Regular ArticleActive search for chronic thromboembolic pulmonary hypertension does not appear indicated after acute pulmonary embolism
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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When and how to investigate chronic thrombo-embolic pulmonary hypertension after a pulmonary embolism?
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2020, Critical Care ClinicsCitation Excerpt :Although there are no defined diagnostic criteria, post-PE syndrome is diagnosed in patients with persistent dyspnea and exercise intolerance who may or may not have residual evidence of perfusion defect on V/Q scan with documented exercise limitation on cardiopulmonary exercise testing as evidenced by a percent predicted Vo2 peak of less than 80%.37,40 Although the incidence of CTEPH after PE is relatively low, the detection of CTEPH is of paramount importance to the well-being of these patients because CTEPH is a severe, progressive, and life-threatening disease process that has a cure if identified appropriately.10,41 The cure for CTEPH is pulmonary endarterectomy; however, 20% to 40% of patients are not surgical candidates at the time of diagnosis.35,36,42,43
Chronic Thromboembolic Pulmonary Hypertension
2018, Heart Failure ClinicsCitation Excerpt :One study of 227 patients with PH found that VQ scan had a sensitivity of 96%-97.4% for CTEPH compared with 51% for CTPA.49 More recent studies, including a systematic review and meta-analysis, have shown improved sensitivity for CTPA in diagnosing CTEPH,50–52 however CTPA remains less sensitive for detecting distal segmental and subsegmental disease.9 Despite these limitations, CTPA can provide useful information in the diagnosis and evaluation of CTEPH.
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2016, American Journal of MedicineCitation Excerpt :The true incidence of chronic thromboembolic pulmonary hypertension after a pulmonary embolism is not known. In one prospective study, the incidence of chronic thromboembolic pulmonary hypertension was estimated to be 2.7% at 1 year in 110 acute pulmonary embolism patients who were experiencing persistent dyspnea.26 In another single-center study with 223 patients with first episode of symptomatic pulmonary embolism, the cumulative incidence of symptomatic chronic thromboembolic pulmonary hypertension was found to be 1.0% at 6 months, 3.1% at 1 year, and 3.8% at 2 years.3
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SS and NSG contributed equally to the preparation of the manuscript.