2019 ESC guidelines for pulmonary embolism

2019 ESC guidelines for pulmonary embolism diagnosis and management

1. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism Dr.Dina Abdelsalam.MD Tanta University

2. Why do we need new Guidelines on the diagnosis and management of PE?

3. What’s new in the 2019 Guidelines?

4. Epidemiology Venous thromboembolism (VTE) , clinically presenting as DVT or PE , is globally the 3rd most frequent acute cardiovascular syndrome behind MI and stroke. Annual incidence rates for PE range from 39.115 per 100 000 population; for DVT, incidence rates range from 53.162 per 100 000 population. Incidence of VTE is almost eight times higher in individuals aged ≥80 years than in the fifth decade of life. PE may cause ≤300 000 deaths per year in the US, ranking high among the causes of cardiovascular mortality. Most of these patients, 34% died suddenly before therapy could be initiated or take effect. Of the other patients, 59% were diagnosed after death and only 7% of patients who died early were correctly diagnosed with PE before death.

5. Case fatality rates of acute PE may be decreasing: Increased use of more effective therapies and interventions, Possibly better adherence to guidelines. Significant positive effect on the prognosis of PE in recent years. However, it may be false drop in case fatality rates. Due to tendency of overdiagnosis in the modern era.

6. Predisposing factors

7. Pathophysiology

8. Pathophysiology and determinants of outcome Acute PE interferes with both circulation and gas exchange. RV failure due to acute pressure overload is considered the primary cause of death in severe PE. PAP increases if >30-50% of the total cross-sectional area of the pulmonary arterial bed is occluded by thromboemboli .

9. Pathophysiology

10. Respiratory failure in PE is predominantly a consequence of haemodynamic disturbances. ventilation/perfusion mismatch, which contributes to hypoxaemia . Increased ventilation to compensate for hypoxemia leads to decrease Co2 leads to hypocapnia

11. Diagnosis

12. Avoiding overuse of diagnostic tests for pulmonary embolism Searching for PE in every patient with dyspnea or chest pain may lead to high costs and complications of unnecessary tests. The Pulmonary Embolism Rule-out Criteria (PERC) were developed for emergency department patients with the purpose of selecting, patients with low likelihood of having PE . They comprise eight clinical variables significantly associated with an absence of PE: Age < 50 years; pulse < 100 beats per minute; SaO 2 >94%; No unilateral leg swelling; No haemoptysis ; No recent trauma or surgery; No history of VTE; and No oral hormone use. Studies suggested safe exclusion of PE in patients with low clinical probability who, in addition, met all criteria of the PERC rule .( with caution ).

13. D-Dimer testing D-dimer levels are elevated in plasma in the presence of acute thrombosis because of simultaneous activation of coagulation and fibrinolysis. The negative predictive value of D-dimer testing is high, and a normal D-dimer level renders acute PE or DVT unlikely. On the other hand, the positive predictive value of elevated D-dimer levels is low and D-dimer testing is not useful for confirmation of PE. D-dimer is also more frequently elevated in patients with: Cancer, Hospitalized patients, Severe infection or inflammatory disease, Pregnancy.

14. Age-adjusted D-dimer cut-offs The specificity of D-dimer in suspected PE decreases steadily with age to 10% in patients >80 years of age. The use of age-adjusted cutoffs may improve the performance of D-dimer testing in the elderly. A multinational prospective management study evaluated a previously validated age-adjusted cut-off ( age× 10 mg/L, for patients aged >50 years ) in a cohort of 3346 patients. Patients with a normal age adjusted D-dimer value did not undergo CTPA; they were left untreated and followed for a 3 month period. Among the 766 patients who were >_75 years of age, 673 had a non-high clinical probability. Use of the age-adjusted (instead of the ‘standard’ 500 mg/L) D-dimer cut-off increased the number of patients in whom PE could be excluded from 6.4 to 30%, without additional false-negative findings.

15. Assessment of pulmonary embolism severity and the risk of early death

16. Risk stratification of patients with acute PE High risk of early death : Haemodynamic instability Patients with PE who present without haemodynamic instability : The assessment of two sets of prognostic criteria: ( i ) clinical, imaging, and laboratory indicators of PE severity (presence of RV dysfunction) (ii) presence of comorbidity and any other aggravating conditions.

17. Treatment in acute phase

18. Haemodynamic support

19. Anticoagulation and reperfusion

20. PE in cancer Patients

21. PE in pregnancy:

22. Follow up

23. What’s new in the 2019 Guidelines?

24. The following are key points to remember D-dimer cut-offs should be adjusted to age and pretest probability rather than fixed values. Terminology such as “provoked” vs. “unprovoked” PE/venous thromboembolism (VTE) is no longer supported by the guidelines; instead they propose using terms like “reversible risk factor,” “any persistent risk factor,” or “no identifiable risk factor.” A revised risk-adjusted management algorithm is proposed accounting for clinical severity, right ventricular dysfunction, and other comorbidities with emphasis on multidisciplinary teams (Class IIa ) and early PE risk stratification. Hemodynamic instability is now clearly defined as presence of cardiac arrest needing resuscitation or obstructive shock or persistent hypotension not caused by other pathologies. Rescue intravenous (IV) thrombolysis is now a Class I recommendation (previously Class IIa ), and interventional thrombus removing therapy (catheter-based or surgical) is now a Class IIa (previously Class IIb) recommendation in hemodynamically deteriorating PE.

25. Direct oral anticoagulants (DOACs) are now recommended as first choice anticoagulants over warfarin even in those who are warfarin eligible. A reduced dose of apixaban or rivaroxaban for extended anticoagulation should be considered after the first 6 months of treatment. Edoxaban or rivaroxaban should be considered as an alternative to low molecular weight heparin in patients with cancer, with caution in gastrointestinal cancer due to the increased bleeding risk with DOACs. A dedicated diagnostic algorithm is proposed for suspected PE in pregnancy. Using D-dimer and other clinical prediction rules to rule out PE during pregnancy is now Class IIa recommendation (previously Class IIb). DOACs are not recommended in pregnancy (Class III). Routine follow-up with an integrated inpatient-outpatient care delivery model 3-6 months after as well as referring symptomatic patients with mismatched perfusion defects (on V/Q scan) >3 months post-PE to an expert chronic thromboembolic pulmonary hypertension center is a Class I recommendation.

26. Thank you