Elsevier

Thrombosis Research

Volume 125, Issue 5, May 2010, Pages e202-e205
Thrombosis Research

Regular Article
Active search for chronic thromboembolic pulmonary hypertension does not appear indicated after acute pulmonary embolism

https://doi.org/10.1016/j.thromres.2009.12.016Get rights and content

Abstract

Introduction

Chronic thromboembolic pulmonary hypertension (CTEPH) is a life threatening but often, by pulmonary endarterectomy, curable disease. The incidence of CTEPH after an acute pulmonary embolism (PE) appears to be much higher than previously thought. Systematic follow-up of patients after PE might increase the number of diagnosed CTEPH patients.

Aim

To study whether, compared to current clinical practice, a systematic search for CTEPH in patients after acute PE would increase the number of patients diagnosed with symptomatic, potentially treatable CTEPH.

Methods

Consecutive patients with a prior diagnosis of acute PE were presented with a questionnaire, designed to establish the presence of either new or worsened dyspnea after the acute PE episode. If so, patients were evaluated for the presence of CTEPH.

Results

PE patients (n = 110; 56 ± 18 years) were included after a median follow-up of three years. Overall mortality was 34% (37 patients); 1 patient had died due to CTEPH.

In total 62 out of 69 questionnaires were returned; 23 patients reported new or worsened dyspnea related to the PE episode, and qualified for additional testing. In 2 patients, CTEPH was already diagnosed prior to this study. None of the remaining patients met the criteria for the diagnosis of CTEPH. The overall incidence of 2.7% (3/110; 95%CI 0.6-7.8%) is in agreement with earlier reported incidences.

Conclusion

Our findings do not point to a role for a systematic search and pro-active approach towards patients with a recent history of pulmonary embolism to increase the number of patients diagnosed with potentially treatable CTEPH.

Introduction

Chronic thromboembolic pulmonary hypertension (CTEPH) results from incomplete resolution of vascular obstruction caused by pulmonary thromboembolism [1], [2], [3] . CTEPH is a life threatening, but potentially surgically correctable cause of pulmonary hypertension which has been neglected in the past. If left untreated, a gradual hemodynamic and symptomatic decline can be observed in these patients which is considered to be caused by the development of a secondary small vessel arteriopathy [2], [4]. The incidence of CTEPH as a late complication of acute pulmonary embolism (PE) was originally believed to be very low (0.1%-0.5%) [2]; however, based on recent prospective studies the incidence is believed to be much higher (1%-4%) [5], [6], [7]. Untreated CTEPH has a dismal prognosis, with an overall 5 years survival of less than 50%, prognosis being directly related to the hemodynamic severity of disease at the moment of diagnosis [8]. With the introduction and refinement of pulmonary endarterectomy (PEA) the prognosis of surgically treatable CTEPH patients has improved dramatically, in particular when operated prior to reaching end stage disease [9]. Novel medical treatment may be of benefit in CTEPH patients suffering from distal, surgically inaccessible chronic thromboembolic disease [10], [11].

Patients with acute PE are traditionally treated with anticoagulants for 6 to 12 months, and current guidelines do not address the need for active follow-up in order to detect CTEPH [12] . It might be argued, however, that by applying the current guidelines potentially curable patients who develop CTEPH will be lost to follow-up. Moreover, patients may be diagnosed while already suffering from severe, incurable disease or may even be misdiagnosed given the relative unawareness with CTEPH by caregivers in general. In view of the high incidence of PE, on the other hand, systematic follow-up of all patients will have major implications for the management of patients after PE; moreover, also the cost-benefit ratio of a systematic follow-up should be taken into account. Whether a systematic follow-up will indeed increase the number of patients diagnosed with potentially treatable CTEPH, however, is as yet unknown.

Therefore, we studied, whether compared to current clinical practice, a systematic search for CTEPH in consecutive patients diagnosed in our hospital with acute PE would have increased the number of patients diagnosed with symptomatic, potentially treatable CTEPH.

Section snippets

Methods and materials

Between November 2002 and December 2004, a large diagnostic management study was performed that included patients with clinically suspected PE in twelve Dutch hospitals. That study, described in detail elsewhere, demonstrated that a diagnostic management strategy with a clinical decision rule, a D-dimer test and spiral CT, is safe in the work-up of patients with clinically suspected PE [13]. Patients were treated at diagnosis for 5-10 days with low molecular weight heparin intra-muscularly

Results

A total of 110 consecutive patients were eligible for this study based on proven acute PE determined by multi-slice computed tomography which took place within the study period of the previous multicentre study [13]. The baseline clinical characteristics are detailed in Table 1. The mean age was 56 years and 55% were female. Two third were outpatients and patients underwent diagnostic testing after a median duration of symptoms of three days. At the time of PE diagnosis, one quarter of the

Discussion

This study shows an overall incidence of CTEPH of 2.7% (3/110; 95%CI 0.6-7.8%), which is in agreement with previously reported incidences [5], [6]. All three patients had sought medical attention because of persistent complaints after their acute PE episode, and all were diagnosed with CTEPH before the study-questionnaire was sent. Based upon our observation, we suggest that it is not worthwhile to actively screen for CTEPH in patients with a documented episode of acute pulmonary embolism.

It is

Conflict of interest statement

Authors have no financial disclosure to make.

Role of the funding source

There were no sponsors involved in this study, therefore authors have no sources of funding to declare.

Acknowledgments

Authors have no acknowledgments to make.

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    1

    SS and NSG contributed equally to the preparation of the manuscript.

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