Changes in PE guidelines include new DOAC recommendation

By Mardi Chapman

1 Oct 2019

New guidelines for the diagnosis and management of acute pulmonary embolism (PE) have caught up with practice in that they now recommend a DOAC as the preferred form of anticoagulant treatment.

The previous guidelines recommended DOACs as an alternative option to low molecular weight heparin (LMWH).

The stronger 2019 recommendations for DOACs exclude patients with severe renal impairment, during pregnancy and lactation, and in patients with anti-phospholipid antibody syndrome.

Another new recommendation regarding treatment in the acute phase is to consider multidisciplinary team care for high risk cases and selected cases of intermediate risk PE.

ECMO may be considered in refractory circulatory collapse or cardiac arrest but always in combination with a reperfusion technique, the 2019 ERS Congress in Madrid was told.

Chair of the ESC/ERS guidelines Professor Stavros Konstantinides, from the Centre for Thrombosis and Hemostasis at the Johannes Gutenberg University Mainz in Germany, said there were no major changes in the diagnostic algorithm for PE.

CT pulmonary angiography (CTPA) remains the gold standard for diagnosis.

Professor Konstantinides told the meeting that another new recommendation was to search for right ventricular (RV) dysfunction in patients, even in presence of a low PESI score.

“We are becoming a little more cautious,” he said.

“We did find in a recent meta-analysis, published in the European Heart Journal in 2018, that acute mortality was in the range of 2-4% if RV dysfunction was found.”

He said it was also very important to look for any mobile thrombi in the heart because they can be present even if the patient is feeling fine and can cause death within a few minutes.

The guidelines include a new section on PE in pregnancy.

Co-chair of the ESC/ERS guidelines Professor Guy Meyer, from the Paris Descartes University, said much of the assessment of PE in pregnancy was the same as outside pregnancy.

“The first step is to assess the clinical probability of PE and in women with low or intermediate probability, to first do the D-dimer test and start anticoagulation with LMWH.”

“And then when D-dimer is positive, first do a compression proximal duplex ultrasound especially if there are symptoms or signs suggestive of DVT.”

When a proximal DVT was not present – in the majority of cases – the recommendation was for a chest X-ray and if normal, the choice of a CTPA or perfusion lung scan.

“When these investigations are negative, PE is ruled out,” Professor Meyer said.

“On the other hand when the CTPA or perfusion lung scan is indeterminate or positive, you need review by a radiologist or a nuclear physician experienced in the diagnosis of PE in pregnancy.”

Professor Meyer said radiation exposure from ventilation or perfusion lung scans or CTPA was far below the security limits and was no risk for the foetus.

However the radiation delivered to the breast tissue in a young woman was a little higher with CTPA as compared to ventilation and perfusion lung scans.

A new recommendation in the guidelines regarding PE in patients with cancer was to consider endoxaban or rivaroxaban as an alternative to LMWH, except in patients with GI cancer.

The guidelines also introduced a new recommendation for routine clinical evaluation at 3-6 months after an acute PE.

Drug tolerance and adherence, hepatic and renal function and bleeding risk should be reassessed at regular intervals over the long term.

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