Perspective:

This guideline statement from the European Society of Cardiology discusses the appropriate diagnosis and management strategies for acute pulmonary embolism (PE). The following are eleven key points from the guideline statement:

1. In suspected high-risk acute PE (presence of shock or hypotension), emergent computed tomography (CT) angiography or bedside transthoracic echocardiography is recommended for diagnostic purposes (Class I). Pulmonary angiography may be considered in unstable patients referred directly to a catheterization laboratory to exclude acute coronary syndromes (Class IIb).

2. In suspected acute PE without shock or hypotension, use of a validated risk stratification scheme (e.g., Modified Well’s or Revised Geneva scores) should be employed (Class I). If pretest probability is low or intermediate, D-dimer test should be used in outpatient and emergency department settings (Class I). Low pretest probability and a negative D-dimer test excludes acute PE (Class I). D-dimer testing is not recommended in patients with a high pretest probability for acute PE (Class III).

3. Normal CT angiography excludes PE in patients with low or intermediate pretest probability (Class I). Normal perfusion lung scintigram (V/Q scan) excludes acute PE (Class I). Lower limb compression ultrasound with a proximal deep venous thrombosis (DVT) in a patient with a clinically suspected PE confirms the diagnosis of acute PE (Class I).

4. In acute PE patients without shock or hypotension, use of the PESI or sPESI score can be considered to distinguish between low- and intermediate-risk PE (Class IIa). Similarly, assessment of the right ventricle with echocardiography or CT, along with assessment of myocardial injury (usually troponin testing), can be considered for further risk stratification (Class IIa).

5. In patients with high-risk acute PE (shock or hypotension), initial therapy should include intravenous anticoagulation with unfractionated heparin (Class I) and thrombolytic therapy (Class I). Surgical pulmonary embolectomy is recommended in patients with a contraindication to thrombolysis or when thrombolytic therapy has failed (Class I).

6. In patients with intermediate- or low-risk acute PE, initiation of parenteral anticoagulation is recommended (Class I). Use of low molecular weight heparin (LMWH) or fondaparinux is recommended for most patients (Class I). In parallel to parenteral anticoagulation, treatment with warfarin (international normalized ratio [INR] goal 2-3) is recommended (Class I).

1. Rivaroxaban (15 mg twice a day for 3 weeks, then 20 mg daily) or apixaban (10 mg twice a day for 7 days, then 5 mg twice a day) are alternatives to the combination of parenteral and warfarin anticoagulation (Class I for both).
   
   
2. In place of warfarin, dabigatran (150 mg twice a day, 110 mg twice a day for patients ≥80 or taking verapamil) is recommended following the acute phase of parenteral anticoagulation (Class I).
   
   
3. New oral anticoagulants (dabigatran, rivaroxaban and apixaban) are not recommended in patients with severe renal impairment (Class III).
   

7. Routine use of systemic thrombolytic therapy is not recommended in low- and intermediate-risk acute PE patients (Class III). Thrombolytic therapy can be considered in patients with intermediate- to high-risk acute PE with clinical signs of hemodynamic decompensation (Class IIa).

8. Patients with low-risk acute PE should be considered for early discharge and continuation of treatment at home if proper outpatient care and anticoagulation therapy can be arranged (Class IIa).

9. Routine use of inferior vena cava (IVC) filters in patients with acute PE is not recommended (Class III). IVC filters can be considered in patients with a contraindication to anticoagulation (Class IIa) or with recurrence of PE despite therapeutic anticoagulation (Class IIa).

10. Anticoagulation should be given for 3 months in all patients (Class I). Indefinite treatment is recommended for patients with a recurrent unprovoked PE (Class I), and considered for patients with a first unprovoked PE and low risk of bleeding (Class IIa). In patients with acute PE and cancer, consider administering weight-adjusted LMWH for the first 3-6 months (Class IIa).

11. All patients with chronic thromboembolic pulmonary hypertension (CTEPH) should be assessed for potential operability by a multidisciplinary team (Class I), and should receive life-long anticoagulation (Class I). Riociguat is recommended for symptomatic CTEPH patients who are inoperable (Class I).