Pulmonary embolism – An EFIM guideline critical appraisal and adaptation for practicing clinicians


DOI: https://dx.doi.org/10.18565/therapy.2022.1.7-20

Becattini С., Kokorin V.A., Lesniak W., Marin-Leon I., Medrano F.J., Morbidoni L., Marra A.M., Biskup E., Riera-Mestre A., Dicker D.

1) Internal and Emergency Medicine Department, University of Perugia, Perugia, Italy; 2) N.I. Pirogov Russian National Research Medical University (RNRMU), Department of Hospital Therapy named after academician P.E. Lukomsky, Moscow, Russia; 3) Evidence Based Medicine Unit, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland; 4) CIBERESP-IBIS-ROCIO-University Hospital; Fundación Enebro, Seville, Spain; 5) Instituto de Biomedicina de Sevilla (Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla), CIBERESP and Department of Medicine, Universidad de Sevilla, Seville, Spain; 6) Internal Medicine Unit «Principe di Piemonte» Hospital Senigallia (AN), Italy; 7) Department of Translational Medical Sciences, “Federico II” University Hospital and school of medicine, Naples, Italy; 8) Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany; 9) University Hospital of Basel, Division of Internal Medicine, University of Basel, Switzerland; 10) Shanghai University of Medicine and Health Sciences, Shanghai, China; 11) Internal Medicine Department, Hospital Universitari Bellvitge – Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain; 12) Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain; 13) Internal Medicine Department, Hasharon Hospital-Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
Abstract. Several trials have been conducted in the last decades that challenged the management of patients with acute pulmonary embolism (PE) in terms of diagnosis and treatment. Updated international clinical practice guidelines (CPGs) endorsed the evidence from these trials. The aim of this document was to adapt recommendations from existing CPGs to assist physicians in decision making concerning specific and complex scenarios related to acute PE.
Methods: The flow for the adaptation procedure was first the identification of unsolved clinical issues in patients with acute PE (PICOs), then critically appraise the existing CPGs and choose the recommendations, which are the most applicable to these specific and complex scenarios.
Results: Five PICOs were identified and CPGs appraisal was performed. Concerning diagnosis of PE when computed tomographic pulmonary angiography is not available/contraindicated and D-dimer is less specific, perfusion lung scan is the preferred option in the majority of clinical scenarios. For the treatment of PE when relevant clinical conditions like pregnancy or severe renal failure are present heparin is to be used. Poor evidence and low-level recommendations exist on the best bleeding prediction rule in patients treated for PE. The duration of anticoagulation needs to be tailored concerning the presence of predisposing factors for index PE and the consequent risk for recurrence. Finally, recommendations on the opportunity to screen for cancer and thrombophilia patients without recognized thrombosis risk factors for PE are reported. Overall, 35 recommendations were endorsed and the rationale for the selection is reported in the main text.
Conclusion: By the use of proper methodology for the adaptation process, this document offers a simple and updated guide for practicing clinicians dealing with complex patients.
Keywords: adapt, internal medicine, clinical practice guideline, consensus, pulmonary embolism, guidelines
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