The European Society of Cardiology (ESC) has published new guidelines for managing patients with pulmonary embolism (PE).
The guidelines now include recommendations for all new oral anticoagulants, a risk-stratification algorithm, new advice on managing PE in specific patient populations, and age-specific D-dimer cutoffs, among other additions.
The guidelines were presented at the ESC Congress 2014 and published in the European Heart Journal and on the ESC website.
Previous ESC Guidelines on acute PE were published in 2000 and 2008.
“These are the first major international guidelines with a complete set of recommendations on the use of new oral anticoagulants in VTE [venous thromboembolism],” said guidelines author Stavros Konstantinides, MD, PhD, of the Johannes Gutenberg University Mainz in Germany.
“For each drug, we provide detailed recommendations on how and when to use it, and whether it should be first-line treatment or an alternative to standard treatment.”
Managing specific patients
For the first time, the guidelines include formal recommendations for managing PE in pregnancy and in cancer patients.
The guidelines also highlight recently identified risk factors for VTE, including in vitro fertilization, which increases the risk of VTE in early pregnancy.
And the guidelines include a new chapter on the diagnosis and treatment of chronic thromboembolic pulmonary hypertension.
Risk stratification
Another first with the new guidelines is the inclusion of an algorithm for risk stratification. It incorporates all available tools and provides recommendations for managing patients according to risk.
“Patients with PE or suspected PE who are in shock are at high risk, but at least 95% of patients are at intermediate or low risk, and defining how to manage them has not been clear,” Dr Konstantinides said.
“Previously, we used echocardiography and/or a CT scan to evaluate the right ventricle but did not combine this information with clinical data. These topics have advanced in the past 6 years, and now we can integrate clinical scores of severity, imaging with echo and CT, and biomarkers to define levels of risk.”
“And, more importantly, we now have solid evidence to give recommendations on rescue rather than primary thrombolysis in patients at intermediate risk of early adverse outcome. We are also now able to recommend how to identify low-risk patients [who] may be considered for early discharge despite a confirmed PE episode.”
D-dimer cutoffs
Another new addition to the guidelines is age-adjusted D-dimer cutoffs, which have been introduced to identify patients of all ages who do not require anticoagulation.
Until now, anticoagulation could be withheld in patients with D-dimer levels less than 500 µg/L, but D-dimer rises naturally with age.
The guidelines reference evidence suggesting that, for patients older than 50, the cutoff may now be their age times 10. For example, in a 65-year-old, the cutoff would be 650 µg/L.
“These guidelines provide the most comprehensive recommendations ever for the diagnosis and treatment of PE,” Dr Konstantinides concluded. “Clinicians can confidently risk-stratify their patients with suspected PE and provide appropriate treatment including the new oral anticoagulants.”
