Commented abbreviated 2014 version of ESC guidelines on the diagnosis and management of acute pulmonary embolism

Czech version

Authors: P. Heinc; F. Kováčik; J. Látal; J. Přeček; A. Smékal; L. Rec
Authors‘ workplace: I. interní klinika – kardiologická LF UP a FN Olomouc
Published in: Kardiol Rev Int Med 2015, 17(3): 234-244
Category: Cardiology Review

Overview

The major innovation of the current European guidelines on the diagnosis and management of acute pulmonary embolism is a new risk stratification, where the most contentious medium risk category was cancelled. According to the size of the right ventricle, function of the right ventricle and the troponin level in this group of patients has now been categorised into the groups with either high risk or low risk. According to this new categorisation, specified diagnostic methods and advanced treatment are presented, including new oral anticoagulants, thrombolysis and embolectomy. The guidelines also update the issues of pulmonary embolism in pregnancy and in connection with cancer.

Keywords:
pulmonary embolism – risk stratification – diagnostic principles – therapeutic strategies

Sources

1. Heit JA. The epidemiology of venous thromboembolism in the community. Arterioscler Thromb Vasc Biol 2008; 28: 370– 372. doi: 10.1161/ ATVBAHA. 108.162545.

2. McIntyre KM, Sasahara AA. The hemodynamic response to pulmonary embolism in patients without prior cardiopulmonary disease. Am J Cardiol 1971; 28: 288– 294.

3. Marcus JT, Gan CT, Zwanenburg JJ et al. Interventricular mechanical asynchrony in pulmonary arterial hypertension: left‑ to‑ right delay in peak shortening is related to right ventricular overload and left ventricular underfilling. J Am Coll Cardiol 2008; 51: 750– 757. doi: 10.1016/ j.jacc.2007.10.041.

4. Lankeit M, Jiménez D, Kostrubiec M et al. Predictive value of the high‑sensitivity troponin T assay and the simplified pulmonary embolism severity index in hemodynamically stable patients with acute pulmonary embolism: a prospective validation study. Circulation 2011; 124: 2716– 2724. doi: 10.1161/ CIRCULATIONAHA.111.051177.

5. Wells PS, Ginsberg JS, Anderson DR et al. Use of a clinical model for safe management of patients with suspected pulmonary embolism. Ann Intern Med 1998; 129: 997– 1005.

6. Douma RA, Mos IC, Erkens PM et al. Performance of 4 clinical decision rules in the diagnostic management of acute pulmonary embolism: a prospective cohort study. Ann Intern Med 2011; 154: 709– 718. doi: 10.7326/ 0003‑ 4819‑ 154‑ 11‑ 201106070‑ 00002.

7. Chabloz P, Reber G, Boehlen F et al. TAFI antigen and D‑dimer levels during normal pregnancy and at delivery. Br J Haematol 2001; 115: 150– 152.

8. Ghaye B, Szapiro D, Mastora I et al. Peripheral pulmonary arteries: how far in the lung does multi‑detector row spiral CT allow analysis? Radiology 2001; 219: 629– 636.

9. Stein PD, Fowler SE, Goodman LR et al. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med 2006; 354: 2317– 2327.

10. Sostman HD, Stein PD, Gottschalk A et al. Acute pulmonary embolism: sensitivity and specificity of ventilation‑ perfusion scintigraphy in PIOPED II study. Radiology 2008; 246: 941– 946. doi: 10.1148/ radiol.2463070270.

11. Stein PD, Athanasoulis C, Alavi A et al. Complications and validity of pulmonary angiography in acute pulmonary embolism. Circulation 1992; 85: 462– 468.

12. van Beek EJ, Reekers JA, Batchelor DA et al. Feasibility, safety and clinical utility of angiography in patients with suspected pulmonary embolism. Eur Radiol 1996; 6: 415– 419.

13. Roy PM, Colombet I, Durieux P et al. Systematic review and meta‑analysis of strategies for the diagnosis of suspected pulmonary embolism. BMJ 2005; 331: 259.

14. Bova C, Greco F, Misuraca G et al. Diagnostic utility of echocardiography in patients with suspected pulmonary embolism. Am J Emerg Med 2003; 21: 180– 183.

15. Kurzyna M, Torbicki A, Pruszczyk P et al. Disturbed right ventricular ejection pattern as a new Doppler echocardiographic sign of acute pulmonary embolism. Am J Cardiol 2002; 90: 507– 511.

16. Pruszczyk P, Goliszek S, Lichodziejewska B et al. Prognostic Value of echocardiography in normotensive patients with acute pulmonary embolism. JACC Cardiovasc Imaging 2014; 7: 553– 560.

17. Kucher N, Luder CM, Dörnhöfer T et al. Novel management strategy for patients with suspected pulmonary embolism. Eur Heart J 2003; 24: 366– 376.

18. Righini M, Le Gal G, Aujesky D et al. Diagnosis of pulmonary embolism by multidetector CT alone or combined with venous ultrasonography of the leg: a randomised non‑inferiority trial. Lancet 2008; 371: 1343– 1352. doi: 10.1016/ S0140‑ 6736(08)60594‑ 2.

19. Sanchez O, Trinquart L, Colombet I et al. Prognostic value of right ventricular dysfunction in patients with haemodynamically stable pulmonary embolism: a systematic review. Eur Heart J 2008; 29: 1569– 1577. doi: 10.1093/ eurheartj/ ehn208.

20. Henzler T, Roeger S, Meyer M et al. Pulmonary embolism: CT signs and cardiac biomarkers for predicting right ventricular dysfunction. Eur Respir J 2012; 39: 919– 926. doi: 10.1183/ 09031936.00088711.

21. Lankeit M, Jimenez D, Kostrubiec M et al. Validation of N‑terminal pro‑brain natriuretic peptide cut‑off values for risk stratification of pulmonary embolism. Eur Respir J 2014; 43: 1669– 1677. doi: 10.1183/ 09031936.00211613.

22. Binder L, Pieske B, Olschewski M et al. N‑terminal pro‑brain natriuretic peptide or troponin testing followed by echocardiography for risk stratification of acute pulmonary embolism. Circulation 2005; 112: 1573– 1579.

23. Mercat A, Diehl JL, Meyer G et al. Hemodynamic effects of fluid loading in acute massive pulmonary embolism. Crit Care Med 1999; 27: 540– 544.

24. Raschke RA, Gollihare B, Peirce JC. The effectiveness of implementing the weight‑based heparin nomogram as a practice guideline. Arch Intern Med 1996; 156: 1645– 1649.

25. Middeldorp S. How I treat pregnancy‑related venous thromboembolism. Blood 2011; 118: 5394– 5400. doi: 10.1182/ blood‑ 2011‑ 04‑ 306589.

26. Samama MM, Poller L. Contemporary laboratory monitoring of low molecular weight heparins. Clin Lab Med 1995; 15: 119– 123.

27. Goldhaber SZ, Haire WD, Feldstein ML et al. Alteplase versus heparin in acute pulmonary embolism: randomised trial assessing right‑ ventricular function and pulmonary perfusion. Lancet 1993; 341: 507– 511.

28. Konstantinides S, Tiede N, Geibel A et al. Comparison of alteplase versus heparin for resolution of major pulmonary embolism. Am J Cardiol 1998; 82: 966– 970.

29. Meneveau N, Schiele F, Metz D et al. Comparative efficacy of a two‑hour regimen of streptokinase versus alteplase in acute massive pulmonary embolism: immediate clinical and hemodynamic outcome and one‑year follow‑up. J Am Coll Cardiol 1998; 31: 1057– 1063.

30. Daniels LB, Parker JA, Patel SR et al. Relation of duration of symptoms with response to thrombolytic therapy in pulmonary embolism. Am J Cardiol 1997; 80: 184– 188.

31. Lee AY, Rickles FR, Julian JA et al. Randomized comparison of low molecular weight heparin and coumarin derivatives on the survival of patients with cancer and venous thromboembolism. J Clin Oncol 2005; 23: 2123– 2129.

32. Murin S, Romano PS, White RH. Comparison of outcomes after hospitalization for deep venous thrombosis or pulmonary embolism. Thromb Haemost 2002; 88: 407– 414.

33. Grifoni S, Vanni S, Magazzini S et al. Association of persistent right ventricular dysfunction at hospital discharge after acute pulmonary embolism with recurrent thromboembolic events. Arch Intern Med 2006; 166: 2151– 2156.

34. Palareti G, Cosmi B, Legnani C et al. D‑dimer testing to determine the duration of anticoagulation therapy. N Engl J Med 2006; 355: 1780– 1789.

35. Ridge CA, McDermott S, Freyne et al. Pulmonary embolism in pregnancy: comparison of pulmonary CT angiography and lung scintigraphy. AJR Am J Roentgenol 2009; 193: 1223– 1227. doi: 10.2214/ AJR.09.2360.