Chest
Volume 136, Issue 5, November 2009, Pages 1202-1210
Journal home page for Chest

Original Research
Pulmonary Hypertension
Prospective Evaluation of Right Ventricular Function and Functional Status 6 Months After Acute Submassive Pulmonary Embolism: Frequency of Persistent or Subsequent Elevation in Estimated Pulmonary Artery Pressure

https://doi.org/10.1378/chest.08-2988Get rights and content

Background

No published data have systematically documented pulmonary artery pressure over an intermediate time period after submassive pulmonary embolism (PE). The aim of this work was to document the rate of pulmonary hypertension, as assessed noninvasively by estimated right ventricular systolic pressure (RVSP) of ≥ 40 mm Hg 6 months after the diagnosis of submassive PE.

Methods

We enrolled 200 normotensive patients with CT angiography-proven PE and a baseline echocardiogram to estimate RVSP. All patients received therapy with unfractionated heparin initially, but 21 patients later received alteplase in response to circulatory shock or respiratory failure. Patients returned at 6 months for repeat RVSP measurement, and assessments of the New York Heart Association (NYHA) score and 6-min walk distance (6MWD).

Results

Six months after receiving a diagnosis, 162 of 180 survivors (90%) returned for follow-up, including 144 patients who had been treated with heparin (heparin-only group) and 18 patients who had been treated with heparin plus alteplase (heparin-plus-alteplase group). Among the heparin-only patients, the RVSP at diagnosis was ≥ 40 mm Hg in 50 of 144 patients (35%; 95% CI, 27% to 43%), compared with 10 of 144 patients at follow-up (7%; 95% CI, 3% to 12%). However, the RVSP at follow-up was higher than the baseline RVSP in 39 of 144 patients (27%; 95% CI, 9% to 35%), and 18 of these 39 patients had a NYHA score of ≥ 3 or exercise intolerance (6MWD, < 330 m). Among heparin-plus-alteplase patients, the RVSP was ≥ 40 mm Hg in 11 of 18 patients at diagnosis (61%; 95% CI, 36% to 83%), compared with 2 of 18 patients at follow-up (11%; 95% CI, 1% to 35%). The RVSP at follow-up was not higher than at the time of diagnosis in any of the heparin-plus-alteplase patients (95% CI, 0% to 18%).

Conclusions

Six months after experiencing submassive PE, a significant proportion of patients had echocardiographic and functional evidence of pulmonary hypertension.

Section snippets

Materials and Methods

This study was approved by the Institutional Review Board and Privacy Board at Carolinas Medical Center, a large, urban academic hospital in Charlotte, NC. We prospectively enrolled ED patients and hospital inpatients with confirmed PE from January 2002 until February 2005.

Results

We enrolled 210 patients (age range, 18 to 87 years) from January 2002 to May 2005 (Fig 1). The mean time between the initiation of heparin therapy and the performance of the echocardiogram was 13 ± 1 h. Ten patients were excluded from the study shortly after enrollment because of the inability to obtain an echocardiogram (n = 3) or an over-read of the CT angiogram such that the final, written interpretation indicated no evidence of acute PE (n = 7). The per-protocol study cohort thus included

Discussion

This study extends the current knowledge about the expected course of echocardiographically estimated RV function and pressure after acute submassive PE in patients treated with standard anticoagulation. We measured the change in echocardiographic measurements of RV function and estimated the RVSP at diagnosis and 6 months thereafter in a cohort of 200 patients with clearly defined acute submassive PE. All 200 patients, 21 of whom had their treatment escalated to include alteplase in response

Acknowledgments

Author contributions: Dr. Kline wrote the study protocol, obtained funding, collected and analyzed the data, and wrote the article. Dr. Steuerwald collected and analyzed the data, performed search procedures and structured the data extraction for Table 5, and assisted in editing the revisions of the article. Dr. Marchick assisted with the data analysis, writing the first draft, and editing the revisions of the article. Dr. Hernandez-Nino collected and analyzed the data. Dr. Rose helped to write

References (0)

Cited by (214)

  • Evaluation and management of patients with chronic thromboembolic pulmonary hypertension - consensus statement from the ISHLT

    2021, Journal of Heart and Lung Transplantation
    Citation Excerpt :

    Therefore, it is essential to keep a high index of suspicion for CTEPH particularly in the context of an acute PE, a new diagnosis of PH, or in the presence of unexplained dyspnea. Delayed diagnosis of CTEPH results in unnecessary suffering and monetary waste on inappropriate treatments.72-83 Progression of disease can also lead to worsening of the small vessel vasculopathy and the development of right heart failure, which can be associated with worse surgical outcomes in terms of operative risks and PH resolution.84,85

View all citing articles on Scopus

Funding/Support: This work was supported by the National Heart, Lung, and Blood Institute [grant R01HL074384] (to Dr. Kline).

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).

View full text