Introduction Pulmonary Hypertension (PH) is defined as raised Pulmonary Arterial Systolic Pressure ≥25mmHg at rest on Right Heart Catheterisation.1 Chronic Thromoboembolic Pulmonary Hypertension (CTEPH) is a recognised complication of pulmonary embolism (PE),with a reported annual cumulative incidence of 3.1%.2 Patients with evidence of PH or Right Ventricular Dysfunction (RVD) during admission should be referred for echocardiography usually 3–6 months after discharge to establish PH resolution.1
Objective To identify patients at risk of CTEPH, evaluate their follow-up plans and establish the proportion with evidence of acute RVD/PH who are investigated for persistent PH.
Methods Retrospective analysis of all diagnoses of PE on Computed Tomography Pulmonary Angiography (CTPA) in 2010 in a single Trust. Patients were stratified according to size and location of PE, and any reported radiological evidence of RVD. Echocardiography reports were reviewed for evidence of PH.
Results 19.3%(329/1702) of CTPA scans revealed PE: Massive (28.6%); Submassive (28.0%); Peripheral (44.4%). Only 17.6%(58/329) had inpatient echocardiography, with 55.1%(32/58) suggesting PH (PASP≥ 36 mmHg). 78.1%(25/32) of these patients survived to 6 months and follow-up echocardiography was performed within 6 months for 40%(10/25) of this subset.
Overall, 80.9% (266/329) of patients with confirmed PE survived past 6 months. Follow-up echocardiogram was performed within 6 months on 20.3% (54/266) of survivors; PH was demonstrated in 18.5%(10/54).
RV strain was reported in 15.2% (50/329) of CTPA scans. Follow-up echocardiogram was performed within 6 months on 19.5% (8/41) of those alive at 6 months.
84.2%(154/183)of individuals diagnosed with a massive or submassive PE survived to 6 months. Respiratory or cardiology follow-up was planned for 23% (36/154).
Conclusions Our findings suggest follow-up after acute PE is suboptimal, potentially missing early PH due to a low number of early echocardiograms. The relatively high percentage of PH on echocardiography compared to reported rates is likely due to selection bias. The results suggest there may be a missed cohort at risk of developing PH, i.e. those with RV strain on CTPA or high thrombus load, being denied early or more aggressive interventions such as pulmonary endarterectomy.
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Pengo et al. NEJM 2004; 350:2257–64.