A new severity-based classification system and strong endorsement for multidisciplinary pulmonary embolism response teams (PERTs) feature prominently in recently published multisociety guidelines on the evaluation and management of acute PE in adults.
The American College of Cardiology (ACC)/American Heart Association (AHA) Joint Committee on Clinical Practice Guidelines, in collaboration with eight other societies, released the guidelines—spanning diagnosis, treatment, and follow-up—in February. The document was published jointly in the Journal of the American College of Cardiology (JACC) and Circulation.
“There have been significant advances in the understanding of pulmonary embolism and treatments to effectively manage this condition,” said chair of the guideline writing committee Mark A Creager (Geisel School of Medicine at Dartmouth College, Hanover, USA; Heart and Vascular Center at Dartmouth Health, Lebanon, USA) in a press release from the AHA. “This guideline is a roadmap to help clinicians navigate these advances for the safest and most effective approaches to care for people with this condition.”
The new guideline includes patient treatment recommendations by care setting, including which patients can be discharged from the emergency department and managed as outpatients; which patients require hospitalisation; and which patients need critical care. It also acknowledges that implementation of the recommendations depends on the availability of local resources, such as specialists for consultations, imaging tests and advanced interventions.
Among several take-home messages, Creager and colleagues highlight three as representing the most “impactful” changes, and addressing established gaps in clinical practice.
One such key update is the presentation of a new clinical classification system. The authors outline five categories and subcategories, ranging from low to high risk for adverse outcomes. Patients in Categories A and B have no or mild symptoms and low risk of experiencing severe complications; they often can be safely discharged from the emergency department. Categories C–E include people with symptoms of acute PE who are at higher risk of adverse outcomes and require hospitalisation.
Another core takeaway is the recommendation that advanced therapies, including systemic thrombolysis, catheter-based thrombolysis, mechanical thrombectomy, and surgical embolectomy are “reasonable” for patients with acute PE in Category E1—denoting recurrent or persistent hypotension with cardiogenic shock—and “can be considered” for patients with acute PE in Category D1–2, which signifies transient hypotension and normotensive shock.
The importance of PERTs is also a central message in the new guidelines, with the authors labelling this setup as “essential for appropriate risk stratification and management” and recommend their use “to improve timeliness of care”.
“We anticipate that decisions guided by these recommendations will result in more rapid diagnosis and application of effective, evidence-based treatments, leading to better outcomes, such as decreased risk of death and disability, for people with acute pulmonary embolism,” Creager said in the AHA press release.
Speaking to Venous News, co-author Eric Secemsky (Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, USA) added: “These are the first multisocietal, multidisciplinary guidelines in the USA and they set a new approach for the diagnosis, classification and treatment of acute PE. We look forward to implementation of these guidelines in clinical practice and future updates reflecting the ongoing investment in generating robust randomised clinical trial data.”
The guideline, led by the AHA and the ACC Joint Committee on Clinical Practice Guidelines, was developed in collaboration with and endorsed by the American College of Clinical Pharmacy (ACCP); the American College of Emergency Physicians (ACEP); the American College of Chest Physicians (CHEST); the Society for Cardiovascular Angiography & Interventions (SCAI); the Society of Hospital Medicine (SHM); the Society of Interventional Radiology (SIR); the Society for Vascular Medicine (SVM); and the Society of Vascular Nursing (SVN).
