2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism

untitledSee discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/265173880
2014 ESC Guidelines on the diagnosis and management of acute pulmonary
embolism: The Task Force for the Diagnosis and Management of Acute
Pulmonary Embolism of the European Society...
Article  in  European Heart Journal · August 2014
Source: PubMed
24 authors, including:
Some of the authors of this publication are also working on these related projects:
Risk stratification and management of patients with acute pulmonary embolism View project
EPICOR (long-tErm follow-uP of anti-thrombotic management patterns In acute CORonary syndrome patients) View project
Stavros Konstantinides
385 PUBLICATIONS   17,259 CITATIONS   
1,022 PUBLICATIONS   26,965 CITATIONS   
SEE PROFILE
All content following this page was uploaded by Mareike Lankeit on 03 September 2014.
The user has requested enhancement of the downloaded file.
ESC GUIDELINES
2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism 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 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 Huisman (The Netherlands), Marc Humbert† (France), Nils Kucher (Switzerland), Irene Lang (Austria), Mareike Lankeit (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 Universityof Mainz, University Medical Centre Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany. Tel: +49 613 1176255, Fax: +49 613 1173456. Email: [email protected], and Department of Cardiology, Democritus University of Thrace, Greece. Email: [email protected].
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: [email protected]. † 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: [email protected].
European Heart Journal doi:10.1093/eurheartj/ehu283
European Heart Journal Advance Access published August 29, 2014 by guest on Septem
ber 3, 2014 http://eurheartj.oxfordjournals.org/
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. Buller (Netherlands), Constantinos H. Davos (Greece), Christi Deaton (UK), Geert-Jan Geersing (Netherlands), Miguel Angel Gomez 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.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Keywords Guidelines † Pulmonaryembolism † Venous thrombosis † Shock † Hypotension † Chestpain † Dyspnoea
† Heart failure † Diagnosis † Treatment–Anticoagulation † Thrombolysis
Table of Contents Abbreviations and acronyms . . . . . . . . . . . . . . . . . . . . . . . . 3
1. Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
2. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
2.1 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
3. Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
3.3 D-dimer testing . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
3.5 Lung scintigraphy . . . . . . . . . . . . . . . . . . . . . . . . . . 11
3.6 Pulmonary angiography . . . . . . . . . . . . . . . . . . . . . . 11
3.8 Echocardiography . . . . . . . . . . . . . . . . . . . . . . . . . . 11
3.10. Diagnostic strategies . . . . . . . . . . . . . . . . . . . . . . . 12
or hypotension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
shock or hypotension . . . . . . . . . . . . . . . . . . . . . . . . 13
4. Prognostic assessment . . . . . . . . . . . . . . . . . . . . . . . . . . 15
4.1 Clinical parameters . . . . . . . . . . . . . . . . . . . . . . . . . 15
or computed tomographic angiography . . . . . . . . . . . . . . . 16
4.3 Laboratory tests and biomarkers . . . . . . . . . . . . . . . . 17
4.3.1 Markers of right ventricular dysfunction . . . . . . . . . 17
4.3.2 Markers of myocardial injury . . . . . . . . . . . . . . . . 17
4.3.3 Other (non-cardiac) laboratory biomarkers . . . . . . 18
4.4 Combined modalities and scores . . . . . . . . . . . . . . . . 19
4.5 Prognostic assessment strategy . . . . . . . . . . . . . . . . . 19
5. Treatment in the acute phase . . . . . . . . . . . . . . . . . . . . . . 20
5.1 Haemodynamic and respiratory support . . . . . . . . . . . 20
5.2 Anticoagulation . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
5.3 Thrombolytic treatment . . . . . . . . . . . . . . . . . . . . . . 23
5.4 Surgical embolectomy . . . . . . . . . . . . . . . . . . . . . . . 24
5.6 Venous filters . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
5.8 Therapeutic strategies . . . . . . . . . . . . . . . . . . . . . . . 26
(high-risk pulmonary embolism) . . . . . . . . . . . . . . . . . . 26
(intermediate- or low-risk pulmonary embolism) . . . . . . . 26
5.9 Areas of uncertainty . . . . . . . . . . . . . . . . . . . . . . . . 27
6. Duration of anticoagulation . . . . . . . . . . . . . . . . . . . . . . . 29
6.1 New oral anticoagulants for extended treatment . . . . . . 30
7. Chronic thromboembolic pulmonary hypertension . . . . . . . . 31
7.1 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
7.2 Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
7.4 Treatment and prognosis . . . . . . . . . . . . . . . . . . . . . 32
8. Specific problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
8.2 Pulmonary embolism and cancer . . . . . . . . . . . . . . . . 35
8.2.1 Diagnosis of pulmonary embolism in patients with
cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
embolism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
8.3.1 Septic embolism . . . . . . . . . . . . . . . . . . . . . . . . 36
by guest on Septem ber 3, 2014
http://eurheartj.oxfordjournals.org/ D
8.3.6 Tumour embolism . . . . . . . . . . . . . . . . . . . . . . 37
Abbreviations and acronyms
ACS acute coronary syndrome AMPLIFY Apixaban for the Initial Management of Pulmonary
Embolism and Deep-Vein Thrombosis as First-line Therapy
aPTT activated partial thromboplastin time b.i.d. bis in diem (twice daily) b.p.m. beats per minute BNP brain natriuretic peptide BP blood pressure CI confidence interval CO cardiac output COPD chronic obstructive pulmonary disease CPG Committee for Practice Guidelines CRNM clinically relevant non-major CT computed tomographic/tomogram CTEPH chronic thromboembolic pulmonary hypertension CUS compression venous ultrasonography DSA digital subtraction angiography DVT deep vein thrombosis ELISA enzyme-linked immunosorbent assay ESC European Society of Cardiology H-FABP heart-type fatty acid-binding protein HIT heparin-induced thrombocytopenia HR hazard ratio ICOPER International Cooperative Pulmonary Embolism
Registry ICRP International Commission on Radiological Protection INR international normalized ratio iPAH idiopathic pulmonary arterial hypertension IVC inferior vena cava LMWH low molecular weight heparin LV left ventricle/left ventricular MDCT multi-detector computed tomographic (angiography) MRA magnetic resonance angiography NGAL neutrophil gelatinase-associated lipocalin NOAC(s) Non-vitamin K-dependent new oral anticoagulant(s) NT-proBNP N-terminal pro-brain natriuretic peptide o.d. omni die (every day) OR odds ratio PAH pulmonary arterial hypertension PE pulmonary embolism PEA pulmonary endarterectomy PEITHO Pulmonary EmbolIsm THrOmbolysis trial PESI pulmonary embolism severity index PH pulmonary hypertension
PIOPED Prospective Investigation On Pulmonary Embolism Diagnosis
PVR pulmonary vascular resistance RIETE Registro Informatizado de la Enfermedad Throm-
boembolica venosa RR relative risk rtPA recombinant tissue plasminogen activator RV right ventricle/ventricular SPECT single photon emission computed tomography sPESI simplified pulmonary embolism severity index TAPSE tricuspid annulus plane systolic excursion Tc technetium TOE transoesophageal echocardiography TTR time in therapeutic range TV tricuspid valve UFH unfractionated heparin V/Q scan ventilation–perfusion scintigraphy VKA vitamin K antagonist(s) VTE venous thromboembolism
1. Preamble Guidelines summarize and evaluate all available evidence at the time of the writing process, on a particular issue with the aim of assisting health professionals in selecting the best management strategies for an individual patient, with a given condition, taking into account the impact on outcome, as well as the risk-benefit-ratio of particular diag- nostic or therapeutic means. Guidelines and recommendations should help the health professionals to make decisions in their daily practice. However, the final decisions concerning an individual patient must be made by the responsible health professional(s) in consultation with the patient and caregiver as appropriate.
A great number of Guidelines have been issued in recent years by the European Society of Cardiology (ESC) as well as by other soci- eties and organisations. Because of the impact on clinical practice, quality criteria for the development of guidelines have been estab- lished in order to make all decisions transparent to the user. The recommendations for formulating and issuing ESC Guidelines can be found on the ESC Web Site (http://www.escardio.org/guidelines- surveys/esc-guidelines/about/Pages/rules-writing.aspx). ESC Guide- lines represent the official position of the ESC on a given topic and are regularly updated.
Members of this Task Force were selected by the ESC to represent professionals involved with the medical care of patients with this pathology. Selected experts in the field undertook a comprehensive review of the published evidence for management (including diagno- sis, treatment, prevention and rehabilitation) of a given condition according to ESC Committee for Practice Guidelines (CPG) policy. A critical evaluation of diagnostic and therapeutic procedures was performed including assessment of the risk-benefit-ratio. Estimates of expected health outcomes for larger populations were included, where data exist. The level of evidence and the strength of recom- mendation of particular management options were weighed and graded according to predefined scales, as outlined in Tables 1 and 2.
The experts of the writing and reviewing panels filled in declara- tions of interest forms which might be perceived as real or potential
ESC Guidelines Page 3 of 48
by guest on Septem ber 3, 2014
http://eurheartj.oxfordjournals.org/ D
sources of conflicts of interest. These forms were compiled into one file and can be found on the ESC Web Site (http://www.escardio.org/ guidelines). Any changes in declarations of interest that arise during the writing period must be notified to the ESC and updated. The Task Force received its entire financial support from the ESC without any involvement from healthcare industry.
The ESC CPG supervises and coordinates the preparation of new Guidelines produced by Task Forces, expert groups or consensus panels. The Committee is also responsible for the endorsement process of these Guidelines. The ESC Guidelines undergo extensive review by the CPG and external experts. After appropriate revisions it is approved by all the experts involved in the Task Force. The fina- lized document is approved by the CPG for publication in the Euro- pean Heart Journal. It was developed after careful consideration of the scientific and medical knowledge and the evidence available at the time of their dating.
The task of developing ESC Guidelines covers not only the integra- tion of the most recent research, but also the creation of educational tools and implementation programmes for the recommendations. To implement the guidelines, condensed pocket guidelines versions, summary slides, booklets with essential messages, summary cards for non-specialists, electronic version for digital applications (smart- phones etc) are produced. These versions are abridged and, thus, if needed, one should always refer to the full text version which is freely available on the ESC Website. The National Societies of the ESC are encouraged to endorse, translate and implement the ESC Guidelines. Implementation programmes are needed because it has been shown that the outcome of disease may be favourably influenced by the thorough application of clinical recommendations.
Surveys and registries are needed to verify that real-life daily prac- tice is in keeping with what is recommended in the guidelines, thus completing the loop between clinical research, writing of guidelines, disseminating them and implementing them into clinical practice.
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, diag- nostic or therapeutic medical strategies. However, the ESC Guide- lines do not override in any way whatsoever the individual responsibility of health professionals to make appropriate and ac- curate decisions in consideration of each patient s health condition and in consultation with that patient and the…