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............................................................................................... 3 General considerations

3.1 Epidemiology

Venous thromboembolism (VTE), clinically presenting as DVT or PE, is globally the third most frequent acute cardiovascular syndrome behind myocardial infarction and stroke.2 In epidemiological studies, annual incidence rates for PE range from 39115 per 100 000 population; for DVT, incidence rates range from 53162 per 100 000 population.3,4 Cross-sectional data show that the incidence of VTE is almost eight times higher in individuals aged >_80 years than in the fifth decade of life.3 In parallel, longitudinal studies have revealed a rising tendency in annual PE incidence rates47 over time. Together with the substantial hospitalassociated, preventable, and indirect annual expenditures for VTE (an estimated total of up to e8.5 billion in the European Union),8 these data demonstrate the importance of PE and DVT in ageing populations in Europe and other areas of the world. They further suggest that VTE will increasingly pose a burden on health systems worldwide in the years to come. PE may cause <_300 000 deaths per year in the US, ranking high among the causes of cardiovascular mortality.3 In six European countries with a total population of 454.4 million, more than 370 000 deaths were related to VTE in 2004, as estimated on the basis of an epidemiological model.9 Of these patients, 34% died suddenly or within a few hours of the acute event, before therapy could be initiated or take effect. Of the other patients, death resulted from acute PE that was diagnosed after death in 59% and only 7% of patients who died early were correctly diagnosed with PE before death.9

2.2.3 Main new recommendations 2019

Diagnosis

A D-dimer test, using an age-adjusted cut-off or adapted to clinical probability, should be considered as an alternative to the fixed cut-off level. IIa If a positive proximal CUS is used to confirm PE, risk assessment should be considered to guide management. IIa V/Q SPECT may be considered for PE diagnosis. IIb Risk assessment Assessment of the RV by imaging or laboratory biomarkers should be considered, even in the presence of a low PESI or a sPESI of 0. IIa Validated scores combining clinical, imaging, and laboratory prognostic factors may be considered to further stratify PE severity. IIb Treatment in the acute phase When oral anticoagulation is initiated in a patient with PE who is eligible for a NOAC (apixaban, dabigatran, edoxaban, or rivaroxaban), a NOAC is the recommended form of anticoagulant treatment. I Set-up of multidisciplinary teams for management of high-risk and selected cases of intermediate-risk PE should be considered, depending on the resources and expertise available in each hospital. IIa ECMO may be considered, in combination with surgical embolectomy or catheter-directed treatment, in refractory circulatory collapse or cardiac arrest. IIb Chronic treatment and prevention of recurrence Indefinite treatment with a VKA is recommended for patients with antiphospholipid antibody syndrome. I Extended anticoagulation should be considered for patients with no identifiable risk factor for the index PE event. IIa Extended anticoagulation should be considered for patients with a persistent risk factor other than antiphospholipid antibody syndrome. IIa Extended anticoagulation should be considered for patients with a minor transient/reversible risk factor for the index PE event. IIa A reduced dose of apixaban or rivaroxaban should be considered after the first 6 months. IIa PE in cancer Edoxaban or rivaroxaban should be considered as an alternative to LMWH, with the exception of patients with gastrointestinal cancer. IIa PE in pregnancy Amniotic fluid embolism should be considered in a pregnant or post-partum woman, with unexplained haemodynamic instability or respiratory deterioration, and disseminated intravascular coagulation. IIa

Continued Thrombolysis or surgical embolectomy should be

considered for pregnant women with high-risk PE. IIa NOACs are not recommended during pregnancy or lactation. III Post-PE care and long-term sequelae Routine clinical evaluation is recommended 36 months after acute PE. I An integrated model of care is recommended after acute PE to ensure optimal transition from hospital to ambulatory care. I It is recommended that symptomatic patients with mismatched perfusion defects on a V/Q scan >3 months after acute PE are referred to a pulmonary hypertension/CTEPH expert centre, taking into account the results of echocardiography, natriuretic peptide, and/or cardiopulmonary exercise testing. I

CPET = cardiopulmonary exercise testing; CTEPH = Chronic thromboembolic pulmonary hypertension; CUS = compression ultrasonography; ECMO = extracorporeal membrane oxygenation; LMWH = low-molecular weight heparin; NOAC(s) = non-vitamin K antagonist oral anticoagulant(s); PE = pulmonary embolism; PESI = Pulmonary Embolism Severity Index; RV = right ventricular; SPECT = single-photon emission computed tomography; sPESI = simplified Pulmonary Embolism Severity Index; VKA(s) = vitamin K antagonist(s); V/Q = ventilation/perfusion (lung scintigraphy). 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