The 2019 European guidelines on pulmonary embolism illustrated with the aid of an exemplary case report

Abstract

The European Society of Cardiology guidelines for the diagnosis and management of acute pulmonary embolism (PE) developed in collaboration with the European Respiratory Society (ERS) has been updated in 2019. Recommendations were added or updated on all stages of the evaluation and management of pulmonary embolism, encompassing diagnosis, early treatment, and long-term management. We illustrate an exemplary case, assembled for the purposes of this review, of a 70-year-old woman who presented at the emergency department with dyspnoea and thoracic pain. She was diagnosed with intermediate–high-risk acute PE and promptly treated with low molecular weight heparin. After 24 h of stay in intensive care unit, she was transferred to the cardiology department and switched to non-vitamin K-dependent oral anticoagulant apixaban 10 mg b.i.d. for 7 days and then 5 mg b.i.d. After discharge from the hospital 8 days later, she received standard-dose apixaban 5 mg b.i.d. for 6 months; the dose was reduced to 2.5 mg b.i.d. for long-term secondary prevention. During follow-up, investigations for PE sequelae were performed due to persisting dyspnoea. This exemplary case report puts into context the main novel recommendations from the 2019 ESC Guidelines, including the combination of clinical (pre-test) probability and adjusted D-dimer cut-offs for diagnosis of acute PE, the key role of right ventricular dysfunction in risk stratification, the choice and dosage of oral anticoagulant agents in early and extended anticoagulation, and the identification and management of chronic sequelae in the long-term follow-up.