The present focus issue of the Journal is dedicated to acute pulmonary embolism (PE)
and its chronic sequelae. Several international experts critically review the current
state of the art in the diagnosis and management of the disease, and outline the implications
for optimal contemporary patient care.
Venous thromboembolism (VTE), clinically presenting as PE or deep vein thrombosis
(DVT), is globally the third most frequent manifestation of thrombosis and acute cardiovascular
syndrome behind myocardial infarction and stroke.[1]
[2] The annual incidence of PE has been reported to range from 39 to 115 per 100,000
population; it is even higher for DVT without clinically evident PE.[3] Beyond absolute numbers at a given time point, however, it is mostly the alarming
trends that emphasize the growing importance of the disease. In fact, the incidence
of VTE is almost eight times higher in individuals aged 80 years or older than in
the fifth decade of life.[3] In parallel, longitudinal studies have shown a steadily rising tendency in annual
PE incidence[4]
[5] and PE-related mortality rates[6]
[7] over the past 20 years. Based on these data, and viewed from the perspective of
the global demographic change towards an aging population, it becomes obvious that
the clinical and epidemiological impact of acute PE in terms of morbidity and mortality,
and the financial burden imposed by PE on health care systems, will all continue to
increase substantially in the years to come.
In the focus article by Drs. Righini and Robert-Ebadi, published in Issue 1 of Hämostaseologie, the authors reviewed the diagnostic modalities and strategies for patients with
suspected acute PE.[8] Despite the uninterrupted and undisputed dominance of computed tomographic pulmonary
angiography (CTPA) in diagnostic algorithms since 2006, the first steps of assessing
the clinical or ‘pre-test’ probability by clinical decision rules and D-dimer testing
have by no means lost their importance. On the contrary, efforts continue to concentrate
on optimizing the performance of these scores to reduce as much as possible the number
of unnecessary time-consuming, costly and potentially hazardous CTPA examinations.
Scintigraphic and magnetic resonance technology are also making progress, although
the clinical data not yet suffice to justify modifications in current recommendations
for clinical practice. Furthermore, the article focuses on clinically relevant gaps
of knowledge and areas of uncertainty, notably imaging findings in patients with a
previous history of VTE and the diagnostic challenge of isolated symptomatic sub-segmental
PE.
In this issue of Hämostaseologie, Drs. Donadini and Ageno then discuss advances in risk assessment of patients with
confirmed acute PE as well as the initial anticoagulation regimens in these patients.[9] Direct, non-vitamin K-dependent oral anticoagulants are increasingly becoming the
first-line option for patients with acute PE, but this does not mean that the anticoagulation
chapter can be considered ‘closed’. In fact, the most critical question on anticoagulation
is also the one that remains most difficult to answer in everyday practice: ‘How long
to anticoagulate the patient after PE and with what dose?’ The authors provide guidance
by critically reviewing existing scores for assessment of VTE recurrence versus bleeding,
also in light of the results of recent studies, which investigated the safety and
efficacy of extended, reduced-dose anticoagulation.
Following the recommendations for management of the general population, Drs. Werth
and Beyer-Westendorf highlight the difficulties in specific situations and in patients
at particularly high risk.[10] It is well known that solid evidence derived from randomized trials does not exist
for pregnant patients. Therefore, practice in this setting is shaped by extrapolations,
pathophysiological considerations, cohort data and personal experience. Nevertheless,
or rather exactly because of this, clinicians need guidance and recommendations by
experts in the field. Similar challenges exist in patients with chronic kidney disease
and particularly those with severe renal failure, a further focus of this chapter.
Fortunately, progress is visible in the field of anticoagulation for cancer-associated
thrombosis, with recent data on the efficacy and safety of direct oral anticoagulants
compared with prolonged parenteral heparin treatment.
Most patients with acute PE are treated with anticoagulant drugs, but for carefully
selected patients, mechanical or pharmacomechanical re-perfusion can be a life-saving
option. Drs. Engelberger and Kucher review the promising recent evidence and continuing
progress related to catheter-directed techniques and regimens of locally delivered
thrombolytic drugs.[11] This is a field that had remained stagnant for many decades; now, thanks to the
contribution of the authors and other interventional experts, it is moving forward
to fill an important gap in PE management.
Last but not least, it is becoming increasingly clear that neither the problems related
to PE are confined to the first few days nor the need for patient follow-up and post-PE
care ends after discharge from the hospital. Moreover, the critical decisions during
the follow-up phase are not limited to determining the ‘optimal’ duration of anticoagulation,
which was mentioned earlier. This was highlighted by the article by Drs. Klok and
Barco in Issue 1 of this year in which they focus on our rapidly evolving knowledge—and
perception—of what comes after PE.[12] Importantly, the spectrum of late PE sequelae includes but is not synonymous with
chronic thromboembolic pulmonary hypertension. It extends to broadly defined clinical
symptoms and signs of functional limitation, for which the umbrella ‘post-PE syndrome’
is at present the working title. The authors discuss the challenging task to develop
and validate reliable and cost-effective follow-up and screening strategies, and provide
guidance based on our current state of knowledge in a rapidly evolving area.
We hope that the readers of Hämostaseologie will find in this focus issue a comprehensive update of the most relevant recent
advances in the diagnosis and management of PE, combined with useful advice and guidance
for challenging situations encountered in clinical practice.
