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2014 ESC Guidelines on the Diagnosis & Treatment of
Pulmonary embolism Prof. Fausto J. Pinto, FESC, FACC, FASE
President, ESC University Hospital Sta Maria University of Lisbon, Portugal
Professor Fausto J. Pinto, MD, PhD, FESC, FASE, FACC, FSCAI
•Disclosures: Consultancy, advisory boards and lecture fees: Abbott, Astra Zeneca, Bayer, Bial, BMS, Benecke, Biotronik, Boehringher Ingelheim, Covidien, GE, Irokio, Medtronic, Menarini, Merck, MSD, Novartis, Pfizer, Sanofi, Servier, St Jude Medical, Tabuk
www.escardio.org/guidelines
2014 ESC Guidelines on the Diagnosis & Management of ACUTE PULMONARY EMBOLISM
European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
Chairpersons: Stavros Konstantinides (Germany/Greece), Adam Torbicki (Poland)
NEW aspects:
Recently identified predisposing factors Simplification of clincal prediction rules Age-adjusted D-dimer cut-offs Sub-segmental PE Incidental, clinically unsuspected PE Advanced risk stratification of intermediate-risk PE Initiation of treatment with vitamin K antagonists Trt & secondary prophylaxis of VTE with NOAC Efficacy & safety of reperfusion TRT for patients at intermediate rsik Early discharge & home Trt of PE Current diagnosis & Trt of chronic thromboembolic PH PE in pregnancy & cancer
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Clinical Case
● 73 year old female
● Referred to the emergency ward for acute dyspnea and dizziness lasting for 8 hours
● Comorbidities :
– Obesity
– Hypertension
– Type 2 diabetes
– Rheumatoid arthritis with severe functional impairment
● Medication :
– Statin : atorvastatin 10 mg daily
– ACE inhibitor : ramipril 10 mg daily
– Beta blocker : atenolol 50 mg daily
– Blood glucose lowering therapy : metformin 3g daily
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Predisposing factors for venous thromboembolism
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Predisposing factors for venous thromboembolism
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Clinical findings at admission
● Initial clinical examination :
– Height=156 cm; weight=88 kg; BMI=35 kg/m²
– Systolic blood pressure = 88 mmHg
– Heart rate = 95 bpm
– Swelling of the left leg
– Tachypnea : respiratory rate of 28 breaths per min
– PaO2 = 6.2 kPa; lactate = 2.5 mmol/L (normal range 0.5-1.6 mmol/L)
– Pulse oximetry (arterial oxyhaemoglobin saturation) = 87% breathing room air
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
ECG recording at admission
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Clinical characteristics of patients with suspected PE in the emergency room
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Clinical prediction rules for pulmonary embolism Wells rule
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Clinical prediction rules for pulmonary embolism Revised Geneva score
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Initial risk stratification of acute PE
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Original and simplified pulmonary embolism severity index (PESI)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Original and simplified pulmonary embolism severity index (PESI)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Recommendations for prognostic assessment
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Single Choice Question
● You suspect high-risk PE. Patient is stabilized by supportive treatment (epinephrine) while awaiting diagnostic workup.
● Which of the following imaging tests is the most appropriate for the definitive confirmation of PE diagnosis :
A. Pulmonary angiography
B. Echocardiography
C. CT scan
D. Magnetic resonance angiography
E. V/Q scintigraphy
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Single Choice Question
● You suspect high-risk PE. Patient is stabilized by supportive treatment (epinephrine) while awaiting diagnostic workup.
● Which of the following imaging tests is the most appropriate for the definitive confirmation of PE diagnosis :
A. Pulmonary angiography
B. Echocardiography
C. CT scan
D. Magnetic resonance angiography
E. V/Q scintigraphy
Not a 1st line choice of imaging test any more .
Procedure-related complications (including
death), especially in pts with haemodynamic compromise
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Single Choice Question
● You suspect high-risk PE. Patient is stabilized by supportive treatment (epinephrine) while awaiting diagnostic workup.
● Which of the following imaging tests is the most appropriate for the definitive confirmation of PE diagnosis :
A. Pulmonary angiography
B. Echocardiography
C. CT scan
D. Magnetic resonance angiography
E. V/Q scintigraphy
Unequivocal signs of RV dysfunction may justify
reperfusion treatment in a highly unstable pt, but
definitive confirmation of the diagnosis should be
considered in a stabilized pt.
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Single Choice Question
● You suspect high-risk PE. Patient is stabilized by supportive treatment (epinephrine) while awaiting diagnostic workup.
● Which of the following imaging tests is the most appropriate for the definitive confirmation of PE diagnosis :
A. Pulmonary angiography
B. Echocardiography
C. CT scan
D. Magnetic resonance angiography
E. V/Q scintigraphy
:
Low sensitivity, high proportion of inconclusive
MRA scans
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Single Choice Question
● You suspect high-risk PE. Patient is stabilized by supportive treatment (epinephrine) while awaiting diagnostic workup.
● Which of the following imaging tests is the most appropriate for the definitive confirmation of PE diagnosis :
A. Pulmonary angiography
B. Echocardiography
C. CT scan
D. Magnetic resonance angiography
E. V/Q scintigraphy High rate of non-diagnostic scans.
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Single Choice Question
● You suspect high-risk PE. Patient is stabilized by supportive treatment (epinephrine) while awaiting diagnostic workup.
● Which of the following imaging tests is the most appropriate for the definitive confirmation of PE diagnosis :
A. Pulmonary angiography
B. Echocardiography
C. CT scan
D. Magnetic resonance angiography
E. V/Q scintigraphy
Correct answer : C.
High positive predictive value in pts with high clinical
probability.
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Diagnostic algorithm: high-risk PE
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Recommendations for diagnosis
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Initial course
● Patient’s haemodynamic status deteriorates suddenly
while awaiting CT scan.
● Clinical examination :
– Systolic blood pressure = 72 mmHg
– Heart rate = 111 bpm
– Tachypnoea : respiratory rate of 35 breaths per min
– Pale, cool, with blotchy skin
– Profuse sweating
– Pulse oximetry = 83% under oxygen therapy (8 L/min)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Repeat ECG recording
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Single Choice Question
● Patient’s condition is so critical that it only allows bedside
diagnostic tests.
● Which of the following items would be of help in emergency management decisions :
A. Plasma D-dimer measurement
B. Echocardiography and/or compression venous ultrasonography (CUS)
C. Assessment of the PESI score
D. Troponin & BNP (NT-proBNP) testing
E. Clinical probability assessment
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Single Choice Question
● Patient’s condition is so critical that it only allows bedside
diagnostic tests.
● Which of the following items would be of help in emergency management decisions :
A. Plasma D-dimer measurement
B. Echocardiography and/or compression venous ultrasonography (CUS)
C. Assessment of the PESI score
D. Troponin & BNP (NT-proBNP) testing
E. Clinical probability assessment
Correct answer :
Low positive predictive value. Not recommended in pts with high clinical
probability.
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Single Choice Question
● Patient’s condition is so critical that it only allows bedside
diagnostic tests.
● Which of the following items would be of help in emergency management decisions :
A. Plasma D-dimer measurement
B. Echocardiography and/or compression venous ultrasonography (CUS)
C. Assessment of the PESI score
D. Troponin & BNP (NT-proBNP) testing
E. Clinical probability assessment
Useful for optimal risk stratification of adverse
outcomes, while high-risk patients require an emergency
diagnostic algorithm. Neither affords diagnostic
certainty.
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Single Choice Question
● Patient’s condition is so critical that it only allows bedside
diagnostic tests.
● Which of the following items would be of help in emergency management decisions :
A. Plasma D-dimer measurement
B. Echocardiography and/or compression venous ultrasonography (CUS)
C. Assessment of the PESI score
D. Troponin & BNP (NT-proBNP) testing
E. Clinical probability assessment
Clinical probability is
usually high in suspected high-risk PE.
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Single Choice Question
● Patient’s condition is so critical that it only allows bedside
diagnostic tests.
● Which of the following items would be of help in emergency management decisions :
A. Plasma D-dimer measurement
B. Echocardiography and/or compression venous ultrasonography (CUS)
C. Assessment of the PESI score
D. Troponin & BNP (NT-proBNP) testing
E. Clinical probability assessment
Correct answer : B.
Evidence of RV dysfunction, right heart thrombi, or proximal DVT are
sufficient to prompt immediate reperfusion without further testing in highly unstable pt with supected
high-risk PE.
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Tranthoracic Echocardiography
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Single Choice Question
● Primary reperfusion strategy is considered in this high-risk PE patient.
● Which of the following items is false ?
A. Systemic thrombolysis is the treatment of choice in this setting
B. Surgical pulmonary embolectomy should be considered as an alternative
C. Percutaneous catheter-directed treatment should be considered as an alternative
D. Parenteral anticoagulation should not be initiated until the diagnosis of PE is confirmed
E. Absolute contraindications to thrombolysis might become relative in a pt with immediately life-threatening high-risk PE
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Single Choice Question
● Primary reperfusion strategy is considered in this high-risk PE patient.
● Which of the following items is false ?
A. Systemic thrombolysis is the treatment of choice in this setting
B. Surgical pulmonary embolectomy should be considered as an alternative
C. Percutaneous catheter-directed treatment should be considered as an alternative
D. Parenteral anticoagulation should not be initiated until the diagnosis of PE is confirmed
E. Absolute contraindications to thrombolysis might become relative in a pt with immediately life-threatening high-risk PE
Correct answer: D is false.
Immediate parenteral anticoagulation should be initiated while awaiting the
results of diagnostic tests, in pts with high or intermediate
clinical probability of PE.
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Recommendations for acute phase treatment
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Risk-adjusted management algorithm