Acute Pulmonary Embolism - European Society of Cardiology 2019
V1.1.1. February 23, 2023
Classification of PE severity and risk of early death (in-hospital or 30 day mortality)
Definition of hemodynamic instability (high-risk PE)
Risk-adjusted management for acute PE
Initial anticoagulation and reperfusion therapy
Anticoagulation (AC) should be started immediately after PE diagnosis. Based on the latest evidence, 2019 ESC Guidelines recommends different AC agents depending on the risk-adjusted management of PE:
High risk PE
It is recommended that anticoagulation with unfractionated heparin (UFH), including a weight-adjusted bolus injection, be initiated without delay in patients with high-risk PE. Recommendation IC.
Systemic thrombolytic therapy is recommended for high-risk PE. Recommendation IB.
Surgical pulmonary embolectomy is recommended for patients with high-risk PE, in whom thrombolysis is contraindicated or has failed. Recommendation IC.
Percutaneous catheter-directed treatment should be considered for patients with high-risk PE, in whom thrombolysis is contraindicated or has failed. Recommendation IIaC.
Intermediate and low risk PE
If anticoagulation is initiated parenterally, Low Molecular Weight Heparin (LMWH) or fondaparinux is recommended (over UFH) for most patients. Recommendation IA.
When oral anticoagulation is started in a patient with PE who is eligible for a Novel Oral Anticoagulants (NOAC)(apixaban, dabigatran, edoxaban, or rivaroxaban), a NOAC is recommended in preference to a Vitamin K Antagonist (VKA). Recommendation IA.
When patients are treated with a VKA, overlapping with parenteral anticoagulation is recommended until an INR of 2.5 (range 2-3) is reached. Recommendation IA.
Rescue thrombolytic therapy is recommended for patients with haemodynamic deterioration on anticoagulation treatment. Recommendation IB.
Treatment of right ventricular failure in acute high-risk PE
Related drugs
Fibrinolytics
Streptokinase
Urokinase
Heparins
Unfractionated Heparin
Enoxaparin (LMWH)
Dalteparin (LMWH)
Fondaparinoux
NOACs
Apixaban
Dabigatran
Rivaroxaban
Vasoactive / inotropic agents
Dobutamine
VKA
Acenocoumarol
Warfarin
References
Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J. 2020;41(4):543-603. doi:10.1093/eurheartj/ehz405
European Heart Journal (Open Access)
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