International recommendations on management strategies in addition to anticoagulant treatment
| Guidelines . | Risk class . | Management strategy . | Level of recommendation . |
|---|---|---|---|
| ESC 2014* | High risk | Systemic thrombolysis | I B |
| Percutaneous embolectomy | IIa C | ||
| Surgical embolectomy | I C | ||
| Intermediate high risk | Systemic thrombolysis | I B (in case of decompensation) | |
| Close monitoring | IIa B | ||
| Percutaneous embolectomy | IIb B (if decompensation + bleeding risk) | ||
| Surgical embolectomy | IIb C (if decompensation + bleeding risk) | ||
| Low risk | Home treatment | IIa B | |
| AHA/ACC‡ | Massive† | Fibrinolysis | IIa B (reasonable if acceptable risk of bleeding) |
| Catheter embolectomy and fragmentation or surgical embolectomy (depending on local expertise) | IIa C (if contraindications to or unstable after fibrinolysis) | ||
| Submassive§ | Fibrinolysis | IIb C|| | |
| III B against if minor RVD/myocardial | |||
| Necrosis, and no clinical worsening | |||
| Low risk¶ | Fibrinolysis | III B against | |
| CHEST 2016# | Low risk | Home treatment/early discharge | II B (if home circumstances are adequate) |
| No hypotension | Thrombolysis | I B against | |
| Hypotension** | Catheter-assisted thrombus removal | II C | |
| All patients | Vena cava filter | I B against | |
| NICE# | HD unstable | Consider thrombolytic therapy | |
| HD stable | Do not offer thrombolytic therapy |
| Guidelines . | Risk class . | Management strategy . | Level of recommendation . |
|---|---|---|---|
| ESC 2014* | High risk | Systemic thrombolysis | I B |
| Percutaneous embolectomy | IIa C | ||
| Surgical embolectomy | I C | ||
| Intermediate high risk | Systemic thrombolysis | I B (in case of decompensation) | |
| Close monitoring | IIa B | ||
| Percutaneous embolectomy | IIb B (if decompensation + bleeding risk) | ||
| Surgical embolectomy | IIb C (if decompensation + bleeding risk) | ||
| Low risk | Home treatment | IIa B | |
| AHA/ACC‡ | Massive† | Fibrinolysis | IIa B (reasonable if acceptable risk of bleeding) |
| Catheter embolectomy and fragmentation or surgical embolectomy (depending on local expertise) | IIa C (if contraindications to or unstable after fibrinolysis) | ||
| Submassive§ | Fibrinolysis | IIb C|| | |
| III B against if minor RVD/myocardial | |||
| Necrosis, and no clinical worsening | |||
| Low risk¶ | Fibrinolysis | III B against | |
| CHEST 2016# | Low risk | Home treatment/early discharge | II B (if home circumstances are adequate) |
| No hypotension | Thrombolysis | I B against | |
| Hypotension** | Catheter-assisted thrombus removal | II C | |
| All patients | Vena cava filter | I B against | |
| NICE# | HD unstable | Consider thrombolytic therapy | |
| HD stable | Do not offer thrombolytic therapy |
ACC, American College of Cardiology; AHA, American Heart Association; GRADE, strength of recommendation and quality of evidence; NICE, National Institute of Clinical Excellence.
Quality of evidence and strength of recommendations:
Level of evidence A: Data from multiple randomized clinical trials or meta-analyses. Level of evidence B: Data from a single randomized clinical trial or large nonrandomized studies. Level of evidence C: Consensus of opinion of experts and/or small studies, retrospective studies, registries. Class I: Evidence and/or general agreement of benefit/efficacy: is recommended/indicated. Class IIa: Weight of evidence/opinion in favor of usefulness/efficacy: should be. Class IIb: Usefulness/efficacy less well established by evidence/opinion: maybe. Class III: Evidence and/or general agreement of benefit/efficacy on nonusefulness/efficacy and in some cases harm: not recommended.
Sustained systolic blood pressure <90 mmHg for ≥15 minutes or requiring inotropic support, not due to a cause other than PE; pulselessness, or persistent profound bradycardia (heart rate <40 beats per minute with signs or symptoms of shock).
American Heart Association levels of evidence used to assess the quality of evidence and strength of recommendations:Level of evidence A: Data from multiple randomized clinical trials or meta-analyses. Level of evidence B: Data from a single randomized clinical trial or nonrandomized studies. Level of evidence C: Only consensus opinion of experts, case studies, or standard of care. Class I: Benefit >>> risk: should be. Class IIa: Benefit >> risk: it is reasonable. Class IIb: Benefit ≥ risk: maybe. Class III: Risk ≤ benefit: should not.
Acute PE without systemic hypotension (systolic blood pressure ≥90 mmHg) but with either RVD or myocardial necrosis.
If new hemodynamic instability, worsening respiratory insufficiency, severe RVD, or major myocardial necrosis and low risk of bleeding.
Normotensive with normal biomarker levels and no RVD.
GRADE approach used to assess the quality of evidence and strength of recommendations:Level of evidence A: Data from multiple randomized clinical trials or meta-analyses. Level of evidence B: Data from a single randomized clinical trial or large nonrandomized studies. Level of evidence C: Consensus of opinion of experts and/or small studies, retrospective studies, registries. Class I: Evidence and/or general agreement of benefit/efficacy: is recommended/indicated. Class IIa: Weight of evidence/opinion in favor of usefulness/efficacy: should be. Class IIb: Usefulness/efficacy less well established by evidence/opinion: maybe. Class III: Evidence and/or general agreement of benefit/efficacy on nonusefulness/efficacy and in some cases harm: not recommended.
(1) A high bleeding risk, (2) failed systemic thrombolysis, or (3) shock that is likely to cause death before systemic thrombolysis can take effect (eg, within hours), if appropriate expertise and resources are available.