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Document Reviewers: Nazzareno Galie ́ (CPG Review Coordinator) (Italy), J. Simon R. Gibbs (CPG Review Coordinator) (United Kingdom), Victor Aboyans (France), Walter Ageno (Italy), Stefan Agewall (Norway), Ana G. Almeida (Portugal), Felicita Andreotti (Italy), Emanuele Barbato (Italy), Johann Bauersachs (Germany), Andreas Baumbach (United Kingdom), Farzin Beygui (France), Jørn Carlsen (Denmark), Marco De Carlo (Italy), Marion Delcroix1 (Belgium), Victoria Delgado (Netherlands), Pilar Escribano Subias (Spain), Donna Fitzsimons (United Kingdom), Sean Gaine1 (Ireland), Samuel Z. Goldhaber (United States of America), Deepa Gopalan (United Kingdom), Gilbert Habib (France), Sigrun Halvorsen (Norway), David Jenkins (United Kingdom), Hugo A. Katus (Germany), Barbro Kjellstro ̈ m (Sweden), Mitja Lainscak (Slovenia), Patrizio Lancellotti (Belgium), Geraldine Lee (United Kingdom), Gre ́goire Le Gal (Canada), Emmanuel Messas (France), Joao Morais (Portugal), Steffen E. Petersen (United Kingdom), Anna Sonia Petronio (Italy), Massimo Francesco Piepoli (Italy), Susanna Price (United Kingdom), Marco Roffi(Switzerland), Aldo Salvi (Italy), Olivier Sanchez1 (France), Evgeny Shlyakhto (Russian Federation), Iain A. Simpson (United Kingdom), Stefan Stortecky (Switzerland), Matthias Thielmann (Germany), Anton Vonk Noordegraaf1 (Netherlands) The disclosure forms of all experts involved in the development of these Guidelines are available on the ESC website www.escardio.org/guidelines

For the Supplementary Data which include background information and detailed discussion of the data that have provided the basis for the Guidelines see https://academic.oup.com/eurheartj/article-lookup/doi/ 10.1093/eurheartj/ehz405#supplementary-data Online publish-ahead-of-print 31 August 2019

................................................................................................................................................................................................... Keywords Guidelines • pulmonary embolism • venous thrombosis • shock • dyspnoea • heart failure • right ventricle • diagnosis • risk assessment • echocardiography • biomarkers • treatment • anticoagulation • thrombolysis • pregnancy • venous thromboembolism • embolectomy

Table of contents

Abbreviations and acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 546 1 Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 547 2 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 548 2.1 Why do we need new Guidelines on the diagnosis and management of pulmonary embolism? . . . . . . . . . . . . . . . . . . . . . . . . . . 548 2.2 What is new in the 2019 Guidelines? . . . . . . . . . . . . . . . . . . . . . . . . 549 2.2.1 New/revised concepts in 2019 . . . . . . . . . . . . . . . . . . . . . . . . . . 549 2.2.2 Changes in recommendations 201419 . . . . . . . . . . . . . . . . 549 2.2.3 Main new recommendations 2019 . . . . . . . . . . . . . . . . . . . . . . 550 3 General considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 550 3.1 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 550 3.2 Predisposing factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 551 3.3 Pathophysiology and determinants of outcome . . . . . . . . . . . . . . 552 4 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 554 4.1 Clinical presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 554 4.2 Assessment of clinical (pre-test) probability . . . . . . . . . . . . . . . . . . 554 4.3 Avoiding overuse of diagnostic tests for pulmonary embolism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 555 4.4 D-dimer testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 555 4.4.1 Age-adjusted D-dimer cut-offs . . . . . . . . . . . . . . . . . . . . . . . . . . 555 4.4.2 D-dimer cut-offs adapted to clinical probability . . . . . . . . . . 555 4.4.3 Point-of-care D-dimer assays . . . . . . . . . . . . . . . . . . . . . . . . . . . 555 4.5 Computed tomographic pulmonary angiography . . . . . . . . . . . . . 555 4.6 Lung scintigraphy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 556 4.7 Pulmonary angiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 557 4.8 Magnetic resonance angiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . 557 4.9 Echocardiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 557 4.10 Compression ultrasonography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 558 4.12 Computed tomography venography . . . . . . . . . . . . . . . . . . . . . . . 560 5 Assessment of pulmonary embolism severity and the risk of early death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 560

5.1 Clinical parameters of pulmonary embolism severity . . . . . . . . . 560 5.2 Imaging of right ventricular size and function . . . . . . . . . . . . . . . . . 560 5.2.1 Echocardiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 560 5.2.2 Computed tomographic pulmonary angiography . . . . . . . . 561 5.3 Laboratory biomarkers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 561 5.3.1 Markers of myocardial injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . 561 5.3.2 Markers of right ventricular dysfunction . . . . . . . . . . . . . . . . . 561 5.3.3 Other laboratory biomarkers . . . . . . . . . . . . . . . . . . . . . . . . . . . 561 5.4 Combined parameters and scores for assessment of pulmonary embolism severity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 562 5.5 Integration of aggravating conditions and comorbidity into risk assessment of acute pulmonary embolism . . . . . . . . . . . . . . 562 5.6 Prognostic assessment strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 562 6 Treatment in the acute phase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 564 6.1 Haemodynamic and respiratory support . . . . . . . . . . . . . . . . . . . . . 564 6.1.1 Oxygen therapy and ventilation . . . . . . . . . . . . . . . . . . . . . . . . . 564 Downloaded from academic.oup.com/eurheartj/article/41/4/543/5556136 by guest on 07 October 2026