A symptom-related monitoring program following pulmonary embolism for the early detection of CTEPH: a prospective observational registry study

Abstract

BackgroundChronic thromboembolic pulmonary hypertension (CTEPH) is a long-term complication following an acute pulmonary embolism (PE). It is frequently diagnosed at advanced stages which is concerning as delayed treatment has important implications for favourable clinical outcome. Performing a follow-up examination of patients diagnosed with acute PE regardless of persisting symptoms and using all available technical procedures would be both cost-intensive and possibly ineffective. Focusing diagnostic procedures therefore on only symptomatic patients may be a practical approach for detecting relevant CTEPH.This study aimed to evaluate if a follow-up program for patients with acute PE based on telephone monitoring of symptoms and further examination of only symptomatic patients could detect CTEPH. In addition, we investigated the role of cardiopulmonary exercise testing (CPET) as a diagnostic tool.MethodsIn a prospective cohort study all consecutive patients with newly diagnosed PE (n=170, 76 males, 94 females within 26 months) were recruited according to the inclusion and exclusion criteria. Patients were contacted via telephone and asked to answer standardized questions relating to symptoms. At the time of the final analysis 130 patients had been contacted. Symptomatic patients underwent a structured evaluation with echocardiography, CPET and complete work-up for CTEPH.Results37.7%, 25.5% and 29.3% of the patients reported symptoms after three, six, and twelve months respectively. Subsequent clinical evaluation of these symptomatic patients saw 20.4%, 11.5% and 18.8% of patients at the respective three, six and twelve months time points having an echocardiography suggesting pulmonary hypertension (PH). CTEPH with pathological imaging and a mean pulmonary artery pressure (mPAP) ≥ 25 mm Hg at rest was confirmed in eight subjects. Three subjects with mismatch perfusion defects showed an exercise induced increase of PAP without increasing pulmonary artery occlusion pressure (PAOP). Two subjects with pulmonary hypertension at rest and one with an exercise induced increase of mPAP with normal PAOP showed perfusion defects without echocardiographic signs of PH but a suspicious CPET.ConclusionA follow-up program based on telephone monitoring of symptoms and further structured evaluation of symptomatic subjects can detect patients with CTEPH. CPET may serve as a complementary diagnostic tool.

Quality of life and functional limitations after pulmonary embolism and its prognostic relevance

“…Furthermore, every fourth patient was diagnosed with RV dysfunction on TTE at 6‐month follow‐up. In comparison, RV dysfunction on TTE was observed by Stevinson et al in 16.5% of 109 previously healthy (free of cardiopulmonary diseases or other disabling processes) patients 6 months after a first‐time PE, by Golpe et al in 17.8% of 95 initially hemodynamic stable PE patients after 6 months, by Samaranayake et al in 14.3% of 42 patients with “submassive” PE after a mean follow‐up of 7.6 months, and by Held et al in 11.5% of 130 symptomatic patients 6 months after newly diagnosed PE. The higher prevalence in our study might be related to different definitions of RV dysfunction in the respective studies.…”

Functional Characterization of Patients with Chronic Thromboembolic Disease

“…This is of particular concern, as persisting dyspnea after pulmonary embolism is not a rare finding [12]. As echocardiographic parameters were normal in the CTED patients, but the cardiopulmonary exercise test showed objective limitations, this tool may help to distinguish if symptoms and functional impairment are the consequence of comorbidities or a complication of incomplete thrombus resolution [12]. …”

“…Recently, successful PEA in patients with CTED has been described [14]. Despite normal PAP at rest, exercise intolerance has been reported in these patients [7,11,12,14]. To date, drivers and limiting factors of exercise intolerance in patients with CTED are not adequately characterized.…”

“…Chronic thromboembolic vascular disease (CTED) has been described clinically as pulmonary vascular obstruction with an mPAP at rest of <25 mm Hg [7,11,12,13,14]. Recently, successful PEA in patients with CTED has been described [14].…”

“…It has recently been shown that cardiopulmonary exercise testing (CPET) is able to detect a functional pattern indicating disturbed pulmonary perfusion in subjects with apparent CTEPH [11,12]. It is not yet known if CPET can detect similar patterns in patients with CTED.…”