Pulmonary Embolism Survivors Research Articles

Cost-effectiveness of follow-up algorithms for chronic thromboembolic pulmonary hypertension in pulmonary embolism survivors

IntroductionAchieving an early diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH) in pulmonary embolism (PE) survivors results in better quality of life and survival. Importantly, dedicated follow-up strategies to achieve an earlier CTEPH diagnosis involve costs that were not explicitly incorporated in the models assessing their cost-effectiveness. We performed an economic evaluation of 11 distinct PE follow-up algorithms to determine which should be preferred.Materials and methods11 different PE follow-up algorithms and 1 hypothetical scenario without a dedicated CTEPH follow-up algorithm were included in a Markov model. Diagnostic accuracy of consecutive tests was estimated from patient-level data of the InShape II study (n=424). The life-long costs per CTEPH patient were compared and related to Quality-Adjusted Life-Years (QALYs) for each scenario.ResultsCompared to not performing dedicated follow-up, the integrated follow-up algorithms are associated with an estimated increase of 0.89–1.2 QALY against an incremental cost-effectiveness ratio (ICER) of 25 700–46 300 € per QALY per CTEPH patient. When comparing different algorithms with each other, the maximum differences were 0.27 QALY and €27 600. The most cost-effective algorithm was the InShape IV algorithm, with an ICER of €26 700 per QALY compared to the next best algorithm.ConclusionSubjecting all PE survivors to any of the currently established dedicated follow-up algorithm to detect CTEPH is cost-effective and preferred above not performing a dedicated follow-up, evaluated against the Dutch acceptability threshold of €50 000 per QALY. The model can be used to identify the locally preferred algorithm from an economical point-of-view within local logistical possibilities.

Optimisation of detecting chronic thromboembolic pulmonary hypertension in acute pulmonary embolism survivors: the InShape IV study.

Chronic thromboembolic pulmonary hypertension (CTEPH) is often diagnosed late in acute pulmonary embolism survivors: more efficient testing to expedite diagnosis may considerably improve patient outcomes. The InShape II algorithm safely rules out CTEPH (failure rate 0.29%) while requiring echocardiography in only 19% of patients but may be improved by adding detailed reading of the computed tomography pulmonary angiography diagnosing the index pulmonary embolism. We evaluated 12 new algorithms, incorporating the CTEPH prediction score, ECG reading, N‑terminal pro-brain natriuretic peptide levels and dedicated computed tomography pulmonary angiography reading, in the international InShape II cohort (n=341) and part of the German FOCUS cohort (n=171). Evaluation criteria included failure rate, defined as the incidence of confirmed CTEPH in pulmonary embolism patients in whom echocardiography was deemed unnecessary by the algorithm, and the overall net reclassification index compared to the InShape II algorithm. The algorithm starting with computed tomography pulmonary angiography reading of the index pulmonary embolism for six signs of CTEPH, followed by ECG/N-terminal pro-brain natriuretic peptide level assessment and echocardiography resulted in the most beneficial change compared to InShape II, with a need for echocardiography in 20% (+5%), a failure rate of 0% and a net reclassification index of +3.5%, reflecting improved performance over the InShape II algorithm. In the FOCUS cohort, this approach lowered echocardiography need to 24% (-6%) and missed no CTEPH cases, with a net reclassification index of +6.0%. Dedicated computed tomography pulmonary angiography reading of the index pulmonary embolism improved the performance of the InShape II algorithm and may improve the selection of pulmonary embolism survivors who require echocardiography to rule out CTEPH.

Diagnosis of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism: data from a practice-based longitudinal cohort

BackgroundA large prospective multicenter cohort study with systematic follow-up recently reported a 2.3% 2-year cumulative incidence of chronic thromboembolic pulmonary hypertension (CTEPH) after acute pulmonary embolism (PE). ObjectivesThe present investigation aimed to determine the reported prevalence and incidence of CTEPH diagnosis after acute PE in real-world practice over a 12-year period. MethodsThis study was based on nationwide ambulatory billing claims and drug prescription data of all residents with public health insurance in Germany from 2010 to 2021. ResultsA total of 573 972 patients with acute PE (median age, 71 years; 57.4% women) were identified between 2010 and 2021. Prevalence of CTEPH among patients with history of PE increased during the period from 0.4% in 2010 to 0.9% in 2021. CTEPH was diagnosed in 2556 patients after acute PE, with most (17.6%) diagnoses reported within the first 3 months after the index PE event. The cumulative incidence rate after 3 months (first quarter) was calculated at 0.08% and after the first 2 years (eighth quarter) at 0.36%; it was 0.75% over the entire (90-month) follow-up period. Patients with CTEPH diagnosis during follow-up more often had right ventricular dysfunction at the index acute PE (14.9% vs 8.3%; P < .001). ConclusionThe low CTEPH incidence rate after acute PE in the present analysis suggests low awareness of CTEPH. It further suggests a lack of systematic follow-up protocols for acute PE survivors in the real world. Improved implementation of existing recommendations on follow-up strategies after PE is warranted.

Symptom-related screening programme for early detection of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism: the SYSPPE study

BackgroundChronic thromboembolic pulmonary hypertension (CTEPH) is the most severe long-term complication of acute pulmonary embolism (PE). We aimed to evaluate the impact of a symptom screening programme to detect CTEPH...

Abstract 15055: Annual Healthcare Costs After Acute Pulmonary Embolism: Results From a Prospective Multicenter Cohort Study

Introduction: Analysis of administrative data has helped to determine hospitalization costs related to acute pulmonary embolism (PE) in several countries, but estimating long-term costs of patient care after discharge is a more challenging task. Aims: To determine the direct annual costs related to the care of PE survivors based on data from a longitudinal cohort study performed at 17 German large-volume hospitals. Methods: The Follow-up of Acute Pulmonary Embolism (FOCUS) study enrolled unselected patients with acute PE. In addition to a structured ambulatory follow-up (FU) program (Figure) , we prospectively recorded duration and type of anticoagulation and the main and accompanying causes of all rehospitalizations during the first year of FU. Annual per-patient costs of post-PE care were calculated in 2022 euro (є) and converted to US$ adjusting for purchase parity power. Results: A total of 1,017 patients (45% women; median age 64 years [IQR, 52-74]) were included. Average costs of scheduled ambulatory FU visits and tests were estimated at є136.37 ($189.40) per patient; costs of oral anticoagulation after hospital discharge for the index event amounted to є827.72 ($1,149.61). The annual all-cause hospitalization rate was 31.96% (95% CI, 28.0-35.91%); the Table shows the primary indications and mean hospital costs (overall, and per indication). Of the є1,104.48 ($1,534.0) average rehospitalization costs per patient, 8.9% were related to recurrent thrombosis/PE or bleeding. Conclusions: Our results, derived from the population of a prospective multicenter study, help to dissect the direct annual costs of chronic post-PE care and may inform ambulatory care programs.

Long-Term Outcomes of Pulmonary Embolism Requiring Intensive Care Unit (ICU) Admission

Introduction:Pulmonary embolism (PE) requiring intensive care unit (ICU) admission is associated with high in-hospital mortality, however data on long-term survival outcomes and associated contributors remains limited. We sought to further investigate this using a large binational dataset. Methods:Retrospective cohort study of adults aged &amp;gt;16 years admitted to an Australian or New Zealand (NZ) ICU between January 1, 2018 and December 31, 2022 with a primary admission diagnosis of PE using the Australian and NZ Intensive Care Society (ANZICS) Adult Patient Database (APD). Data were available on baseline characteristics - specifically age, gender, admission co-morbidities (active malignancy, chronic cardiovascular, respiratory, renal and liver disease and illness severity as per the Acute Physiology and Chronic Health Evaluation (APACHE) III scoring system. The need for ICU-specific supports (vasopressors or inotropes, invasive and non-invasive ventilation [NIV], extracorporeal membrane oxygenation [ECMO]) was also recorded. All-cause mortality from 30 days to 48 months after ICU admission was obtained. Descriptive analyses, Kaplan-Meier and Cox proportional hazards models were used to describe survival during this time period. Ethical approval was granted by the Alfred Hospital Human Research Ethics Committee (HREC). Results:6447 patients with PE who had been admitted to 193 ICUs across Australia and NZ were identified, representing 9136 patient-years of follow-up. Median age was 66.5 years (interquartile range [IQR], 53-75). 24.5% were admitted to a rural or regional ICU. Median ICU length of stay was 46.6 hours (IQR, 27-79). Median APACHE III score was 42 (IQR, 31-56). Admission co-morbidities included active malignancy (8.1%), chronic respiratory (7.0%), renal (1.4%) and liver (0.4%) disease. Systolic blood pressure was was ≤90 mmHg at time of ICU admission in 1482 patients (23.9% of those in whom this data was available). Vasopressors or inotropes were required in 986 patients (17.6%), NIV was used in 713 (12.6%), invasive ventilation in 453 (8.0%) and 24 patients (0.43%) received ECMO. The mean duration of invasive ventilation where this was required was 14.9 hours. Kaplan-Meier survival analysis is shown in Figure 1. Overall survival was 92.3% at 30 days (95% CI, 91.6-93.0%), 87.5% at 6 months (95% CI, 86.5-88.3%), 84.4% at 12 months (95% CI 83.4%-85.4%) and 73.0% at 48 months (95% CI, 71.0-74.9%). Active malignancy was the strongest independent predictor of mortality (hazard ratio [HR] 3.3, 95% CI 2.8-4.0). Other independent predictors were chronic liver (HR 2.8), renal (HR 1.7) and respiratory (HR 1.6) disease, immunosuppressive therapy (HR 1.5), and the need for NIV (HR 1.4) or vasopressor and inotropic support (HR 1.3). No significant difference in mortality was observed between rural/regional and tertiary/metropolitan ICUs, however improved survival was observed in patients admitted to Australian ICUs (n = 6032) compared to those in NZ (n = 415) (HR 0.5 [95% CI 0.4-0.8]). Conclusions:Nearly three-quarters of patients admitted to ICU due to PE remain alive 2 years later. The largest risk factor for late mortality is malignancy, along with other chronic diseases, which is similar to previous studies reporting long-term follow-up of PE survivors outside ICU, however patients who need advanced life supports (NIV, ECMO) were also at greater risk. Limitations of this study include retrospective design, broad heterogeneity in admission criteria across different ICUs due to variation in resources across both countries and lack of data therapies such as intravenous thrombolysis and anticoagulation. Further work is needed to understand if changes to acute management of at-risk patients might improve long-term survival outcomes.

OC 01.4 Prevalence of Chronic Thromboembolic Pulmonary Hypertension and Evaluation of Thrombus Resolution in COVID-19-Associated Pulmonary Embolism Survivors

OC 01.4 Prevalence of Chronic Thromboembolic Pulmonary Hypertension and Evaluation of Thrombus Resolution in COVID-19-Associated Pulmonary Embolism Survivors

The Effects of Exercise Training in Patients With Persistent Dyspnea Following Pulmonary Embolism: A Randomized Controlled Trial

Persistent dyspnea, functional limitations, and reduced quality of life (QoL) are common following pulmonary embolism (PE). Rehabilitation is a potential treatment option, but the scientific evidence is limited. Does an exercise-based rehabilitation program improve exercise capacity in PE survivors with persistent dyspnea? This randomized controlled trial was conducted at two hospitals. Patients with persistent dyspnea following PE diagnosed 6 to 72months earlier, without cardiopulmonary comorbidities, were randomized 1:1 to either the rehabilitation or the control group. The rehabilitation program consisted of two weekly sessions of physical exercise for 8weeks and one educational session. The control group received usual care. The primary end point was the difference in Incremental Shuttle Walk Test between groups at follow-up. Secondary end points included differences in the Endurance Shuttle Walk Test (ESWT), QoL (EQ-5D and Pulmonary Embolism-QoL questionnaires) and dyspnea (Shortness of Breath questionnaire). A total of 211 subjects were included: 108 (51%) were randomized to the rehabilitation group and 103 (49%) to the control group. At follow-up, participants allocated to the rehabilitation group performed better on the ISWT compared with the control group (mean difference, 53.0 m; 95%CI, 17.7-88.3; P= .0035). The rehabilitation group reported better scores on the Pulmonary Embolism-QoL questionnaire (mean difference, -4%; 95%CI, -0.09 to 0.00; P= .041) at follow-up, but there were no differences in generic QoL, dyspnea scores, or the ESWT. No adverse events occurred during the intervention. In patients with persistent dyspnea following PE, those who underwent rehabilitation had better exercise capacity at follow-up than those who received usual care. Rehabilitation should be considered in patients with persistent dyspnea following PE. Further research is needed, however, to assess the optimal patient selection, timing, mode, and duration of rehabilitation. ClinicalTrials.gov; No.: NCT03405480; URL: www. gov.

Psychological distress in pulmonary embolism survivors in a pulmonary embolism response team clinic: Protocol for a prospective observational study

BackgroundPulmonary embolism (PE) is a leading cause of cardiovascular death. Psychological distress in PE is understudied and underrecognized. ObjectivesThe primary aim of this proposed protocol was to describe the incidence of psychological distress symptoms (anxiety, depression, posttraumatic stress, and fear of recurrence) in the survivors of PE after discharge from hospitalization. The secondary aim was to assess the influence of acute disease, etiology, and treatment of PE on psychological distress. MethodsThis is a prospective observational cohort study in a large tertiary care referral center. The participants are adult patients presenting to the hospital with PE fulfilling objective pulmonary embolism response team (PERT) activation criteria. After discharge, patients complete a series of validated measures of psychological distress (anxiety, depression, posttraumatic stress, and fear of recurrence) and quality of life at follow-ups approximately 1, 3, 6, and 12 months after diagnosis and treatment of their PE. Factors influencing each type of distress are evaluated. ConclusionThis protocol aims to identify the unmet needs of patients experiencing psychological distress following PE. It will describe anxiety, depression, fear of recurrence, and posttraumatic symptoms in PE survivors during the first year of outpatient follow-up in a PERT clinic.

Electrocardiogram, Echocardiogram and NT-proBNP in Screening for Thromboembolism Pulmonary Hypertension in Patients after Pulmonary Embolism.

Background: The annual mortality of patients with untreated chronic thromboembolism pulmonary hypertension (CTEPH) is approximately 50% unless a timely diagnosis is followed by adequate treatment. In pulmonary embolism (PE) survivors with functional limitation, the diagnostic work-up starts with echocardiography. It is followed by lung scintigraphy and right heart catheterization. However, noninvasive tests providing diagnostic clues to CTEPH, or ascertaining this diagnosis as very unlikely, would be extremely useful since the majority of post PE functional limitations are caused by deconditioning. Methods: Patients after acute PE underwent a structured clinical evaluation with electrocardiogram, routine laboratory tests including NT-proBNP and echocardiography. The aim of this study was to verify whether the parameters from echocardiographic or perhaps electrocardiographic examination and NT-proBNP concentration best determine the risk of CTEPH. Results: Out of the total number of patients (n = 261, male n = 123) after PE who were included in the study, in the group of 155 patients (59.4%) with reported functional impairment, 13 patients (8.4%) had CTEPH and 7 PE survivors had chronic thromboembolic pulmonary disease (CTEPD) (4.5%). Echo parameters differed significantly between CTEPH/CTEPD cases and other symptomatic PE survivors. Patients with CTEPH/CTEPD also had higher levels of NT-proBNP (p = 0.022) but concentration of NT-proBNP above 125 pg/mL did not differentiate patients with CTEPH/CTEPD (p > 0.05). Additionally, the proportion of patients with right bundle brunch block registered in ECG was higher in the CTEPH/CTED group (23.5% vs. 5.8%, p = 0.034) but there were no differences between the other ECG characteristics of right ventricle overload. Conclusions: Screening for CTEPH/CTEPD should be performed in patients with reduced exercise tolerance compared to the pre PE period. It is not effective in asymptomatic PE survivors. Patients with CTEPH/CTED predominantly had abnormalities indicating chronic thromboembolism in the echocardiographic assessment. NT-proBNP and electrocardiographic characteristics of right ventricle overload proved to be insufficient in predicting CTEPH/CTEPD development.

Effects of pulmonary rehabilitation on cardiac magnetic resonance parameters in patients with persistent dyspnea following pulmonary embolism.

BackgroundPersistent dyspnea and reduced exercise capacity is common in pulmonary embolism (PE) survivors. Although improved right ventricular function after pulmonary rehabilitation has been demonstrated in chronic thromboembolic pulmonary hypertension, it is still unknown whether a similar effect also occurs in other patients with dyspnea after pulmonary embolism.PurposeThe aim of this study was to explore potential effects of a pulmonary rehabilitation program on cardiac structure and function as assessed with cardiac magnetic resonance (CMR).Material and methodsTwenty-six PE survivors with persistent dyspnea were included. Right and left ventricular assessment with CMR was performed before and after an eight-week pulmonary rehabilitation program.ResultsDyspnea as measured by the Shortness of Breath Questionnaire improved significantly after rehabilitation: 15 (IQR: 7–31) versus 8 (IQR: 3–17). Absolute right ventricular global longitudinal strain by CMR was reduced from 19% to 18% (95% CI of difference: 0–3 percent points), and absolute RV lateral strain from 26% to 24% (95% CI of difference: 1–4 percent points). Right ventricular mass was reduced after rehabilitation from 49 g to 44 g (95% CI of difference: 2–8 g).ConclusionAlthough there was a substantial improvement in dyspnea after rehabilitation, we found only a minor reduction in absolute right ventricular longitudinal strain and right ventricular mass. No other CMR parameter changed. We therefore suggest that rehabilitation effect of in this patient group was not primarily mediated by cardiac adaptions.

A Novel Doppler TRPG/AcT Index Improves Echocardiographic Diagnosis of Pulmonary Hypertension after Pulmonary Embolism.

Background: We hypothesized that a Doppler index, the ratio of tricuspid regurgitation peak gradient (TRPG) to pulmonary ejection acceleration time (AcT), improves the assessment of the echocardiographic probability of pulmonary hypertension in the identification of CTEPH and chronic thromboembolic pulmonary disease (CTED) in symptomatic patients after PE. Doppler echocardiography is recommended as the initial imaging tool for the diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH) after acute pulmonary embolism (PE). Methods: We analyzed the data from 845 consecutive PE (468 women; 61 ± 18 years) survivors who completed at least 6 months of anticoagulation therapy. Here, 555 patients (325 women; 66 ± 16 years) reporting functional impairment (FI) underwent transthoracic echocardiography. We included 506 patients (297 women; age 63.4 ± 16.6 years) in whom both AcT and TRPG were available into the current study. The presence of a minimum of intermediate echocardiographic probability of PH necessitated the diagnosis of CTEPH. Results: Echocardiography revealed a high echocardiographic probability of PH in 69 (13.6%) and intermediate echocardiographic probability in 109 (21.5%) patients. CTEPH was diagnosed in 35 (6.9%) patients and CTED in 22 (4.3%) patients. TRPG/AcT was significantly higher in the combined CTEPH + CTED group than in those with other causes of FI (0.412 (0.100–2.197) vs. 0.208 (0.026–0.115), p < 0.001), and the area under the receiver operating characteristic curve of the TRPG/AcT for CTEPH + CTED was 0.804 (95% confidence interval (CI): 0.731–0.876). Importantly, multiple logistic regression showed that TRPG/AcT is a significant predictor of CTEPH + CTED after considering echocardiographic probability (odds ratio = 1.51, 95% CI: 1.25–1.91, p < 0.001). Conditional inference trees analysis revealed that TRPG/AcT > 0.595 identified patients with CTEPH or CTED with a positive predictive value of 78.6% and negative predictive value of 92.7%. Conclusions: A Doppler index TRPG/AcT improves the assessment of symptomatic PE survivors. TRPG/AcT > 0.6 indicates a high probability of CTEPH or CTED, whereas TRPG/AcT < 0.6 allows for the safe exclusion of CTEPH + CTED in patients with a low echocardiographic probability of PH.

Frequency of Thrombotic Risk Factors in Patients with Chronic Thromboembolic Pulmonary Hypertension and Acute Pulmonary Embolism: A Case-Control Study.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a serious complication of acute pulmonary embolism (PE) which remains underdiagnosed. A better understanding of risk factors for CTEPH would improve our ability to predict which PE survivors are at risk. Several medical conditions—including malignancy, splenectomy, thyroid hormone supplementation, the presence of an intravascular device, inflammatory bowel disease, osteomyelitis, and non-O blood group—have been associated with increased risk of CTEPH, primarily in studies comparing patients with CTEPH to individuals with non-thrombotic conditions. Because many of these conditions increase thrombosis risk, it remains unclear whether their association with CTEPH reflects a general effect on thrombosis risk, or a specific effect on the risk of developing CTEPH as an outcome of thrombosis. We performed a case-control study comparing the frequencies of these conditions in patients with CTEPH versus patients with acute PE who did not develop CTEPH. The conditions studied were equally frequent in the CTEPH and PE cohorts, although there was a trend towards an increased frequency of splenectomy and non-O blood group among the CTEPH cohort. Thus, other than the possible exceptions of splenectomy and non-O blood group, the investigated medical conditions do not appear likely to increase the risk of CTEPH as an outcome of acute PE, and thus are unlikely to be useful in predicting CTEPH risk among PE survivors.

Non-invasive early exclusion of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism: the InShape II study

BackgroundThe current diagnostic delay of chronic thromboembolic pulmonary hypertension (CTEPH) after pulmonary embolism (PE) is unacceptably long, causing loss of quality-adjusted life years and excess mortality. Validated screening strategies for...

Determinants and Management of the Post-Pulmonary Embolism Syndrome.

Acute pulmonary embolism (PE) is not only a serious and potentially life-threatening disease in the acute phase, in recent years it has become evident that it may also have a major impact on a patient's daily life in the long run. Persistent dyspnea and impaired functional status are common, occurring in up to 50% of PE survivors, and have been termed the post-PE syndrome (PPES). Chronic thromboembolic pulmonary hypertension is the most feared cause of post-PE dyspnea. When pulmonary hypertension is ruled out, cardiopulmonary exercise testing can play a central role in investigating the potential causes of persistent symptoms, including chronic thromboembolic pulmonary disease or other cardiopulmonary conditions. Alternatively, it is important to realize that post-PE cardiac impairment or post-PE functional limitations, including deconditioning, are present in a large proportion of patients. Health-related quality of life is strongly influenced by PPES, which emphasizes the importance of persistent limitations after an episode of acute PE. In this review, physiological determinants and the diagnostic management of persistent dyspnea after acute PE are elucidated.

Why, Whom, and How to Screen for Chronic Thromboembolic Pulmonary Hypertension after Acute Pulmonary Embolism

Chronic thromboembolic pulmonary hypertension (CTEPH) is considered a long-term complication of acute pulmonary embolism (PE). Diagnosing CTEPH is challenging, as demonstrated by a considerable diagnostic delay exceeding 1 year, which has a negative impact on the patient's prognosis. Dedicated screening CTEPH strategies in PE survivors could potentially help diagnosing CTEPH earlier, although the optimal strategy is unknown. Recently published updated principles for screening in medicine outline the conditions that must be considered before implementation of a population-based screening program. Following these extensive principles, we discuss the pros and cons of CTEPH screening, touching on the epidemiology of CTEPH, the prognosis of CTEPH in the perspective of emerging treatment possibilities, and potentially useful tests and test combinations for screening. This review provides a modern perspective on CTEPH screening including a novel approach using a simple noninvasive algorithm of sequential diagnostic tests applied to all PE survivors.

Accurate and efficient non-invasive strategy for early identification of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism (InShape II study)

Abstract Background The current diagnostic delay of chronic thromboembolic pulmonary hypertension (CTEPH) after acute pulmonary embolism (PE) is unacceptably long exceeding 1 year, causing loss of quality-adjusted life years and excess mortality. Validated screening strategies to diagnose CTEPH earlier are lacking. Importantly, performing echocardiography in all PE patients for this purpose has a low diagnostic yield, is associated with overdiagnosis and is not cost-effective. Moreover, expertise in performing high-quality PH-dedicated echocardiograms may not be available outside expert centers. Aim To validate a simple screening strategy aimed at identifying CTEPH early in the course after acute PE, avoiding echocardiography if possible (Figure 1). Methods In this prospective, international, multicenter management study, consecutive PE survivors were managed according to the predefined algorithm starting three months after acute PE. All were followed for a total period of two years. The study protocol was approved by all local IRBs and all patients provided informed consent. Results 424 patients were included across three European countries (Table 1). Following the algorithm, CTEPH was considered excluded in 343 (81%) patients based on clinical pre-test probability assessment by the “CTEPH prediction score”, evaluation of symptoms and application of the “CTEPH rule-out criteria” (Figure 1); only 19% was subjected to echocardiography. Only 1 of 343 patients managed without echocardiography was diagnosed with CTEPH, 10 months after initial PE, for a failure rate of 0.29% (95% CI 0–1.6%). Overall, 13 patients were diagnosed with CTEPH (incidence 3.1%), of whom 10 within 4 months after PE diagnosis. Conclusions The algorithm accurately ruled out CTEPH and avoided echocardiography in 81% of patients. The vast majority of CTEPH cases were identified early in the course of acute PE which is a considerable improvement compared to current clinical practice with an economic use of healthcare resources. Figure 1. Study flowchart Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): This study was supported by unrestricted grants from Bayer/Merck Sharp &amp; Dohme (MSD) and Actelion Pharmaceuticals Ltd. F.A. Klok and G.J.A.M. Boon were supported by the Dutch Heart Foundation (2017T064).

Clinical features and diagnosis of new malignancy in patients with acute pulmonary embolism and without a history of cancer.

Pulmonary embolism (PE) is frequently associated with cancer. This study aimed to assess patients with acute PE and identify diagnostic predictors of new cancer after 1 year of follow-up. One hundred and twenty-one patients with PE were enrolled consecutively from the emergency department of a single medical center in Taiwan. Data from computed tomography angiography, echocardiogram, electrocardiogram and for baseline comorbidities, clinical presentation, and laboratory parameters were recorded. The surviving discharged patients without a cancer diagnosis were followed-up for 1 year, and new malignancies were recorded. Of 121 patients with acute PE, 44 (36%) had an underlying cancer history (cancer group), and 77 (64%) did not (noncancer group). Baseline demographic characteristics, comorbidities, clinical symptoms, biochemical parameters, echocardiogram data, and electrocardiogram data of the two groups were similar except for a higher hospital mortality rate (56.8% vs 9.1%; p < 0.001), lower body mass index (22.6 ± 4.1 vs 25.5 ± 4.9; p =0.02), higher systolic blood pressure (139.7 ± 33.7 vs 125.4 ± 24.1; p = 0.02), lower low-density lipoprotein level (67.4 ± 38.3 vs 90.4 ± 33.8; p = 0.04), lower creatinine kinase (CK; 43.0 ± 43.0 vs 83.5 ± 83.1; p = 0.01), higher myocardial band (MB) form of CK ratio (0.2 ± 0.2 vs 0.1 ± 0.1; p < 0.01), higher partial pressure of arterial oxygen (122.81 ± 81.2 vs 90.2 ± 59.4; p = 0.03), and less presentation of chest pain (15.9% vs 40.3%; p = 0.01) in the cancer group. Kaplan-Meier curve analysis revealed that the 30-day survival rate was higher in the noncancer group than in the cancer group (log-rank p = 0.04). After 1 year of follow-up, 6 of 59 (10.17%) initial non-cancer-related PE survivors were diagnosed with malignancies. After multivariate analysis, only the initial CK-MB level was associated with a diagnosis of new cancer (hazard ratio [HR]: 1.37, 95% confidence interval [CI]: 1.029-1.811; p = 0.03). This study suggests that the CK-MB level is associated with future malignancy in patients with PE. Patients with cancer-related PE had a worse 30-day survival rate.

“The post-pulmonary syndrome - results of echocardiographic driven follow up after acute pulmonary embolism”

IntroductionThe concept of post Pulmonary Embolism syndrome includes various combinations of functional, haemodynamic or imaging abnormalities in patients after pulmonary embolism (PE). Although residual obstruction of pulmonary vascular bed is suggested to be a major cause of post Pulmonary Embolism syndrome (post-PE syndrome) other cardiopulmonary abnormalities can be responsible for functional impairment. Therefore, we analyzed the frequency of post-PE syndrome and its potential causes. Material and methodsWe report data of consecutive 845 PE survivors (468 F, aged 62 ± 18 yrs) who were anticoagulated, and followed for at least 6 months. All symptomatic subjects at follow up underwent diagnostic workup. Results35% (290/845) of PE survivors recovered functionally, while 65% patients reported a decreased exercise tolerance compatible with post-PE syndrome. One hundred and five symptomatic cases were lost to follow up. After diagnostic workup, chronic thromboembolic pulmonary hypertension (CTEPH) was diagnosed in 38 of 450 (8.4%) symptomatic subjects and chronic thromboembolic pulmonary disease (CTED) was diagnosed in 15/450 (3.3%) of them. Chronic heart failure with reduced ejection fraction (EF) was found in 6.9% (31/450) of patients and 154 patients (34.2%) had leftsided diastolic dysfunction. Valve heart disease was detected in 6.2% (28/450), atrial fibrillation in 31/450 (6.9%), Other causes of reduced exercise tolerance include coronary artery disease in 31/450 (6.9%), pulmonary disease 42/450 (9.3%), morbid obesity 15/450 (3.3%), neoplasms 15/450 (3.3%), psychiatric disorders 1%, rheumatoid disease 1%, anemia 1%. ConclusionsApproximately 65% of PE survivors report functional impairment, despite at least 6 months of anticoagulation. Persistent pulmonary artery thromboemboli resulting in CTEPH or CTED were detected in 7.2% of PE survivors and 11.8% of symptomatic patients. Leftsided diastolic dysfunction was the most prevalent echocardiographic abnormality, and remained the most common cause of functional limitation affected 34.2% of symptomatic cases.

P2768Post-PE impairment is mostly related to newly diagnosed heart failure with preserved ejection fraction

Abstract Introduction Recently, the concept of post-PE impairment (PPEI) was proposed which includes various combinations of functional, haemodynamic or imaging abnormalities in patients after acute pulmonary embolism (PE). Chronic residual obstruction of pulmonary vascular bed, despite adequate anticoagulation, is suggested to be a major cause of PPEI. Material and methods We report data of consecutive 700 PE survivors (390 F, aged 62±18 yrs). In all patients PE was diagnosed and treated according to ESC recommendations. Patients were anticoagulated and followed for at least 6 months in outpatient clinic (median 6, 6–18 months). All symptomatic subjects underwent detailed diagnostic workup which included standardized echocardiography, lung scintigraphy, pulmonary functional tests, and chest CT, RHC and coronary angiography when appropriate. Results 207/700 (29,6%) of PE survivors completely recovered functionally. However, when compared to prePEperiod 493/700 (70,4%) patients reported functional limitation compatible with PPEI. Exertional dyspnoea was present in 36,5% of symptomatic patients, then 25,5% others presented effort angina with or without dyspnoea, 11% of symptomatic patients reported palpitations and 27% complained of reduced exercise tolerance. After diagnostic workup, CTEPH was diagnosed in 38 of 493 (7,7%) symptomatic subjects (5,4% of all survivors) and chronic thromboembolic pulmonary disease (CTED) in 12/493 (2,4%) of them. 52,9% pts have chronic heart failure with reduced ejection fraction (EF) 4,2% and 37,2% with preserved EF; valve heart disease was detected in 8,9% and significant arrhythmia, mostly atrial fibrillation, in 2,6%. Breathlessness and reduce exercise tolerance in the others were caused by coronary artery diseases or non-cardiovascular pathologies (e.g. anaemia, pulmonary disease). Conclusions Follow-up demonstrated that after an episode of PE, approximately 70% of patients report functional impairment. Although persistent pulmonary artery thromboemobli resulting in CTEPH or CTED were detected in 7,1% of PE survivors and 10% of symptomatic patients. Left ventricular diastolic dysfunction is the most common cause of PPEI.