凝晨ESC GUIDELINES 2014ESC Guidelines on the diagnosis and
management of acute pulmonary embolism
The Task Force for the Diagnosis and Management of Acute
Pulmonary Embolism of the European Society of Cardiology (ESC)Endorsed by the European Respiratory Society (ERS)
Authors/Task Force Members:Stavros Konstantinides *(Chairperson)(Germany/Greece),Adam Torbicki *(Co-chairperson)(Poland),Giancarlo Agnelli (Italy),Nicolas Danchin (France),David Fitzmaurice (UK),Nazzareno Galie `(Italy),
J.Simon R.Gibbs (UK),Menno Huisman (The Netherlands),Marc Humbert ?(France),Nils Kucher (Switzerland),Irene Lang (Austria),Mareike Lankeit (Germany),John Lekakis (Greece),Christoph Maack (Germany),Eckhard Mayer (Germany),
Nicolas Meneveau (France),Arnaud Perrier (Switzerland),Piotr Pruszczyk (Poland),Lars H.Rasmussen (Denmark),Thomas H.Schindler (USA),Pavel Svitil (Czech
Republic),Anton Vonk Noordegraaf (The Netherlands),Jose Luis Zamorano (Spain),Maurizio Zompatori (Italy)
ESC Committee for Practice Guidelines (CPG):Jose Luis Zamorano (Chairperson)(Spain),Stephan Achenbach (Germany),Helmut Baumgartner (Germany),Jeroen J.Bax (Netherlands),Hector Bueno (Spain),Veronica Dean (France),Christi Deaton (UK),?etin Erol (Turkey),Robert Fagard (Belgium),Roberto Ferrari (Italy),David Hasdai (Israel),Arno Hoes (Netherlands),Paulus Kirchhof (Germany/UK),Juhani Knuuti (Finland),Philippe Kolh (Belgium),Patrizio Lancellotti (Belgium),Ales Linhart (Czech Republic),Petros Nihoyannopoulos (UK),Massimo F.
Piepoli *Corresponding authors.Stavros Konstantinides,Centre for Thrombosis and Hemostasis,Johannes Gutenberg University of Mainz,University Medical Centre Mainz,Langenbeckstrasse 1,55131Mainz,Germany.Tel:+496131176255,Fax:+496131173456.Email:stavros.konstantinides@unimedizin-mainz.de ,and Department of Cardiology,Democritus University of Thrace,Greece.Email:skonst@med.duth.gr .
Adam Torbicki,Department of Pulmonary Circulation and Thromboembolic Diseases,Medical Centre of Postgraduate Education,ECZ-Otwock,Ul.Borowa 14/18,05-400Otwock,Poland.Tel:+48227103052,Fax:+4822710315.Email:adam.torbicki@ecz-otwock.pl .
?Representing the European Respiratory Society
Other ESC entities having participated in the development of this document:
ESC Associations:Acute Cardiovascular Care Association (ACCA),European Association for Cardiovascular Prevention &Rehabilitation (EACPR),European Association of Cardio-vascular Imaging (EACVI),Heart Failure Association (HFA),ESC Councils:Council on Cardiovascular Nursing and Allied Professions (CCNAP),Council for Cardiology Practice (CCP),Council on Cardiovascular Primary Care (CCPC)
ESC Working Groups:Cardiovascular Pharmacology and Drug Therapy,Nuclear Cardiology and Cardiac Computed Tomography,Peripheral Circulation,Pulmonary Circulation and Right Ventricular Function,Thrombosis.
Disclaimer:The ESC Guidelines represent the views of the ESC and were produced after careful consideration of the scienti?c and medical knowledge and the evidence available at the time of their publication.
The ESC is not responsible in the event of any contradiction,discrepancy and/or ambiguity between the ESC Guidelines and any other of?cial recommendations or guidelines issued by the relevant public health authorities,in particular in relation to good use of healthcare or therapeutic strategies.Health professionals are encouraged to take the ESC Guidelines fully into account when exercising their clinical judgment,as well as in the determination and the implementation of preventive,diagnostic or therapeutic medical strategies;however,the ESC Guidelines do not override,in any way whatsoever,the inpidual responsibility of health professionals to make appropriate and accurate decisions in consideration of each patient’s health condition and in consultation with that patient and,where appropriate and/or necessary,the patient’s caregiver.Nor do the ESC Guidelines exempt health professionals from taking into full and careful consideration the relevant of?cial updated recommendations or guidelines issued by the competent public health authorities,in order to manage each patient’s case in light of the scienti?cally accepted data pursuant to their respective ethical and professional obligations.It is also the health professional’s responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription.
National Cardiac Societies document reviewers:listed in the Appendix.
&The European Society of Cardiology 2014.All rights reserved.For permissions please email:journals.permissions@e43f5da204a1b0717ed5dd2a.European Heart Journal doi:10.1093/eurheartj/ehu283
European Heart Journal Advance Access published August 29, 2014 at Fujian University of Traditional Chinese Medicine on August 30, 2014e43f5da204a1b0717ed5dd2a/Downloaded from
(Italy),Piotr Ponikowski(Poland),Per Anton Sirnes(Norway),Juan Luis Tamargo(Spain),Michal Tendera(Poland), Adam Torbicki(Poland),William Wijns(Belgium),Stephan Windecker(Switzerland).
Document Reviewers:?etin Erol(CPG Review Coordinator)(Turkey),David Jimenez(Review Coordinator)(Spain), Walter Ageno(Italy),Stefan Agewall(Norway),Riccardo Asteggiano(Italy),Rupert Bauersachs(Germany),
Cecilia Becattini(Italy),Henri Bounameaux(Switzerland),Harry R.Bu¨ller(Netherlands),Constantinos H.Davos (Greece),Christi Deaton(UK),Geert-Jan Geersing(Netherlands),Miguel Angel Go′mez Sanchez(Spain),
Jeroen Hendriks(Netherlands),Arno Hoes(Netherlands),Mustafa Kilickap(Turkey),Viacheslav Mareev(Russia), Manuel Monreal(Spain),Joao Morais(Portugal),Petros Nihoyannopoulos(UK),Bogdan A.Popescu(Romania), Olivier Sanchez?(France),Alex C.Spyropoulos(USA).
The disclosure forms provided by the experts involved in the development of these guidelines are available on the ESC website e43f5da204a1b0717ed5dd2a/guidelines.
------------------------------------------------------------------------------------------------------------------------------------------------------Keywords Guidelines?Pulmonary embolism?Venous thrombosis?Shock?Hypotension?Chest pain?Dyspnoea ?Heart failure?Diagnosis?Treatment–Anticoagulation?Thrombolysis
Table of Contents
Abbreviations and acronyms (3)
1.Preamble (3)
2.Introduction (4)
2.1Epidemiology (5)
2.2Predisposing factors (5)
2.3Natural history (6)
2.4Pathophysiology (6)
2.5Clinical classi?cation of pulmonary embolism severity (7)
3.Diagnosis (7)
3.1Clinical presentation (7)
3.2Assessment of clinical probability (8)
3.3D-dimer testing (8)
3.4Computed tomographic pulmonary angiography (10)
3.5Lung scintigraphy (11)
3.6Pulmonary angiography (11)
3.7Magnetic resonance angiography (11)
3.8Echocardiography (11)
3.9Compression venous ultrasonography (12)
3.10.Diagnostic strategies (12)
3.10.1Suspected pulmonary embolism with shock
or hypotension (12)
3.10.2Suspected pulmonary embolism without
shock or hypotension (13)
3.11.Areas of uncertainty (14)
4.Prognostic assessment (15)
4.1Clinical parameters (15)
4.2Imaging of the right ventricle by echocardiography
or computed tomographic angiography (16)
4.3Laboratory tests and biomarkers (17)
4.3.1Markers of right ventricular dysfunction (17)
4.3.2Markers of myocardial injury (17)
4.3.3Other(non-cardiac)laboratory biomarkers (18)
4.4Combined modalities and scores (19)
4.5Prognostic assessment strategy (19)
5.Treatment in the acute phase (20)
5.1Haemodynamic and respiratory support (20)
5.2Anticoagulation (20)
5.2.1Parenteral anticoagulation (20)
5.2.2Vitamin K antagonists (21)
5.2.3New oral anticoagulants (22)
5.3Thrombolytic treatment (23)
5.4Surgical embolectomy (24)
5.5Percutaneous catheter-directed treatment (24)
5.6Venous?lters (24)
5.7Early discharge and home treatment (25)
5.8Therapeutic strategies (26)
5.8.1Pulmonary embolism with shock or hypotension
(high-risk pulmonary embolism) (26)
5.8.2Pulmonary embolism without shock or hypotension
(intermediate-or low-risk pulmonary embolism) (26)
5.9Areas of uncertainty (27)
6.Duration of anticoagulation (29)
6.1New oral anticoagulants for extended treatment (30)
7.Chronic thromboembolic pulmonary hypertension (31)
7.1Epidemiology (31)
7.2Pathophysiology (31)
7.3Clinical presentation and diagnosis (31)
7.4Treatment and prognosis (32)
8.Speci?c problems (34)
8.1Pregnancy (34)
8.1.1Diagnosis of pulmonary embolism in pregnancy (34)
8.1.2Treatment of pulmonary embolism in pregnancy (34)
8.2Pulmonary embolism and cancer (35)
8.2.1Diagnosis of pulmonary embolism in patients with
cancer (35)
8.2.2Prognosis for pulmonary embolism in patients with
cancer (35)
8.2.3Management of pulmonary embolism in patients with
cancer (35)
8.2.4Occult cancer presenting as unprovoked pulmonary
embolism (36)
8.3Non-thrombotic pulmonary embolism (36)
8.3.1Septic embolism (36)
8.3.2Foreign-material pulmonary embolism (36)
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8.3.3Fat embolism (36)
8.3.4Air embolism (37)
8.3.5Amniotic?uid embolism (37)
8.3.6Tumour embolism (37)
9.Appendix (37)
References (37)
Abbreviations and acronyms
ACS acute coronary syndrome
AMPLIFY Apixaban for the Initial Management of Pulmonary Embolism and Deep-Vein Thrombosis as First-line
Therapy
aPTT activated partial thromboplastin time
b.i.d.bis in diem(twice daily)
b.p.m.beats per minute
BNP brain natriuretic peptide
BP blood pressure
CI con?dence interval
