New guidelines for the diagnosis and management of pulmonary embolism: Key changes

Abstract

Pulmonary embolism (PE) is an important public health problem. In August 2019, the European Society of Cardiology in collaboration with the European Respiratory Society released new guidelines for the diagnosis and management of PE. We discuss the basic changes between these recent guidelines and the previous guidelines that were published in 2014. Regarding diagnosis, the new guidelines propose the use of an age-adjusted cut-off level of D-dimers instead of a fixed cut-off value. A D-dimer test adapted to clinical possibility should also be considered instead of fixed cut-off level of D-dimer. Detailed recommendations for the diagnosis of PE during pregnancy are also provided. Regarding risk stratification, assessment of PE-related early mortality risk is recommended. Moreover, the importance of right ventricular dysfunction is emphasized in low-risk patients. For further risk stratification of the severity of PE in patients without hemodynamic instability, use of validated scores that combine clinical, imaging and laboratory PE-related prognostic factors might also be considered. Regarding treatment, the possibility of early discharge is mentioned in patients without severe comorbidities, who are not of high risk for sudden death and in whom proper medical management at home and proper medical follow up can be ensured. The new guidelines also suggest that pro-brain natriuretic peptide levels, right ventricular function and the presence of thrombus in the right heart could be useful for guiding the decision of early discharge. Overall, these new guidelines introduce several key changes and knowledge and adherence to them will improve the outcome of patients with PE.

Keywords: Pulmonary embolism; Guidelines; Diagnosis; Treatment; D-dimers; Pregnancy

Core tip: We discuss the basic changes between the recent guidelines published in August 2019 by the European Society of Cardiology in collaboration with the European Respiratory Society regarding the diagnosis and management of pulmonary embolism and the previous guidelines that were published in 2014. The use of age-specific cut-off levels of D-dimers, detailed recommendations for risk stratification and the possibility of outpatient management are some of the key changes. Knowledge and adherence to these new guidelines will improve the outcome of patients with pulmonary embolism.