Determinants and Management of the Post–Pulmonary Embolism Syndrome

Abstract

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.

Optimal follow-up after acute pulmonary embolism: a position paper of the European Society of Cardiology Working Group on Pulmonary Circulation and Right Ventricular Function, in collaboration with the European Society of Cardiology Working Group on Atherosclerosis and Vascular Biology, endorsed by the European Respiratory Society

“…The PPES is defined as new or progressive dyspnoea, exercise intolerance, and/or impaired functional or mental status after at least 3 months of adequate anticoagulation following acute PE, which cannot be explained by other (pre-existing) comorbidities. 34 , 35 It is reported in up to 40–60% of PE survivors. Incomplete thrombus resolution occurs in 25–50% of patients after acute PE despite adequate anticoagulation, but bears no clinical significance in most cases.…”

Post-Pulmonary Embolism Syndrome and Functional Outcomes after Acute Pulmonary Embolism

“…21 Decreased daily physical activity after a PE diagnosis with resulting physical deconditioning is one of the main explanations for post-PE functional impairment. 11 18 19 20 43 44 In addition, persistent thoracic pain, anxiety, and postthrombotic panic syndrome, as well as fear for recurrences or complications, contribute largely to functional limitations, on both the social and professional level. 45 46 47 Post-PE functional impairment is associated with reduced QoL and higher prevalence of depression and permanent work-related disability.…”

Postpulmonary Embolism Follow-Up and Epidemiology of Chronic Thromboembolic Pulmonary Hypertension

“…As discussed above, CTEPH is the most severe diagnosis on a spectrum of long-term complications that can arise after the diagnosis of acute PE. 19,21,42,43 It is unknown whether this spectrum of disease exists as a progressive continuum versus a group of related disease processes after acute PE. While the incidence of CTEPH after acute PE episode is between 0.1% and 9.1%, multiple studies have reported that up to 50% of patients experience residual pulmonary symptoms or exercise/functional limitations after acute PE, thus bringing about the entity of the PPES, which includes CTEPH, CTED, post-PE cardiac impairment and post-PE functional impairment.…”