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................................................................................................................................................................... (2) If you suspect acute PE, institute anticoagulation therapy as soon as possible, while the diagnostic workup is ongoing, unless the patient is bleeding or has absolute contraindications to this therapy. (3) Use recommended, validated diagnostic algorithms for PE, including standardized assessment of (pre-test) clinical probability and D-dimer testing. They help to avoid unnecessary, expensive, and potentially harmful imaging tests and exposure to ionizing radiation. (4) If the CTPA report suggests single subsegmental PE, consider the possibility of a false-positive finding. Discuss the findings again with the radiologist and/or seek a second opinion to avoid misdiagnosis, and unnecessary, potentially harmful anticoagulation treatment. (5) Confirmation of PE in a patient, without haemodynamic instability, must be followed by further risk assessment involving clinical findings, evaluation of the size and/or function of the RV, and laboratory biomarkers as appropriate. This information will help you to decide on the need for reperfusion treatment or monitoring for patients at elevated risk, or consider the option of early discharge and continuation of anticoagulation on an ambulatory basis for patients at low risk. (6) As soon as you diagnose (or strongly suspect) high-risk PE, select the best reperfusion option (systemic thrombolysis, surgical embolectomy, or catheter-directed treatment) considering the patient’s risk profile, and the resources and expertise available at your hospital. For patients with intermediate-high-risk PE, reperfusion is not first-line treatment, but you should prospectively plan the management strategy with your team to have a contingency plan ready if the situation deteriorates. (7) Prefer anticoagulation with a NOAC over the ‘traditional’ LMWH-VKA regimen unless the patient has contraindication(s) to this type of drug. (8) Always remember that, with the exception of acute PE provoked by a strong transient/reversible risk factor, there is a lifelong risk of VTE recurrence after a first episode of PE. Consequently, reexamine the patient after the first 3 - 6 months of anticoagulation, weigh the benefits vs. risks of continuing treatment, and decide on the extension and dose of anticoagulant therapy, also considering the patient’s preference. Remember to recommend regular follow-up examinations, e.g. at yearly intervals. (9) If you suspect PE in a pregnant patient, consider diagnostic pathways and algorithms including CTPA or V/Q lung scan, which can be used safely during pregnancy. (10) After acute PE, patients should not be lost to follow-up. Apart from checking for possible signs of VTE recurrence, cancer, or bleeding complications of anticoagulation, ask the patient if there is persisting or new-onset dyspnoea or functional limitation. If yes, implement a staged diagnostic workup to exclude CTEPH or chronic thromboembolic disease, and to detect/treat comorbidity or ‘simple’ deconditioning. Follow-up imaging is not routinely recommended in an asymptomatic patient, but it may be considered in patients with risk factors for development of CTEPH. 13 Gaps in the evidence

Diagnosis • The optimal method to adjust (based on the patient’s age or in combination with clinical probability) the D-dimer threshold, permitting the exclusion of PE while reducing the number of unnecessary imaging tests to a minimum, remains to be determined. • The diagnostic value and clinical significance of isolated subsegmental contrast-filling defects in the modern CTPA era remain controversial. • No robust data exist to guide the decision on whether to treat incidental PE with anticoagulants compared with a strategy of watchful waiting. • For patients presenting with non-traumatic chest pain, the benefits vs. risks of ‘triple rule-out’ (for coronary artery disease, PE, and aortic dissection) CT angiography need further evaluation before such an approach can be routinely recommended. Assessment of pulmonary embolism severity and the risk of early death • The optimal, clinically most relevant combination (and cut-off levels) of clinical and biochemical predictors of early PE-related death remain to be determined, particularly with regard to identifying possible candidates for reperfusion treatment among patients with intermediate-risk PE. • The need for assessment of the RV status in addition to clinical parameters, to classify a patient with acute symptomatic PE as being at low vs. intermediate risk, needs to be confirmed by further prospective management (cohort) studies. Treatment in the acute phase • The clinical benefits vs. risks of reduced-dose thrombolysis and catheter-based reperfusion modalities in patients with intermediate-high-risk PE should be evaluated in prospective randomized trials. • The place of ECMO in the management of acute high-risk PE awaits support by additional evidence from prospective management (cohort) studies. • The optimal anticoagulant drug(s) and regimen in patients with renal insufficiency and CrCl <30 mL/min remain unclear. • The criteria for selecting patients for early discharge and outpatient treatment of PE, and particularly the need for assessment of the RV status with imaging methods and/or laboratory markers in addition to calculating a clinical score, need to be further validated in prospective cohort studies. Chronic treatment and prevention of recurrence • The clinical value and the possible therapeutic implications of models or scores assessing the risk of VTE recurrence, and the risk of bleeding under anticoagulation, need to be revisited in the NOAC era. • The effectiveness of extended treatment with a reduced dose, or apixaban or rivaroxaban, should be confirmed in patients with a high risk of recurrent PE. Downloaded from academic.oup.com/eurheartj/article/41/4/543/5556136 by guest on 07 October 2026