2014ESC急性肺栓塞诊断和管理指南(英文版)(2)

CO cardiac output

COPD chronic obstructive pulmonary disease

CPG Committee for Practice Guidelines

CRNM clinically relevant non-major

CT computed tomographic/tomogram

CTEPH chronic thromboembolic pulmonary hypertension CUS compression venous ultrasonography

DSA digital subtraction angiography

DVT deep vein thrombosis

ELISA enzyme-linked immunosorbent assay

ESC European Society of Cardiology

H-FABP heart-type fatty acid-binding protein

HIT heparin-induced thrombocytopenia

HR hazard ratio

ICOPER International Cooperative Pulmonary Embolism Registry

ICRP International Commission on Radiological Protection INR international normalized ratio

iPAH idiopathic pulmonary arterial hypertension

IVC inferior vena cava

LMWH low molecular weight heparin

LV left ventricle/left ventricular

MDCT multi-detector computed tomographic(angiography) MRA magnetic resonance angiography

NGAL neutrophil gelatinase-associated lipocalin

NOAC(s)Non-vitamin K-dependent new oral anticoagulant(s) NT-proBNP N-terminal pro-brain natriuretic peptide

o.d.omni die(every day)

OR odds ratio

PAH pulmonary arterial hypertension

PE pulmonary embolism

PEA pulmonary endarterectomy

PEITHO Pulmonary EmbolIsm THrOmbolysis trial

PESI pulmonary embolism severity index

PH pulmonary hypertension PIOPED Prospective Investigation On Pulmonary Embolism Diagnosis

PVR pulmonary vascular resistance

RIETE Registro Informatizado de la Enfermedad Throm-boembolica venosa

RR relative risk

rtPA recombinant tissue plasminogen activator

RV right ventricle/ventricular

SPECT single photon emission computed tomography sPESI simpli?ed pulmonary embolism severity index TAPSE tricuspid annulus plane systolic excursion

Tc technetium

TOE transoesophageal echocardiography

TTR time in therapeutic range

TV tricuspid valve

UFH unfractionated heparin

V/Q scan ventilation–perfusion scintigraphy

VKA vitamin K antagonist(s)

VTE venous thromboembolism

1.Preamble

Guidelines summarize and evaluate all available evidence at the time of the writing process,on a particular issue with the aim of assisting health professionals in selecting the best management strategies for an inpidual patient,with a given condition,taking into account the impact on outcome,as well as the risk-bene?t-ratio of particular diag-nostic or therapeutic means.Guidelines and recommendations should help the health professionals to make decisions in their daily practice.However,the?nal decisions concerning an inpidual patient must be made by the responsible health professional(s)in consultation with the patient and caregiver as appropriate.

A great number of Guidelines have been issued in recent years by the European Society of Cardiology(ESC)as well as by other soci-eties and organisations.Because of the impact on clinical practice, quality criteria for the development of guidelines have been estab-lished in order to make all decisions transparent to the user.The recommendations for formulating and issuing ESC Guidelines can be found on the ESC Web Site(e43f5da204a1b0717ed5dd2a/guidelines-surveys/esc-guidelines/about/Pages/rules-writing.aspx).ESC Guide-lines represent the of?cial position of the ESC on a given topic and are regularly updated.

Members of this Task Force were selected by the ESC to represent professionals involved with the medical care of patients with this pathology.Selected experts in the?eld undertook a comprehensive review of the published evidence for management(including diagno-sis,treatment,prevention and rehabilitation)of a given condition according to ESC Committee for Practice Guidelines(CPG)policy.

A critical evaluation of diagnostic and therapeutic procedures was performed including assessment of the risk-bene?t-ratio.Estimates of expected health outcomes for larger populations were included, where data exist.The level of evidence and the strength of recom-mendation of particular management options were weighed and graded according to prede?ned scales,as outlined in Tables1and2. The experts of the writing and reviewing panels?lled in declara-tions of interest forms which might be perceived as real or potential

ESC Guidelines Page3of48

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sources of con?icts of interest.These forms were compiled into one ?le and can be found on the ESC Web Site(e43f5da204a1b0717ed5dd2a/ guidelines).Any changes in declarations of interest that arise during the writing period must be noti?ed to the ESC and updated.The Task Force received its entire?nancial support from the ESC without any involvement from healthcare industry.

The ESC CPG supervises and coordinates the preparation of new Guidelines produced by Task Forces,expert groups or consensus panels.The Committee is also responsible for the endorsement process of these Guidelines.The ESC Guidelines undergo extensive review by the CPG and external experts.After appropriate revisions it is approved by all the experts involved in the Task Force.The?na-lized document is approved by the CPG for publication in the Euro-pean Heart Journal.It was developed after careful consideration of

the scienti?c and medical knowledge and the evidence available at the time of their dating.

The task of developing ESC Guidelines covers not only the integra-tion of the most recent research,but also the creation of educational tools and implementation programmes for the recommendations. To implement the guidelines,condensed pocket guidelines versions, summary slides,booklets with essential messages,summary cards for non-specialists,electronic version for digital applications(smart-phones etc)are produced.These versions are abridged and,thus, if needed,one should always refer to the full text version which is freely available on the ESC Website.The National Societies of the ESC are encouraged to endorse,translate and implement the ESC Guidelines.Implementation programmes are needed because it has been shown that the outcome of disease may be favourably in?uenced by the thorough application of clinical recommendations. Surveys and registries are needed to verify that real-life daily prac-tice is in keeping with what is recommended in the guidelines,thus completing the loop between clinical research,writing of guidelines, disseminating them and implementing them into clinical practice. 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,diag-nostic or therapeutic medical strategies.However,the ESC Guide-lines do not override in any way whatsoever the inpidual responsibility of health professionals to make appropriate and ac-curate decisions in consideration of each patient s health condition and in consultation with that patient and the patient’s caregiver where appropriate and/or necessary.It is also the health professio-nal’s responsibility to verify the rules and regulations applicable to drugs and devices at the time of prescription.

2.Introduction

This document follows the two previous ESC Guidelines focussing on clinical management of pulmonary embolism,published in2000 and2008.Many recommendations have retained or reinforced their validity;however,new data has extended or modi?ed our knowl-edge in respect of optimal diagnosis,assessment and treatment of patients with PE.The most clinically relevant new aspects of this 2014version as compared with its previous version published in 2008relate to:

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(1)Recently identi?ed predisposing factors for venous thrombo-

embolism

(2)Simpli?cation of clinical prediction rules

(3)Age-adjusted D-dimer cut-offs

(4)Sub-segmental pulmonary embolism

(5)Incidental,clinically unsuspected pulmonary embolism

(6)Advanced risk strati?cation of intermediate-risk pulmonary

embolism

(7)Initiation of treatment with vitamin K antagonists

(8)Treatment and secondary prophylaxis of venous thrombo-

embolism with the new direct oral anticoagulants

(9)Ef?cacyand safety of reperfusion treatment for patients at inter-

mediate risk

(10)Early discharge and home(outpatient)treatment of pulmonary

embolism

(11)Current diagnosis and treatment of chronic thromboembolic

pulmonary hypertension

(12)Formal recommendations for the management of pulmonary

embolism in pregnancy and of pulmonary embolism in patients with cancer.

These new aspects have been integrated into previous knowledge to suggest optimal and—whenever possible—objectively validated management strategies for patients with suspected or con?rmed pul-monary embolism.

In order to limit the length of the printed text,additional informa-tion,tables,?gures and references are available as web addenda at the ESC website(e43f5da204a1b0717ed5dd2a).

2.1Epidemiology

Venous thromboembolism(VTE)encompasses deep vein throm-bosis(DVT)and pulmonary embolism(PE).It is the third most fre-quent cardiovascular disease with an overall annual incidence of 100–200per100000inhabitants.1,2VTE may be lethal in the acute phase or lead to chronic disease and disability,3–6but it is also often preventable.

Acute PE is the most serious clinical presentation of VTE.Since PE is,in most cases,the consequence of DVT,most of the existing data on its epidemiology,risk factors,and natural history are derived from studies that have examined VTE as a whole.

The epidemiology of PE is dif?cult to determine because it may remain asymptomatic,or its diagnosis may be an incidental?nding;2 in some cases,the?rst presentation of PE may be sudden death.7,8 Overall,PE is a major cause of mortality,morbidity,and hospitaliza-tion in Europe.As estimated on the basis of an epidemiological model,over317000deaths were related to VTE in six countries of the European Union(with a total population of454.4million)in 2004.2Of these cases,34%presented with sudden fatal PE and 59%were deaths resulting from PE that remained undiagnosed during life;only7%of the patients who died early were correctly diag-nosed with PE before death.Since patients older than40years are at increased risk compared with younger patients and the risk approxi-mately doubles with each subsequent decade,an ever-larger number of patients are expected to be diagnosed with(and perhaps die of)PE in the future.9

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