new guidelines for the treatment of acute pulmonary embolism have been presented » Medvestnik

New ESC and European Respiratory Society (ERS) guidelines for the diagnosis and treatment of acute pulmonary embolism (PE) were presented at the ESC 2019 Congress (31 August–4 September 2019). The full document is published in the European Heart Journal and on the ESC website.

According to the chairman of the working group, Professor Stavros Constantinides, the document contains many new recommendations and algorithms compared to the 2014 guidelines. The diagnostic algorithm has been updated, and a clear definition of hemodynamic instability and high-risk PE is given. New recommendations have been added on the duration of treatment with anticoagulants, prolongation of therapy and dose reduction. The 2019 document added new recommendations for the diagnosis and treatment of PE in pregnant and cancer patients.

Main changes and provisions


  1. As an alternative to a fixed value, a D-dimer value adjusted for age (in patients over 50 years (years) x 10 ng/mL) or clinical probability can be used.
  2. A definition of hemodynamic instability and high-risk PE is given (Table 1).

Table 1. Definition of hemodynamic instability that indicates high-risk acute PE (one of the following clinical manifestations)

(1) Cardiac arrest

(2) Obstructive shock

(3) Persistent hypotension

The need for cardiopulmonary resuscitation

SBP < 90 mm Hg. Art. or the need to administer vasopressors to achieve a blood pressure of 90 mmHg. Art. and higher, despite adequate filling status

SBP < 90 mmHg Art. or a drop in SBP of 40 mm Hg. Art. or more, lasting more than 15 minutes, not caused by new arrhythmia, hypovolemia or sepsis


End organ hypoperfusion (altered mental status; cold, clammy skin; oliguria/anuria; elevated serum lactate)

SBP – systolic blood pressure

Treatment in the acute period:

  1. NOACs (new oral anticoagulants that are not vitamin K antagonists) are recommended as first-line therapy in patients eligible for NOACs (apixaban, dabigatran, edoxaban, or rivaroxaban); Vitamin K antagonists are an alternative to NOACs.
  2. The management algorithm for PE was revised taking into account clinical severity, comorbidity and the presence of RV dysfunction.

Extended therapy after the first 3 months

  1. Risk factors for recurrent venous thromboembolism (VTE) were classified (Table 2).

Table 2. Long-term risk factors for VTE recurrence

Estimated long-term risk

Category of risk factors


Low (<3% per year)

Major transient or reversible factors associated with a greater than 10-fold increase in the risk of VTE (compared with patients without a risk factor)

× Surgery with general anesthesia for more than 30 minutes

× Bed rest in hospital for 3 days or more due to acute illness or exacerbation of chronic

× Trauma with fractures

Average (3–8% per year)

Transient or reversible factors associated with a 10-fold increased risk of first VTE

× Minor surgery (general anesthesia for < 30 min)

× Admission to hospital for less than 3 days with acute illness

× Estrogen therapy/contraception

× Pregnancy or postpartum period

× Bed rest in hospital for 3 days or more with acute illness

× Leg injury (without fracture) associated with decreased mobility for 3 days or more

× Long flight

Non-malignant persistent risk factors

× Inflammatory bowel diseases

× Active autoimmune disease

High (>8% per year)

× Active cancer

× One or more previous episodes of VTE

× Antiphospholipid syndrome

  1. The terminology “provoked” or “unprovoked” PE and VTE is no longer supported because it is misleading and does not assist in decision-making regarding the duration of anticoagulant therapy.
  2. In case of prolonged anticoagulation, a dose reduction of apixaban or rivaroxaban should be considered after the first 6 months of treatment.
  3. Extended anticoagulant therapy should be considered in patients with persistent risk factors (Table 2), except for patients with antiphospholipid syndrome.
  4. For patients with antiphospholipid syndrome, indefinite treatment with vitamin K antagonists is recommended.

PE for oncological diseases

  1. Edoxaban or rivaroxaban should be considered as an alternative to low molecular weight heparins (with caution in patients with gastrointestinal cancer due to the increased risk of bleeding when taking NOACs).

PE during pregnancy

  1. NOACs are not recommended during pregnancy or breastfeeding.
  2. Thrombolysis or surgical embolectomy should be considered in pregnant women with high-risk PE.

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