Abstract
ObjectivesCloser reading of computed tomography pulmonary angiography (CTPA) scans of patients presenting with acute pulmonary embolism (PE) may identify those at high risk of developing chronic thromboembolic pulmonary hypertension (CTEPH). We aimed to validate the predictive value of six radiological predictors that were previously proposed.MethodsThree hundred forty-one patients with acute PE were prospectively followed for development of CTEPH in six European hospitals. Index CTPAs were analysed post hoc by expert chest radiologists blinded to the final diagnosis. The accuracy of the predictors using a predefined threshold for ‘high risk’ (≥ 3 predictors) and the expert overall judgment on the presence of CTEPH were assessed.ResultsCTEPH was confirmed in nine patients (2.6%) during 2-year follow-up. Any sign of chronic thrombi was already present in 74/341 patients (22%) on the index CTPA, which was associated with CTEPH (OR 7.8, 95%CI 1.9–32); 37 patients (11%) had ≥ 3 of 6 radiological predictors, of whom 4 (11%) were diagnosed with CTEPH (sensitivity 44%, 95%CI 14–79; specificity 90%, 95%CI 86–93). Expert judgment raised suspicion of CTEPH in 27 patients, which was confirmed in 8 (30%; sensitivity 89%, 95%CI 52–100; specificity 94%, 95%CI 91–97).ConclusionsThe presence of ≥ 3 of 6 predefined radiological predictors was highly specific for a future CTEPH diagnosis, comparable to overall expert judgment, while the latter was associated with higher sensitivity. Dedicated CTPA reading for signs of CTEPH may therefore help in early detection of CTEPH after PE, although in our cohort this strategy would not have detected all cases.Key Points• Three expert chest radiologists re-assessed CTPA scans performed at the moment of acute pulmonary embolism diagnosis and observed a high prevalence of chronic thrombi and signs of pulmonary hypertension.• On these index scans, the presence of ≥ 3 of 6 predefined radiological predictors was highly specific for a future diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH), comparable to overall expert judgment.• Dedicated CTPA reading for signs of CTEPH may help in early detection of CTEPH after acute pulmonary embolism.
Highlights
The potentially life-threatening disease chronic thromboembolic pulmonary hypertension (CTEPH) is preceded by a diagnosis of acute pulmonary embolism (PE) in 75% [1, 2]
There were no clear sex-related differences. In this practice-based cohort of PE patients, a high prevalence of chronic thrombi (22%) and signs of PH (30%) on index computed tomography pulmonary angiography (CTPA) were observed by expert chest radiologists and were both associated with a future CTEPH diagnosis
Overall expert judgment led to suspicion of CTEPH in 8 of 9 CTEPH cases (89%)
Summary
The potentially life-threatening disease chronic thromboembolic pulmonary hypertension (CTEPH) is preceded by a diagnosis of acute pulmonary embolism (PE) in 75% [1, 2]. In studies evaluating computed tomography pulmonary angiography (CTPA) and echocardiography at the time of PE diagnosis, concomitant signs of CTEPH have frequently been described, which may point to the presence of acuteon-chronic thromboembolic disease in these patients [5,6,7,8,9]. Such findings may even indicate diagnostic misclassification since a first presentation of CTEPH may mimic an acute episode of PE. Vigilance on these early signs may play an important role in earlier identification of patients with (high risk of) CTEPH, positively affecting patients’ prognosis
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