The Present and Future
State-of-the-Art Review
Management of Pulmonary Embolism: An Update

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Abstract

Pulmonary embolism (PE) remains a major contributor to global disease burden. Risk-adapted treatment and follow-up contributes to a favorable outcome. Age-adjusted cutoff levels increase D-dimer specificity and may decrease overuse of imaging procedures and overdiagnosis of PE. Primary systemic fibrinolysis has an unfavorable risk–benefit ratio in intermediate-risk PE; catheter-directed techniques are an option for patients with hemodynamic decompensation and high bleeding risk. New oral anticoagulant agents are effective and safe alternatives to standard anticoagulation regimens. Recent trial data do not support insertion of cava filters in patients who can receive anticoagulant treatments. Remaining areas of uncertainty include the therapeutic implications of subsegmental PE, the optimal diagnostic approach to the pregnant patient with suspected PE, and the efficacy and safety of new oral anticoagulant agents in patients with cancer. Campaigns to increase awareness combined with strategies to implement guideline recommendations will be crucial steps towards further optimizing management of acute PE.

Key Words

anticoagulation
cava filters
prognosis
reperfusion
risk assessment
venous thromboembolism

Abbreviations and Acronyms

ASO
antisense oligonucleotide
CI
confidence interval
CT
computed tomography
CTEPH
chronic thromboembolic pulmonary hypertension
DVT
deep vein thrombosis
ESC
European Society of Cardiology
FXI
factor XI
NOAC
non–vitamin K-dependent oral anticoagulant(s)
NT-proBNP
N-terminal pro–B-type natriuretic peptide
OR
odds ratio
PE
pulmonary embolism
PESI
Pulmonary Embolism Severity Index
RR
relative risk
rtPA
recombinant tissue-type plasminogen activator
SPECT
single-photon emission computed tomography
sPESI
simplified Pulmonary Embolism Severity Index
VKA
vitamin K antagonist
V/Q
ventilation/perfusion
VTE
venous thromboembolism

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The work of Drs. Konstantinides, Barco, and Lankeit was supported by the German Federal Ministry of Education and Research (BMBF 01EO1003 and 01EO1503). The authors are responsible for the contents of this paper. Dr. Konstantinides has received consultancy and lecture honoraria from Bayer HealthCare, Boehringer Ingelheim, Daiichi-Sankyo, and Pfizer–Bristol-Myers Squibb; payment for travel accommodation/meeting expenses from Bayer HealthCare; and institutional grants from Boehringer Ingelheim, Bayer HealthCare, and Daiichi-Sankyo. Dr. Barco has received an educational travel grant from Daiichi-Sankyo. Dr. Lankeit has received consultancy and lecture honoraria from Actelion, Bayer HealthCare, Daiichi-Sankyo, and Pfizer–Bristol-Myers Squibb. Dr. Meyer has received payment for travel accommodation/meeting expenses from Bayer HealthCare, Leo Pharma, and Daiichi-Sankyo; board membership, consultancy, and lecture honoraria to his institution from Bayer HealthCare, Pfizer–Bristol-Myers Squibb, Sanofi, Leo Pharma, and Daiichi-Sankyo; and institutional grants from Boehringer Ingelheim, and Leo Pharma.

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