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or bleeding complications of anticoagulation. The severity of dyspnoea can be assessed using the Medical Research Council scale;160 alternatively, the World Health Organization functional class can be determined (Supplementary Data Table 16).289 In patients complaining of persisting dyspnoea and poor physical performance, TTE should be considered as the next step to assess the probability of (chronic) PH and thus possible CTEPH. The criteria and levels of PH probability are defined by current ESC Guidelines,289 and are listed in Supplementary Data Tables 17 and 18. Patients with a high echocardiographic probability of PH, or those with intermediate probability combined with elevated NTproBNP levels or risk factors/predisposing conditions for CTEPH, such as those listed in Table 13, should be considered for a V/Q scan. If mismatched perfusion defects are found on the V/Q scan, referral to a PH or CTEPH expert centre for further diagnostic workup is indicated. If, on the other hand, the V/Q scan is normal and the patient’s symptoms remain unexplained, CPET may be performed. By providing evidence of reduced maximal aerobic capacity, CPET supports the need for further follow-up visits and helps to identify candidates for pulmonary rehabilitation, exercise, or weight-reduction programmes.435,436 CPET may also be helpful in patients with suspected CTEPH and coexisting left heart and/or respiratory disease; in such cases, it can help to establish the main limiting factor and thus set priorities for the treatment strategy.472 For patients who report as free of dyspnoea or functional limitation at 36-month follow-up after acute PE but have risk factors/predisposing conditions for CTEPH (Table 13), further follow-up visits may be scheduled and the patient must be advised to return if symptoms appear. Alternatively, TTE may be considered to assess the probability of PH (Figure 8). Apart from the recommended screening and diagnostic measures, an integrated model of patient care after PE should be provided, taking into consideration the infrastructure and possibilities offered by each country’s health system. The model should include appropriately qualified nurses, interdisciplinary working with physicians in the care of both in-hospital and ambulatory PE patients, standardized treatment protocols adapted to the capacities of each hospital, and bidirectional referral pathways between general practice and the hospital. Such models ensure smooth transitions between hospital specialists and practitioners; provide continuity, and easy access to care along with information and education; and respect the patients’ preferences, and those of their families and social environment. In this context, nurse-led care models to deliver follow-up have been shown to be effective after acute coronary syndrome,473 in primary care-based management of chronic diseases,474 and in community based self-management initiatives.475 A recently published study investigated the care of 42 patients followed at a pulmonary arterial hypertension (PAH)/CTEPH nurse-led outpatient clinic and showed positive results.476 During patient follow-up visits, appropriately qualified nurses screen for signs and symptoms indicating VTE recurrence or complications of treatment, and assess adherence to medication. Nurses work collaboratively with patients using behavioural frameworks and motivational interviewing, to identify and modify associated risk factors (smoking cessation, diet, physical activity, and exercise). In addition, they promote self-management skills such as the use of compression stockings, safe increase in mobility, increased awareness of signs of recurrence, or complications.

11 Non-thrombotic pulmonary

embolism

This section is included in the Supplementary Data available online on the EHJ and ESC websites (www.escardio.org/guidelines).

12 Key messages

The ESC Task Force has selected 10 simple key messages and rules to guide physicians in the diagnosis and management of PE:

(1) In patients presenting with haemodynamic instability, perform bedside TTE as a fast, immediate step to differentiate suspected highrisk PE from other acute life-threatening situations.

10.4 Recommendations for follow-up after acute pulmonary embolism

Recommendations Classa Levelb Routine clinical evaluationc of patients 36 months after the acute PE episode is recommended.288,352,353,437 I B An integrated model of patient care after PE (involving hospital specialists, appropriately qualified nurses, and primary care physicians) is recommended to ensure optimal transition from hospital to community care. I C In symptomatic patients with mismatched perfusion defects persisting on V/Q scand beyond 3 months after acute PE, referral to a PH/ CTEPH expert centre is recommended, after taking into account the results of echocardiography, natriuretic peptide levels, and/or CPET.477 I C Further diagnostic evaluatione should be considered in patients with persistent or newonset dyspnoea/exercise limitation after PE. IIa C Further diagnostic evaluatione may be considered in asymptomatic patients with risk factors for CTEPH.f 447449,478 IIb C

CPET = cardiopulmonary exercise testing; CT = computed tomography; CTEPH = Chronic thromboembolic pulmonary hypertension; PE = pulmonary embolism; PH = pulmonary hypertension; V/Q = ventilation/perfusion (lung scintigraphy). aClass of recommendation. bLevel of evidence. cFor symptoms suggesting recurrence, bleeding, malignancy, or persistent or new-onset exercise limitation, and to decide on extension of anticoagulant treatment. dAlternatively, dual-energy CT may be used, if appropriate expertise and resources are available on-site. eAs proposed in the algorithm shown in Figure 8. fRisk factors and predisposing conditions for CTEPH are listed in Table 13. Downloaded from academic.oup.com/eurheartj/article/41/4/543/5556136 by guest on 07 October 2026