2014 ESC Guidelines on the Diagnosis & Treatment of ... ESC Guidelines on the Diagnosis &...

2014 ESC Guidelines on the Diagnosis & Treatment of

Pulmonary embolism Prof. Fausto J. Pinto, FESC, FACC, FASE

President, ESC University Hospital Sta Maria University of Lisbon, Portugal

Professor Fausto J. Pinto, MD, PhD, FESC, FASE, FACC, FSCAI

•Disclosures: Consultancy, advisory boards and lecture fees: Abbott, Astra Zeneca, Bayer, Bial, BMS, Benecke, Biotronik, Boehringher Ingelheim, Covidien, GE, Irokio, Medtronic, Menarini, Merck, MSD, Novartis, Pfizer, Sanofi, Servier, St Jude Medical, Tabuk

www.escardio.org/guidelines

2014 ESC Guidelines on the Diagnosis & Management of ACUTE PULMONARY EMBOLISM

European Heart Journal (2014):doi:10.1093/eurheartj/ehu283

Chairpersons: Stavros Konstantinides (Germany/Greece), Adam Torbicki (Poland)

NEW aspects:

Recently identified predisposing factors Simplification of clincal prediction rules Age-adjusted D-dimer cut-offs Sub-segmental PE Incidental, clinically unsuspected PE Advanced risk stratification of intermediate-risk PE Initiation of treatment with vitamin K antagonists Trt & secondary prophylaxis of VTE with NOAC Efficacy & safety of reperfusion TRT for patients at intermediate rsik Early discharge & home Trt of PE Current diagnosis & Trt of chronic thromboembolic PH PE in pregnancy & cancer

www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu281

Clinical Case

● 73 year old female

● Referred to the emergency ward for acute dyspnea and dizziness lasting for 8 hours

● Comorbidities :

– Obesity

– Hypertension

– Type 2 diabetes

– Rheumatoid arthritis with severe functional impairment

● Medication :

– Statin : atorvastatin 10 mg daily

– ACE inhibitor : ramipril 10 mg daily

– Beta blocker : atenolol 50 mg daily

– Blood glucose lowering therapy : metformin 3g daily

Predisposing factors for venous thromboembolism

Clinical findings at admission

● Initial clinical examination :

– Height=156 cm; weight=88 kg; BMI=35 kg/m²

– Systolic blood pressure = 88 mmHg

– Heart rate = 95 bpm

– Swelling of the left leg

– Tachypnea : respiratory rate of 28 breaths per min

– PaO2 = 6.2 kPa; lactate = 2.5 mmol/L (normal range 0.5-1.6 mmol/L)

– Pulse oximetry (arterial oxyhaemoglobin saturation) = 87% breathing room air

ECG recording at admission

Clinical characteristics of patients with suspected PE in the emergency room

Clinical prediction rules for pulmonary embolism Wells rule

Clinical prediction rules for pulmonary embolism Revised Geneva score

Initial risk stratification of acute PE

Original and simplified pulmonary embolism severity index (PESI)

Recommendations for prognostic assessment

Single Choice Question

● You suspect high-risk PE. Patient is stabilized by supportive treatment (epinephrine) while awaiting diagnostic workup.

● Which of the following imaging tests is the most appropriate for the definitive confirmation of PE diagnosis :

A. Pulmonary angiography

B. Echocardiography

C. CT scan

D. Magnetic resonance angiography

E. V/Q scintigraphy

B. Echocardiography

C. CT scan

E. V/Q scintigraphy

Not a 1st line choice of imaging test any more .

Procedure-related complications (including

death), especially in pts with haemodynamic compromise

B. Echocardiography

C. CT scan

E. V/Q scintigraphy

Unequivocal signs of RV dysfunction may justify

reperfusion treatment in a highly unstable pt, but

definitive confirmation of the diagnosis should be

considered in a stabilized pt.

B. Echocardiography

C. CT scan

E. V/Q scintigraphy

Low sensitivity, high proportion of inconclusive

MRA scans

B. Echocardiography

C. CT scan

E. V/Q scintigraphy High rate of non-diagnostic scans.

B. Echocardiography

C. CT scan

E. V/Q scintigraphy

Correct answer : C.

High positive predictive value in pts with high clinical

probability.

Diagnostic algorithm: high-risk PE

Recommendations for diagnosis

Initial course

● Patient’s haemodynamic status deteriorates suddenly

while awaiting CT scan.

● Clinical examination :

– Systolic blood pressure = 72 mmHg

– Heart rate = 111 bpm

– Tachypnoea : respiratory rate of 35 breaths per min

– Pale, cool, with blotchy skin

– Profuse sweating

– Pulse oximetry = 83% under oxygen therapy (8 L/min)

Repeat ECG recording

● Patient’s condition is so critical that it only allows bedside

diagnostic tests.

● Which of the following items would be of help in emergency management decisions :

A. Plasma D-dimer measurement

B. Echocardiography and/or compression venous ultrasonography (CUS)

C. Assessment of the PESI score

D. Troponin & BNP (NT-proBNP) testing

E. Clinical probability assessment

diagnostic tests.

Correct answer :

Low positive predictive value. Not recommended in pts with high clinical

probability.

diagnostic tests.

Useful for optimal risk stratification of adverse

outcomes, while high-risk patients require an emergency

diagnostic algorithm. Neither affords diagnostic

certainty.

diagnostic tests.

Clinical probability is

usually high in suspected high-risk PE.

diagnostic tests.

Correct answer : B.

Evidence of RV dysfunction, right heart thrombi, or proximal DVT are

sufficient to prompt immediate reperfusion without further testing in highly unstable pt with supected

high-risk PE.

Tranthoracic Echocardiography

● Primary reperfusion strategy is considered in this high-risk PE patient.

● Which of the following items is false ?

A. Systemic thrombolysis is the treatment of choice in this setting

B. Surgical pulmonary embolectomy should be considered as an alternative

C. Percutaneous catheter-directed treatment should be considered as an alternative

D. Parenteral anticoagulation should not be initiated until the diagnosis of PE is confirmed

E. Absolute contraindications to thrombolysis might become relative in a pt with immediately life-threatening high-risk PE

● Primary reperfusion strategy is considered in this high-risk PE patient.

● Which of the following items is false ?

A. Systemic thrombolysis is the treatment of choice in this setting

B. Surgical pulmonary embolectomy should be considered as an alternative

C. Percutaneous catheter-directed treatment should be considered as an alternative

D. Parenteral anticoagulation should not be initiated until the diagnosis of PE is confirmed

E. Absolute contraindications to thrombolysis might become relative in a pt with immediately life-threatening high-risk PE

Correct answer: D is false.

Immediate parenteral anticoagulation should be initiated while awaiting the

results of diagnostic tests, in pts with high or intermediate

clinical probability of PE.

Recommendations for acute phase treatment

Risk-adjusted management algorithm

2014 ESC Guidelines on the Diagnosis & Treatment of ... ESC Guidelines on the Diagnosis &...

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