COMMENTARY

New and Improved: ESC Guidelines for Pulmonary Embolism

Samuel Z. Goldhaber, MD

Disclosures

September 17, 2014

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Hello. This is Dr Sam Goldhaber, for the Clog Blog at theheart.org on Medscape, speaking to you from the European Society of Cardiology (ESC) meetings in Barcelona. Today is a very exciting day because the long-awaited pulmonary embolism (PE) updated guidelines have just been released with simultaneous e-publication in the European Heart Journal.[1] This update is the most comprehensive set of guidelines yet in the field of PE. It's quite a lot of reading—48 pages with 475 references, more than a dozen tables, and about a half-dozen figures, plus an appendix of extra tables, available on the website. The guidelines serve as a real baseline for knowledge in the field. I'm just going to go over a few of the highlights.

Most important is that risk stratification is no longer just low risk, intermediate risk (which in the United States we call "submassive PE"), and high risk (which we call "massive PE"). The intermediate-risk category, which has always been the most controversial category for management issues, is now fine-tuned. We have always known that there is a wide spectrum of patients in the submassive PE category, both healthy and sick individuals. Here, the sicker patients in the intermediate-risk category are really called out. These patients not only have right ventricular enlargement and right ventricular dysfunction, but they also have an elevation of their troponin levels, indicating right ventricular myocardial microinfarction. These patients will potentially benefit the most from advanced therapies in addition to anticoagulation (such as thrombolytic therapy or embolectomy).

Another important point is that the updated guidelines fully acknowledge the novel oral anticoagulants, pointing out that in terms of efficacy they are noninferior to traditional low-molecular-weight heparin (LMWH) bridging to warfarin. In terms of safety, there are strong signals of superiority, with about a 50% reduction in intracranial hemorrhage across the board, regardless of which of the four novel oral anticoagulants is used. Moreover, pooled analyses show convincing evidence of a reduction in major hemorrhage compared with traditional anticoagulation using LMWH as a bridge to warfarin. The guidelines leave it to the discretion of the healthcare provider as to whether to use the older LMWH-warfarin approach or the novel agents. The guidelines don't take a firm stance on this.

The guidelines go into many other topics and bring up some issues related to cutting-edge research. Some of the other topics are how to manage pregnant women with PE, how to manage patients with cancer and PE, and how to manage patients who develop chronic thromboembolic pulmonary hypertension, a section which is greatly expanded upon from the previous version of the guidelines.[2] This was a labor of love for those who worked on the new updated ESC guidelines. The guideline committee was chaired by Stavros Konstantinides, who was one of the principal investigators of the PEITHO trial,[3] which studied tenecteplase in intermediate-risk PE. The guidelines are worth downloading from the European Heart Journal and certainly having available as a convenient reference tool. This is Dr Sam Goldhaber, signing off for the Clot Blog.

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