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Supplementary Data ESC Guidelines 1 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): supplementary data The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC) Authors/Task Force Members: Stavros V. Konstantinides* (Chairperson) (Germany/Greece), Guy Meyer* (Co-Chairperson) (France), Cecilia Becattini (Italy), Héctor Bueno (Spain), Geert-Jan Geersing (Netherlands), Veli-Pekka Harjola (Finland), Menno V. Huisman (Netherlands), Marc Humbert1 (France), Catriona Sian Jennings (United Kingdom), David Jiménez (Spain), Nils Kucher (Switzerland), Irene Marthe Lang (Austria), Mareike Lankeit (Germany), Roberto Lorusso (Netherlands), Lucia Mazzolai (Switzerland), Nicolas Meneveau (France), Fionnuala Ní Áinle (Ireland), Paolo Prandoni (Italy), Piotr Pruszczyk (Poland), Marc Righini (Switzerland), Adam Torbicki (Poland), Eric Van Belle (France), José Luis Zamorano (Spain) Document Reviewers: Nazzareno Galié (CPG Review Coordinator) (Italy), J. Simon R. Gibbs (CPG Review Coordinator) (United Kingdom), Victor Aboyans (France), Walter Ageno (Italy), Stefan Agewall (Norway), Ana G. Almeida (Portugal), Felicita Andreotti (Italy), Emanuele Barbato (Italy), Johann Bauersachs (Germany), Andreas Baumbach (United Kingdom), Farzin Beygui (France), Jørn Carlsen (Denmark), Marco De Carlo (Italy), Marion Delcroix1 (Belgium), Victoria Delgado (Netherlands), Pilar Escribano Subias (Spain), Donna Fitzsimons (United Kingdom), Sean Gaine1 (Ireland), Samuel Z. Goldhaber (United States of America), Deepa Gopalan (United Kingdom), Gilbert Habib (France), Sigrun Halvorsen (Norway), David Jenkins (United Kingdom), Hugo A. Katus (Germany), Barbro Kjellström (Sweden), Mitja Lainscak (Slovenia), Patrizio Lancellotti (Belgium), Geraldine Lee (United Kingdom), Grégoire Le Gal (Canada), Emmanuel Messas (France), Joao Morais (Portugal), Steffen E. Petersen (United Kingdom), Anna Sonia Petronio (Italy), Massimo Francesco Piepoli (Italy), Susanna Price (United Kingdom), Marco Roffi (Switzerland), Aldo Salvi (Italy), Olivier Sanchez1 (France), Evgeny Shlyakhto (Russian Federation), Iain A. Simpson (United Kingdom), Stefan Stortecky (Switzerland), Matthias Thielmann (Germany), Anton Vonk Noordegraaf1 (Netherlands) ESC Guidelines 2 The disclosure forms of all experts involved in the development of these Guidelines are available on the ESC website www.escardio.org/guidelines * Corresponding authors: Stavros V. Konstantinides, Center for Thrombosis and Hemostasis, Johannes Gutenberg University Mainz, Building 403, Langenbeckstr. 1, 55131 Mainz, Germany. Tel: +49 613 117 6255, Fax: +49 613 117 3456, Email: [email protected]; and Department of Cardiology, Democritus University of Thrace, 68100 Alexandroupolis, Greece. Email: [email protected]. Guy Meyer, Respiratory Medicine Department, Hôpital Européen Georges Pompidou, 20 Rue Leblanc, 75015 Paris, France. Tel: +33 156 093 461, Fax: +33 156 093 255, Email: [email protected]; and Université Paris Descartes, Sorbonne Paris Cité, 15 rue de l'école de Médecine, 75006 Paris France. ESC Committee for Practice Guidelines (CPG), National Cardiac Societies document reviewers and Author/Task Force Member affiliations: listed in the Appendix of the Full Text. 1Representing the ERS. ESC entities having participated in the development of this document: Associations: Acute Cardiovascular Care Association (ACCA), Association of Cardiovascular Nursing & Allied Professions (ACNAP), European Association of Cardiovascular Imaging (EACVI), European Association of Percutaneous Cardiovascular Interventions (EAPCI), Heart Failure Association (HFA). Councils: Council on Cardiovascular Primary Care. Working Groups: Aorta and Peripheral Vascular Diseases, Cardiovascular Surgery, Pulmonary Circulation and Right Ventricular Function, Thrombosis. The content of these European Society of Cardiology (ESC) Guidelines has been published for personal and educational use only. No commercial use is authorized. No part of the ESC Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of a written request to Oxford University Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC ([email protected]). Disclaimer. The ESC Guidelines represent the views of the ESC and were produced after careful consideration of the scientific and medical knowledge, and the evidence available at the time of their publication. The ESC is not responsible in the event of any contradiction, discrepancy, and/or ambiguity between the ESC Guidelines and any other official recommendations or guidelines issued by the relevant public health authorities, in particular in relation to good use of healthcare or therapeutic strategies. 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, diagnostic, or therapeutic medical strategies; however, the ESC Guidelines do not override, in any way whatsoever, the individual responsibility of health professionals to make appropriate and accurate decisions in consideration of each ESC Guidelines 3 patient’s health condition and in consultation with that patient and, where appropriate and/or necessary, the patient’s caregiver. Nor do the ESC Guidelines exempt health professionals from taking into full and careful consideration the relevant official updated recommendations or guidelines issued by the competent public health authorities, in order to manage each patient’s case in light of the scientifically accepted data pursuant to their respective ethical and professional obligations. It is also the health professional’s responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription. Keywords Guidelines; pulmonary embolism; venous thrombosis; shock; dyspnoea; heart failure; right ventricle; diagnosis; risk assessment; echocardiography; biomarkers; treatment; anticoagulation; thrombolysis; pregnancy; venous thromboembolism; embolectomy 1 Supplementary Tables and Supplementary Figure Supplementary Table 1 The Wells clinical prediction rule for pulmonary embolism Items Clinical decision rule points .............................................. Original version1 Simplified version2 Previous PE or DVT 1.5 1 Heart rate >100 b.p.m. 1.5 1 Surgery or immobilization within the past 4 weeks 1.5 1 Haemoptysis 1 1 Active cancer 1 1 Clinical signs of DVT 3 1 Alterative diagnosis less likely than PE 3 1 Clinical probability Three-level score Low 0—1 N/A Intermediate 2—6 N/A High >_7 N/A Two-level score PE unlikely 0—4 0—1 PE likely >_5 >_2 b.p.m. = beats per minute; DVT = deep vein thrombosis; N/A = not applicable; PE = pulmonary embolism. ESC Guidelines 4 Supplementary Table 2 Findings of pre-existing chronic thromboembolic pulmonary hypertension on computed tomography pulmonary angiography Direct vascular signs Eccentric wall-adherent filling defect(s), which may calcify; different from the central filling defects within a distended lumen, which are the hallmark of acute PE Abrupt tapering and truncation Complete occlusion and pouch defects Intimal irregularity Linear intraluminal filling defects (intravascular webs and bands) Stenosis and post-stenotic dilatation Vascular tortuosity Indirect vascular signs Significant RV hypertrophy, RA dilatation Pericardial effusion Dilatation of pulmonary artery (>29 mm in men and >27 mm in women) and/or calcifications of pulmonary artery Systemic collateral arterial supply (bronchial arterial collaterals towards pulmonary post-obstructive vessels) Parenchymal changes Mosaic attenuation of the lung parenchyma resulting in geographical variation in perfusion The above findings suggest pre-existing CTEPH on CTPA (adapted from Ruggiero and Screaton3 and Gopalan et al.4). CTEPH = chronic thromboembolic pulmonary hypertension; CTPA = computed tomography pulmonary angiography; PE = pulmonary embolism; RA = right atrial; RV = right ventricular. ESC Guidelines 5 4 Supplementary Table 3 Prognostic value and cut-off levels of imaging parameters Parameter n Study design Cut-off value Study outcomea OR or HR Sensitivity Specificity NPV (%) PPV (%) (95% CI) (%) (95% CI) (%) (95% CI) (95% CI) (95% CI) TTE RV dysfunction 1249 Meta-analysis5 Various criteria All-cause mortality 2.4 (1.3—4.3) 74 (61—84) 54 (51—56) 98 (96—99) 8 (6—10) RV/LV diameter ratio 782b Prospective cohort6 >_1.0 All-cause mortality 35.7 (3.4—381.0) 21 (10—39) 83 (80—86) 96 (94—97) 6 (2—11) PE-related mortality 8.9 (1.1—74.7) 50 (20—80) 83 (80—86) 99 (98—100) 4 (2—9) 411b Prospective cohort7 >_1.0 PE-related mortality or 3.9 (1.5—10.2) 61 (39—84) 73 (68—78) 97 (91—99) 13 (5—20) rescue thrombolysis TAPSE 782b Prospective cohort6 <_16 mm All-cause mortality 2.4 (1.2—4.7) 34 (21—52) 82 (79—85) 96 (95—98) 8 (5—14) PE-related mortality 4.4 (1.3—15.3) 50 (24—76) 82 (79—84) 99 (98—100) 3 (1—8) 411b Prospective cohort7 <16 mm PE-related mortality or 27.9 (6.2—124.6) 82 (59—100) 86 (81—90) 99 (98—100) 21 (9—33) rescue thrombolysis McConnell sign 411b Prospective cohort7 Present PE-related mortality or 3.6 (1.5—8.7) 45 (23—67) 82 (78—86) 97 (95—99) 12 (5—19) rescue thrombolysis Right heart thrombi 15 220 Meta-analysis8 Present All-cause
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