ESC Updates Guidance on Management of Acute Pulmonary Embolism

PARIS, France—The European Society of Cardiology (ESC) has issued updated guidelines for the management of patients with acute pulmonary embolism (PE), providing revisions and clarifications to recommendations starting with diagnosis and ending with chronic management and long-term consequences.

The last update in 2014 was informed by major changes in treatment due to the emergence of the direct oral anticoagulants (DOACs). Even though a similar “revolution” has not occurred leading up to the latest iteration of the guidance, there were many aspects of the disease that required adjustments, according to Stavros Konstantinides, MD, PhD (Johannes Gutenberg University Mainz, Germany), chair of the writing group.

“On one hand, we had to issue clear guidance on the extension of anticoagulation after PE. On the other hand, we had to deal with specific vulnerable patient groups, pregnant patients, and also the patients with [venous thromboembolism] and cancer,” Konstantinides told TCTMD. He added that there is now an algorithm that explains how to follow patients after PE and includes a strategy for assessing risk of long-term sequelae like chronic thromboembolic pulmonary hypertension.

The new guidance, developed in collaboration with the European Respiratory Society, was released to coincide with the ESC Congress 2019. It was published online in the European Heart Journal.

Duration of Anticoagulation

Konstantinides said how long to treat patients with anticoagulation was the topic that took up the most time during the development of the guidelines. With the latest recommendations, most patients should at least be considered for long-term, extended, indefinite anticoagulation after acute PE, he said.

“Until now, we said generally [to use] at least 3 months and then decide, and no one knew exactly what that means,” Konstantinides said. “But now, we said there are some categories—like, for example, patients with a current disease—where it is recommended to continue.” In patients with no identifiable risk factor for the index event, or only minor risk factors that may or may not have been the cause of acute PE, he added, “we say you should consider continuing because their recurrence risk is also quite high.”

For patients who receive extended anticoagulation, drug tolerance and adherence, hepatic and renal function, and bleeding risk should be reassessed at regular intervals, according to a class I recommendation.

Of note, for the first time, DOACs are recommended over vitamin K antagonists when patients are eligible for treatment with the newer agents, mirroring guidance regarding management of patients with A-fib. However, there is a class III recommendation against using DOACs during pregnancy or lactation.

Early Discharge and Home Treatment

The 2019 document also takes a firmer stand on the early discharge and home treatment after acute PE. There is a new class IIa (level of evidence A) recommendation stating that carefully selected, low-risk patients should be considered for early discharge and home treatment, as long as proper outpatient care and anticoagulant treatment are possible.

“In North America, this is something that is done more extensively and many people with PE are discharged, of course on treatment, [and] there is not such a high threshold for discharging these patients,” Konstantinides said.

In Europe, not every country has the same health system, he noted, “so it’s not only a medical decision, it’s also a political decision sometimes, and we were a little bit more careful, more prudent [in the past]. But now we make a stronger case. We have new data, recent trials just unleashed in the European Heart Journal and we say yes, if the patient has low risk—of course we define the criteria—then please consider early discharge and home treatment. Our aim is to reduce hospitalization for these patients, which in Europe is in many countries up to 8 or 10 days.”

Adoption of US PERT Model

The updated also contains a nod toward the emergence of PE response teams (PERTs) in the United States. There is a new class IIa (level of evidence C) recommendation stating that such a team should be considered for the management of high-risk and selected intermediate-risk patients depending on the capabilities at each hospital.

PERTs “address the needs of modern systems-based healthcare,” the guideline writers say. “A PERT brings together a team of specialists from different disciplines including, for example, cardiology, pulmonology, hematology, vascular medicine, anesthesiology/intensive care, cardiothoracic surgery, and (interventional) radiology.

“The team convenes in real time (face-to-face or via web conference) to enhance clinical decision-making,” they continue. “This allows the formulation of a treatment plan and facilitates its immediate implementation. The exact composition and operating mode of a PERT are not fixed, depending on the resources and expertise available in each hospital for the management of acute PE.”

Konstantinides said the guideline document was revised to make it more user-friendly, eliminating some tables—which he described as “generally boring”—and adding simplified, more aesthetically pleasing figures and algorithms. The accompanying smartphone app for ESC guidelines also includes interactive tools to ease use of the recommendations in everyday practice, Konstantinides said.

In the days after the guidelines came out, feedback from physicians has been largely positive, Konstantinides reported, adding that he’s confident the acute PE guidance will continue to be one of the most accessed of the ESC documents.