ESC Offers Updated Guidance on Acute Pulmonary Embolism

Patrice Wendling

September 13, 2019

PARIS — Updated acute pulmonary embolism (PE) guidelines from the European Society of Cardiology (ESC) do not take a radical turn away from the previous 2014 iteration but focus instead on providing more precise and concrete recommendations from PE diagnosis and risk stratification through to long-term care.

"In the previous guidelines we had more spectacular news, if you wish, because of the introduction of all the DOACs [direct oral anticoagulants] but, of course, a lot of the things that were recommended in relation to these drugs were not very mature at that time. Now what we were able to do was to tackle specific problems and situations, vulnerable patient groups; so we believe these guidelines address more real needs of the physicians," guideline taskforce Chair Stavros Konstantinides, MD, PhD, Johannes Gutenberg University Mainz, Germany, told | Medscape Cardiology.

The guidelines, developed in collaboration with the European Respiratory Society, were presented at the ESC 2019 congress and published concurrently in the European Heart Journal.

The new guidance provides a more explicit definition of hemodynamic instability, encompassing at least one cardiac arrest requiring cardiopulmonary resuscitation, obstructive shock, and persistent hypotension lasting more than 15 minutes and not caused by new-onset arrhythmia, hypovolemia, or sepsis. In these high-risk patients, bedside transesophageal echocardiography is recommended.

In suspected PE without hemodynamic instability, the diagnostic strategy is based on clinical probability, using either clinical judgment or a validated prediction rule. For those with low or intermediate clinical probability or if PE is unlikely, a D-dimer test, preferably a high-sensitivity assay, should be performed first. If the D-dimer is negative, no treatment is required; and, if positive, should be followed by computed tomography pulmonary angiography (CTPA). Patients with a high clinical probability or PE likely should be referred directly to CTPA.

Notably, the guidelines now favor using serum D-dimer cutoff levels adjusted for age and clinical probability of PE as an alternative to the standard fixed cutoff. Use of the recommended diagnostic algorithms for PE, including D-dimer testing, may help to avoid "unnecessary, expensive, and potentially harmful imaging tests and exposure to ionizing radiation," the document notes.

Possible Pushback

"An area which is always quite controversial," is that they now recommend looking for right ventricular dysfunction, even in patients who appear to be stable and at low risk based on clinical scores, Konstantinides said. "It was not emphasized like this in the previous guidelines and certainly some non-cardiological physicians may react and say this will be too much work. We explain in the guidelines why it is not and why we believe it is important, but we may have some need for discussion on that."

The class IIa recommendation states that right ventricle assessment, by imaging or laboratory biomarkers, should be considered in the presence of a low Pulmonary Embolism Severity Index (PESI) or simplified PESI of 0.

A second area of potential controversy is that the new document strengthens its guidance regarding home treatment of PE, with a class IIa recommendation that carefully selected, low-risk patients should be considered for early discharge and home treatment as long as the patient has no other reason for hospitalization, has family or social support, and easy access to medical care.

"In the US, this is quite common and in Canada this is the rule for the vast majority, but in Europe there are some countries, like the Netherlands, where the patients may stay up to 10 days in hospital," observed Konstantinides. "So this is not purely a medical issue; this is also an issue of the society or the political aspects of what the health system can offer.

"It's very difficult to make a recommendation for 58 countries," he said. "For some, it is too audacious; for others it is too conservative. So we may have some discussion."

Extended Anticoagulation

Also new in the guidelines is that DOACs are now preferred as first-line treatment over the traditional low-molecular weight heparin (LMWH)-vitamin K antagonist regimen for patients without a contraindication.

The guidelines also include a totally new algorithm for diagnosing and managing PE in pregnancy that, notably, features a class III recommendation against using DOACs during pregnancy or lactation. A therapeutic fixed dose of LMWH, based on early pregnancy body weight, is the recommended therapy for PE in the majority of pregnant women without hemodynamic instability (class I). LMWH administration, however, is not recommended within 4 hours of removal of an epidural catheter (class III).

One of the biggest changes in the new guideline is the extension of anticoagulation after PE from a minimum of 3 months to a maximum of a lifetime, depending on the risk of recurrence, Konstantinides noted. Three new class I recommendations featured in the proposed strategy for post-PE care are:

  • routine clinical evaluation 3 to 6 months after acute PE

  • an integrated model of patient care after PE to ensure optimal transition from hospital to community care

  • referral of symptomatic patients with mismatched perfusion defects on a ventilation-perfusion scan beyond 3 months after acute PE to a pulmonary hypertension/chronic thromboembolic pulmonary hypertension expert center, after taking into account the results of echocardiography, natriuretic peptide levels, and/or cardiopulmonary exercise testing

Finally, the 2019 guidelines provide specific recommendations for managing PE in the growing population of patients with cancer. They are also available in a pocket guideline app with more than 145 interactive tools, algorithms, calculators, and charts and scores, Konstantinides said.

Konstantinides reported personal fees from Daiichi Sankyo, Pfizer, Bayer Healthcare, BTG Biocompatibles Group UK, and Merck Sharp & Dohme; and research funding from Boehringer Ingelheim, Bayer, Merck Sharp & Dohme, Daiichi Sankyo, and Actelion.

European Society of Cardiology (ESC) Congress 2019. Presented September 3, 2019.

Eur Heart J. Published online August 31, 2019. Full text

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