What to Do and What Not to Do in Case of PE According to the New European Guidelines

As a “friendly,” easy-to-read document, the new European guidelines on pulmonary embolism (PE) include an excellent summary chart with new and modified items (compared with the 2014 guidelines), and also some sort of final conclusion composed of crucial tips and contraindications that come in handy in case of emergency.

Diagnosis stage

• In suspected high-risk PE, perform bedside echocardiography or, if available, a computed tomography pulmonary angiography.

• In suspected high-risk PE, initiate without delay endovenous anticoagulation with unfractionated heparin, including a weight-adjusted bolus injection.

• In suspected PE without hemodynamic instability, initiate anticoagulation in case of high or intermediate clinical probability, while diagnostic studies are conducted.

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• The diagnostic strategy should be based on clinical probability.

• Measure D-dimers in outpatients or emergency department patients with low clinical probability.

• A normal computed tomography angiography rules out a diagnosis of PE in patients with low or intermediate clinical probability.

• Normal pulmonary perfusion rules out a diagnosis of PE.

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• A computed tomography pulmonary angiography that shows one segmental or more proximal filling defect confirms a diagnosis of PE in patients with intermediate or high clinical probability.

• Do not measure D-dimers in patients with high probability of PE, as a negative result does not exclude such diagnosis.

• Magnetic resonance imaging is not a diagnostic imaging test for PE.

Risk assessment

• Stratify patients with suspected or confirmed PE, based on their hemodynamic stability, in order to identify those at high risk.

• In case of patients with hemodynamic stability, further stratify them into intermediate- and low-risk categories, as appropriate.

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Treatment in the acute phase

• Administer endovenous thrombolytic therapy to patients with high-risk PE.

• Consider surgical pulmonary embolectomy for patients with high-risk PE, in whom thrombolysis is contraindicated or has failed.

• When anticoagulation is initiated in patients without hemodynamic instability, prefer low-molecular weight heparin or fondaparinux.

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• When oral anticoagulation is initiated, prefer a new anticoagulant agent (apixaban, dabigatran, edoxaban, or rivaroxaban).

• As an alternative, a vitamin-K inhibitor can be used, overlapping with heparin until an international normalized ratio (INR) of 2.5 (range 2 to 3) has been reached.

• Administer rescue thrombolytic therapy to patients on anticoagulation treatment who experience hemodynamic deterioration.

• Do not use new anticoagulant agents in patients with severe renal impairment or antiphospholipid antibody syndrome.

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• Do not routinely administer thrombolysis in patients with intermediate- or low-risk PE.

• Do not routinely use vena cava filters.

Chronic treatment and prevention of recurrence

• Administer anticoagulation for at least 3 months to all patients with PE.

• Discontinue anticoagulation after 3 months in patients with PE due to a major transient/reversible risk factor.

• Continue anticoagulation indefinitely in patients with recurrent deep-vein thrombosis (at least one previous episode of PE or vein thrombosis) that is not related to a major transient or reversible risk factor.

• Administer anticoagulant treatment with a vitamin-K inhibitor indefinitely in patients with antiphospholipid antibody syndrome.

• Anticoagulated patients must undergo regular controls regarding treatment tolerance and adherence, as well as hepatic and renal function, and bleeding risk.

Original title: 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS).

Reference: Stavros V. Konstantinides et al. European Heart Journal (2020) 41, 543603.

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