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modified our knowledge in respect of the optimal diagnosis, assessment, and treatment of patients with PE. These new aspects have been integrated into previous knowledge to suggest optimal and—whenever possible—objectively validated management strategies for patients with suspected or confirmed PE. To limit the length of the printed text, additional information, tables, figures, and references are available as supplementary data on the ESC website (www.escardio.org). These Guidelines focus on the diagnosis and management of acute PE in adult patients. For further details specifically related to the diagnosis and management of deep vein thrombosis (DVT), the reader is referred to the joint consensus document of the ESC Working Groups of Aorta and Peripheral Vascular Diseases, and Pulmonary Circulation and Right Ventricular Function.1

2.2 What is new in the 2019 Guidelines?

2.2.1 New/revised concepts in 2019

Diagnosis

D-dimer cut-off values adjusted for age or clinical probability can be used as an alternative to the fixed cut-off value. Updated information is provided on the radiation dosage when using CTPA and a lung scan to diagnose PE (Table 6). Risk assessment A clear definition of haemodynamic instability and high-risk PE is provided (Table 4). Assessment of PE severity and early PE-related risk is recommended, in addition to comorbidity/aggravating conditions and overall death risk. A clear word of caution that RV dysfunction may be present, and affect early outcomes, in patients at ‘low risk’ based on clinical risk scores. Treatment in the acute phase Thoroughly revised section on haemodynamic and respiratory support for high-risk PE (Section 6.1). A dedicated management algorithm is proposed for high-risk PE (Supplementary Figure 1). NOACs are recommended as the first choice for anticoagulation treatment in a patient eligible for NOACs; VKAs are an alternative to NOACs. The risk-adjusted management algorithm (Figure 6) was revised to take into consideration clinical PE severity, aggravating conditions/ comorbidity, and the presence of RV dysfunction. Chronic treatment after the first 3 months Risk factors for VTE recurrence have been classified according to high, intermediate, or low recurrence risk (Table 11). Potential indications for extended anticoagulation are discussed, including the presence of a minor transient or reversible risk factor for the index PE, any persisting risk factor, or no identifiable risk factor. Terminology such as ‘provoked’ vs. ‘unprovoked’ PE/VTE is no longer supported by the Guidelines, as it is potentially misleading and not helpful for decision-making regarding the duration of anticoagulation.

Continued VTE recurrence scores are presented and discussed in parallel with

bleeding scores for patients on anticoagulation treatment (Supplementary Tables 13 and 14 respectively). A reduced dose of apixaban or rivaroxaban for extended anticoagulation should be considered after the first 6 months of treatment. PE in cancer Edoxaban or rivaroxaban should be considered as an alternative to LMWH, with a word of caution for patients with gastrointestinal cancer due to the increased bleeding risk with NOACs. PE in pregnancy A dedicated diagnostic algorithm is proposed for suspected PE in pregnancy (Figure 7). Updated information is provided on radiation absorption related to procedures used for diagnosing PE in pregnancy (Table 12). Long-term sequelae An integrated model of patient care after PE is proposed to ensure optimal transition from hospital to community care. Recommendations on patient care have been extended to the entire spectrum of post-PE symptoms and functional limitation, not only CTEPH. A new comprehensive algorithm is proposed for patient follow-up after acute PE (Figure 8).

CTEPH = Chronic thromboembolic pulmonary hypertension; CTPA = computed tomography pulmonary angiography; LMWH = low-molecular weight heparin; NOAC(s) = non-vitamin K antagonist oral anticoagulant(s); PE = pulmonary embolism; RV = right ventricular; VKA(s) = vitamin K antagonist(s); VTE = venous thromboembolism.

2.2.2 Changes in recommendations 201419

Recommendations 2014 2019

Rescue thrombolytic therapy is recommended for patients who deteriorate haemodynamically. IIa I Surgical embolectomy or catheter-directed treatment should be considered as alternatives to rescue thrombolytic therapy for patients who deteriorate haemodynamically. IIb IIa D-dimer measurement and clinical prediction rules should be considered to rule out PE during pregnancy or the post-partum period. IIb IIa Further evaluation may be considered for asymptomatic PE survivors at increased risk for CTEPH. III IIb

CTEPH = Chronic thromboembolic pulmonary hypertension; PE = pulmonary embolism. Coloured columns indicate classes of recommendation (see Table 1 for colour coding). Downloaded from academic.oup.com/eurheartj/article/41/4/543/5556136 by guest on 07 October 2026