany; and Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany; Clinic

of Cardiology and Pneumology, University Medical Center Go¨ttingen, Go¨ttingen, Germany; Roberto Lorusso, Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands; Lucia Mazzolai, Department of Angiology, CHUV, Lausanne, Switzerland; Nicolas Meneveau, Department of Cardiology, University Hospital Jean Minjoz and EA3920, University of Franche-Comte´, Besanc¸on, France;

Fionnuala Nı Ainle, Haematology, Rotunda and Mater University Hospitals, Dublin, University College Dublin, Dublin, Ireland; Paolo Prandoni, Arianna Foundation on Anticoagulation, Bologna, Italy; Piotr Pruszczyk, Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland; Marc Righini, Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland; Adam Torbicki, Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, Warsaw, ECZ-Otwock, Poland; Eric Van Belle, Cardiology, Institut Coeur Poumon CHU de Lille and INSERM U1011 Lille, Lille, France; Jose´ Luis Zamorano, Cardiology, Hospital Ramon y Cajal, Madrid, Spain.

ESC Committee for Practice Guidelines (CPG): Stephan Windecker (Chairperson) (Switzerland), Victor Aboyans (France), Colin Baigent (United Kingdom), Jean-Philippe Collet (France), Veronica Dean (France), Victoria Delgado (Netherlands), Donna Fitzsimons (United Kingdom), Chris P. Gale (United Kingdom), Diederick E. Grobbee (Netherlands), Sigrun Halvorsen (Norway), Gerhard Hindricks (Germany), Bernard Iung (France), Peter Ju¨ni (Canada), Hugo A. Katus (Germany), Ulf Landmesser (Germany), Christophe Leclercq (France), Maddalena Lettino (Italy), Basil S. Lewis (Israel), Bela Merkely (Hungary), Christian Mueller (Switzerland), Steffen E. Petersen (United Kingdom), Anna Sonia Petronio (Italy), Dimitrios J. Richter (Greece), Marco Roffi (Switzerland), Evgeny Shlyakhto (Russian Federation), Iain A. Simpson (United Kingdom), Miguel Sousa-Uva (Portugal), Rhian M. Touyz (United Kingdom).

ESC National Cardiac Societies actively involved in the review process of the 2019 ESC Guidelines on the diagnosis and management of acute pulmonary embolism:

Algeria: Algerian Society of Cardiology, Naima Hammoudi; Armenia: Armenian Cardiologists Association, Hamlet Hayrapetyan; Austria: Austrian Society of Cardiology, Julia Mascherbauer; Azerbaijan: Azerbaijan Society of Cardiology, Firdovsi Ibrahimov; Belarus: Belorussian Scientific Society of Cardiologists, Oleg Polonetsky; Belgium: Belgian Society of Cardiology, Patrizio Lancellotti; Bulgaria: Bulgarian Society of Cardiology, Mariya Tokmakova; Croatia: Croatian Cardiac Society, Bosko Skoric; Cyprus: Cyprus Society of Cardiology, Ioannis Michaloliakos; Czech Republic: Czech Society of Cardiology, Martin Hutyra; Denmark: Danish Society of Cardiology, Søren Mellemkjaer; Egypt: Egyptian Society of Cardiology, Mansour Mostafa; Estonia: Estonian Society of Cardiology, Julia Reinmets; Finland: Finnish Cardiac Society, Pertti J€a€askel€ainen; France: French Society of Cardiology, Denis Angoulvant; Germany: German Cardiac Society, Johann Bauersachs; Greece: Hellenic

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Society of Cardiology, George Giannakoulas; Hungary: Hungarian Society of Cardiology, Endre Zima; Italy: Italian Federation of Cardiology, Carmine Dario Vizza; Kazakhstan: Association of Cardiologists of Kazakhstan, Akhmetzhan Sugraliyev; Kosovo (Republic of): Kosovo Society of Cardiology, Ibadete Bytyc¸i; Latvia: Latvian Society of Cardiology, Aija Maca; Lithuania: Lithuanian Society of Cardiology, Egle Ereminiene; Luxembourg: Luxembourg Society of Cardiology, Steve Huijnen; Malta: Maltese Cardiac Society, Robert Xuereb; Moldova (Republic of): Moldavian Society of Cardiology, Nadejda Diaconu; Montenegro: Montenegro Society of Cardiology, Nebojsa Bulatovic; Morocco: Moroccan Society of Cardiology, Ilyasse Asfalou; North Macedonia: North Macedonian Society of Cardiology, Marijan Bosevski; Norway: Norwegian Society of Cardiology, Sigrun Halvorsen; Poland: Polish Cardiac Society, Bozena Sobkowicz; Portugal: Portuguese Society of Cardiology, Daniel Ferreira; Romania: Romanian Society of Cardiology, Antoniu Octavian Petris; Russian Federation: Russian Society of Cardiology, Olga Moiseeva; San Marino: San Marino Society of Cardiology, Marco Zavatta; Serbia: Cardiology Society of Serbia, Slobodan Obradovic;

Slovakia: Slovak Society of Cardiology, Iveta Simkova; Slovenia: Slovenian Society of Cardiology, Peter Radsel; Spain: Spanish Society of Cardiology, Borja Ibanez; Sweden: Swedish Society of Cardiology, Gerhard Wikstro¨m; Switzerland: Swiss Society of Cardiology, Drahomir Aujesky; Turkey: Turkish Society of Cardiology, Cihangir Kaymaz; Ukraine: Ukrainian Association of Cardiology, Alexander Parkhomenko; United Kingdom of Great Britain and Northern Ireland: British Cardiovascular Society, Joanna Pepke-Zaba.

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