ESC Guidelines on the diagnosis and management of acute pulmonary embolism

ESC GUIDELINES
2014ESCGuidelinesonthediagnosisand
managementofacutepulmonaryembolism
The Task Force for the Diagnosis and Management of Acute
Pulmonary Embolism of the European Society of Cardiology (ESC)
Endorsed by the European Respiratory Society (ERS)
Authors/Task Force Members: Stavros V. Konstantinides*(Chairperson) (Germany/
Greece), Adam Torbicki
*(Co-chairperson) (Poland), Giancarlo Agnelli (Italy),
Nicolas Danchin (France), David Fitzmaurice (UK), Nazzareno Galie`(Italy),
J. Simon R. Gibbs (UK), Menno V. Huisman (The Netherlands), Marc Humbert
†
(France),NilsKucher(Switzerland),IreneLang(Austria),MareikeLankeit (Germany),
John Lekakis (Greece), Christoph Maack (Germany), Eckhard Mayer (Germany),
Nicolas Meneveau (France), Arnaud Perrier (Switzerland), Piotr Pruszczyk (Poland),
Lars H. Rasmussen (Denmark), Thomas H. Schindler (USA), Pavel Svitil (Czech
Republic), Anton Vonk Noordegraaf (The Netherlands), Jose Luis Zamorano (Spain),
Maurizio Zompatori (Italy)
ESC Committee for Practice Guidelines (CPG): Jose Luis Zamorano (Chairperson) (Spain), Stephan Achenbach
(Germany), Helmut Baumgartner (Germany), Jeroen J. Bax (Netherlands), Hector Bueno (Spain), Veronica Dean
(France), Christi Deaton (UK), Çetin Erol (Turkey), Robert Fagard (Belgium), Roberto Ferrari (Italy), David Hasdai
(Israel), Arno Hoes (Netherlands), Paulus Kirchhof (Germany/UK), Juhani Knuuti (Finland), Philippe Kolh (Belgium),
Patrizio Lancellotti (Belgium), Ales Linhart (Czech Republic), Petros Nihoyannopoulos (UK), Massimo F. Piepoli
*Corresponding authors. Stavros Konstantinides, Centre for Thrombosis and Hemostasis, Johannes Gutenberg University of Mainz, University Medical Centre Mainz, Langenbeckstrasse
1, 55131 Mainz, Germany. Tel:+49 613 1176255, Fax:+49 613 1173456. Email:stavros.konstantinides@unimedizin-mainz.de, and Department of Cardiology, Democritus University of
Thrace, Greece. Email:skonst@med.duth.gr.
Adam Torbicki, Department of Pulmonary Circulation and Thromboembolic Diseases, Medical Centre of Postgraduate Education, ECZ-Otwock, Ul. Borowa 14/18, 05-400 Otwock,
Poland. Tel:+48 22 7103052, Fax:+48 22 710315. Email:adam.torbicki@ecz-otwock.pl.
†
Representing the European Respiratory Society
Other ESC entities having participated in the development of this document:
ESC Associations:Acute Cardiovascular Care Association (ACCA), European Association for Cardiovascular Prevention & Rehabilitation (EACPR), European Association of Cardio-
vascular Imaging (EACVI), Heart Failure Association (HFA), ESC Councils: Council on Cardiovascular Nursing and Allied Professions (CCNAP), Council for Cardiology Practice (CCP),
Council on Cardiovascular Primary Care (CCPC)
ESC Working Groups:Cardiovascular Pharmacology and Drug Therapy, Nuclear Cardiology and Cardiac Computed Tomography, Peripheral Circulation, Pulmonary Circulation and
Right Ventricular Function, Thrombosis.
Disclaimer:The ESC Guidelines represent the views of the ESC and were produced after careful consideration of the scientific and medical knowledge and the evidence available at the
time of their publication.
The ESC is not responsible in the event of any contradiction, discrepancy and/or ambiguity between the ESC Guidelines and any other official recommendations or guidelines issued by
the relevant public health authorities, in particular in relation to good use of healthcare or therapeutic strategies. Health professionals are encouraged to take the ESC Guidelines fully into
account when exercising their clinical judgment, as well as in the determination and the implementation of preventive, diagnostic or therapeutic medical strategies; however, the ESC
Guidelines do not override, in any way whatsoever, the individual responsibility of health professionals to make appropriate and accurate decisions in consideration of each patient’s
health condition and in consultation with that patient and, where appropriate and/or necessary, the patient’s caregiver. Nor do the ESC Guidelines exempt health professionals from
taking into full and careful consideration the relevant official updated recommendations or guidelines issued by the competent public health authorities, in order to manage each patient’s
case in light of the scientifically accepted data pursuant to their respective ethical and professional obligations. It is also the health professional’s responsibility to verify the applicable rules
and regulations relating to drugs and medical devices at the time of prescription.
National Cardiac Societies document reviewers:listed in the Appendix.
&The European Society of Cardiology 2014. All rights reserved. For permissions please email: journals.permissions@oup.com.
European Heart Journal (2014)35, 3033–3080
doi:10.1093/eurheartj/ehu283
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(Italy), Piotr Ponikowski (Poland), Per Anton Sirnes (Norway), Juan Luis Tamargo (Spain), Michal Tendera (Poland),
Adam Torbicki (Poland), William Wijns (Belgium), Stephan Windecker (Switzerland).
Document Reviewers: Çetin Erol (CPG Review Coordinator) (Turkey), David Jimenez (Review Coordinator) (Spain),
Walter Ageno (Italy), Stefan Agewall (Norway), Riccardo Asteggiano (Italy), Rupert Bauersachs (Germany),
Cecilia Becattini (Italy), Henri Bounameaux (Switzerland), Harry R. Bu¨ller (Netherlands), Constantinos H. Davos
(Greece), Christi Deaton (UK), Geert-Jan Geersing (Netherlands), Miguel Angel Go´mez Sanchez (Spain),
Jeroen Hendriks (Netherlands), Arno Hoes (Netherlands), Mustafa Kilickap (Turkey), Viacheslav Mareev (Russia),
Manuel Monreal (Spain), Joao Morais (Portugal), Petros Nihoyannopoulos (UK), Bogdan A. Popescu (Romania),
Olivier Sanchez
†
(France), Alex C. Spyropoulos (USA).
The disclosure forms provided by the experts involved in the development of these guidelines are available on the ESC website
www.escardio.org/guidelines.
Online publish-ahead-of-print 29 August 2014
------------------------------------------------------------------------------------------------------------------------------- -----------------------
Keywords Guidelines†Pulmonary embolism†Venous thrombosis†Shock†Hypotension†Chest pain†Dyspnoea
†Heart failure†Diagnosis†Treatment–Anticoagulation†Thrombolysis
Table of Contents
Abbreviations and acronyms . . . . . . . . . . . . . . . . . . . . . . . .3035
1. Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3035
2. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3036
2.1 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3037
2.2 Predisposing factors . . . . . . . . . . . . . . . . . . . . . . . .3037
2.3 Natural history . . . . . . . . . . . . . . . . . . . . . . . . . . . .3038
2.4 Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . .3038
2.5 Clinical classification of pulmonary embolism severity . . .3039
3. Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3039
3.1 Clinical presentation . . . . . . . . . . . . . . . . . . . . . . . .3039
3.2 Assessment of clinical probability . . . . . . . . . . . . . . . .3040
3.3 D-dimer testing . . . . . . . . . . . . . . . . . . . . . . . . . . .3040
3.4 Computed tomographic pulmonary angiography . . . . . .3042
3.5 Lung scintigraphy . . . . . . . . . . . . . . . . . . . . . . . . . .3043
3.6 Pulmonary angiography . . . . . . . . . . . . . . . . . . . . . .3043
3.7 Magnetic resonance angiography . . . . . . . . . . . . . . . .3043
3.8 Echocardiography . . . . . . . . . . . . . . . . . . . . . . . . . .3043
3.9 Compression venous ultrasonography . . . . . . . . . . . . .3044
3.10. Diagnostic strategies . . . . . . . . . . . . . . . . . . . . . . .3044
3.10.1 Suspected pulmonary embolism with shock
or hypotension . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3044
3.10.2 Suspected pulmonary embolism without
shock or hypotension . . . . . . . . . . . . . . . . . . . . . . . .3045
3.11. Areas of uncertainty . . . . . . . . . . . . . . . . . . . . . . .3046
4. Prognostic assessment . . . . . . . . . . . . . . . . . . . . . . . . . .3047
4.1 Clinical parameters . . . . . . . . . . . . . . . . . . . . . . . . .3047
4.2 Imaging of the right ventricle by echocardiography
or computed tomographic angiography . . . . . . . . . . . . . . .3048
4.3 Laboratory tests and biomarkers . . . . . . . . . . . . . . . .3049
4.3.1 Markers of right ventricular dysfunction . . . . . . . . .3049
4.3.2 Markers of myocardial injury . . . . . . . . . . . . . . . .3049
4.3.3 Other (non-cardiac) laboratory biomarkers . . . . . .3050
4.4 Combined modalities and scores . . . . . . . . . . . . . . . .3051
4.5 Prognostic assessment strategy . . . . . . . . . . . . . . . . .3051
5. Treatment in the acute phase . . . . . . . . . . . . . . . . . . . . . .3052
5.1 Haemodynamic and respiratory support . . . . . . . . . . .3052
5.2 Anticoagulation . . . . . . . . . . . . . . . . . . . . . . . . . . .3052
5.2.1 Parenteral anticoagulation . . . . . . . . . . . . . . . . . .3052
5.2.2 Vitamin K antagonists . . . . . . . . . . . . . . . . . . . . .3053
5.2.3 New oral anticoagulants . . . . . . . . . . . . . . . . . . .3054
5.3 Thrombolytic treatment . . . . . . . . . . . . . . . . . . . . . .3055
5.4 Surgical embolectomy . . . . . . . . . . . . . . . . . . . . . . .3056
5.5 Percutaneous catheter-directed treatment . . . . . . . . . .3056
5.6 Venous filters . . . . . . . . . . . . . . . . . . . . . . . . . . . .3056
5.7 Early discharge and home treatment . . . . . . . . . . . . . .3057
5.8 Therapeutic strategies . . . . . . . . . . . . . . . . . . . . . . .3058
5.8.1 Pulmonary embolism with shock or hypotension
(high-risk pulmonary embolism) . . . . . . . . . . . . . . . . . .3058
5.8.2 Pulmonary embolism without shock or hypotension
(intermediate- or low-risk pulmonary embolism) . . . . . . .3058
5.9 Areas of uncertainty . . . . . . . . . . . . . . . . . . . . . . . .3059
6. Duration of anticoagulation . . . . . . . . . . . . . . . . . . . . . . .3061
6.1 New oral anticoagulants for extended treatment . . . . . .3062
7. Chronic thromboembolic pulmonary hypertension . . . . . . . .3063
7.1 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3063
7.2 Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . .3063
7.3 Clinical presentation and diagnosis . . . . . . . . . . . . . . .3063
7.4 Treatment and prognosis . . . . . . . . . . . . . . . . . . . . .3064
8. Specific problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3066
8.1 Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3066
8.1.1 Diagnosis of pulmonary embolism in pregnancy . . . .3066
8.1.2 Treatment of pulmonary embolism in pregnancy . . .3066
8.2 Pulmonary embolism and cancer . . . . . . . . . . . . . . . .3067
8.2.1 Diagnosis of pulmonary embolism in patients with
cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3067
8.2.2 Prognosis for pulmonary embolism in patients with
cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3067
8.2.3 Management of pulmonary embolism in patients with
cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3067
8.2.4 Occult cancer presenting as unprovoked pulmonary
embolism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3068
8.3 Non-thrombotic pulmonary embolism . . . . . . . . . . . .3068
8.3.1 Septic embolism . . . . . . . . . . . . . . . . . . . . . . . .3068
8.3.2 Foreign-material pulmonary embolism . . . . . . . . . .3068
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8.3.3 Fat embolism . . . . . . . . . . . . . . . . . . . . . . . . . .3068
8.3.4 Air embolism . . . . . . . . . . . . . . . . . . . . . . . . . .3069
8.3.5 Amniotic fluid embolism . . . . . . . . . . . . . . . . . . .3069
8.3.6 Tumour embolism . . . . . . .