ESC/ERS 2019 acute pulmonary embolism guidelines: key recommendations

Official guideline2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). ESC, 2020.
Read the official guideline · Checked for a newer edition on 2026-10-20
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Who it applies to

Adults with suspected or confirmed acute PE across emergency, inpatient, and outpatient settings, including special populations such as pregnant patients and those with cancer.

Key recommendations

Use validated clinical prediction rules (e.g. Wells or Geneva score) to estimate pretest probability before imaging.
In hemodynamically unstable patients with high clinical suspicion, proceed directly to CT pulmonary angiography or bedside echocardiography without waiting for D-dimer testing.
In hemodynamically stable patients, use age-adjusted D-dimer thresholds to help exclude PE in low or intermediate probability patients.
Risk-stratify confirmed PE using hemodynamic status, right ventricular dysfunction on imaging, and cardiac biomarkers (troponin, BNP/NT-proBNP) to classify as high, intermediate-high, intermediate-low, or low risk.
Give systemic thrombolysis to patients with high-risk (hemodynamically unstable) PE unless contraindicated.
Reserve routine thrombolysis out of the acute setting for intermediate-high risk patients with hemodynamic deterioration; otherwise manage with anticoagulation alone and close monitoring.
Prefer non-vitamin K antagonist oral anticoagulants (DOACs) over vitamin K antagonists for most patients without contraindications.
Consider early discharge and outpatient treatment for carefully selected low-risk PE patients using validated prognostic scores such as the PESI or sPESI.
Use unfractionated heparin with hemodynamic monitoring in high-risk PE where thrombolysis may be needed or hemodynamic instability is evolving.
Consider catheter-directed treatment or surgical embolectomy for high-risk patients when systemic thrombolysis is contraindicated or has failed.
Base extended anticoagulation duration on balance of recurrence risk and bleeding risk, considering whether PE was provoked by a major transient risk factor, unprovoked, or associated with cancer.
For cancer-associated thrombosis, consider DOACs such as edoxaban or rivaroxaban as an alternative to low molecular weight heparin, except in patients with gastrointestinal cancer where bleeding risk favors LMWH.

What is new in this edition

Introduction of clinical probability-adapted D-dimer cutoffs to improve exclusion of PE.
Greater emphasis on DOACs as preferred first-line anticoagulants over vitamin K antagonists
Clear-cut definition of hemodynamic instability to identify high-risk PE.
Expanded guidance on PE management in cancer patients and pregnancy

Practice points for students

Hemodynamic instability defines high-risk PE and mandates urgent reperfusion consideration, bypassing routine diagnostic algorithms.
sPESI and clinical gestalt help identify patients safe for early discharge or home treatment.
Right ventricular dysfunction plus elevated troponin identifies intermediate-high risk patients needing closer monitoring for deterioration.
D-dimer has high sensitivity but low specificity; a negative result in low-probability patients effectively rules out PE.
Not all intermediate-risk patients need thrombolysis; it is reserved for those who deteriorate hemodynamically.

Condition

Pulmonary embolism