Multicentre observational screening survey for the detection of CTEPH following pulmonary embolism

Abstract

Chronic thromboembolic pulmonary hypertension (CTEPH) is a severe complication of pulmonary embolism. Its incidence following pulmonary embolism is debated. Active screening for CTEPH in patients with acute pulmonary embolism is yet to be recommended.This prospective, multicentre, observational study (Multicentre Observational Screening Survey for the Detection of Chronic Thromboembolic Pulmonary Hypertension (CTEPH) Following Pulmonary Embolism (INPUT on PE); ISRCTN61417303) included patients with acute pulmonary embolism from 11 centres in Switzerland from March 2009 to November 2016. Screening for possible CTEPH was performed at 6, 12 and 24 months using a stepwise algorithm that included a dyspnoea phone-based survey, transthoracic echocardiography, right heart catheterisation and radiological confirmation of CTEPH.Out of 1699 patients with pulmonary embolism, 508 patients were assessed for CTEPH screening over 2 years. CTEPH incidence following pulmonary embolism was 3.7 per 1000 patient-years, with a 2-year cumulative incidence of 0.79%. The Swiss pulmonary hypertension registry consulted in December 2016 did not report additional CTEPH cases in these patients. The survey yielded 100% sensitivity and 81.6% specificity. The second step echocardiography in newly dyspnoeic patients showed a negative predictive value of 100%.CTEPH is a rare but treatable disease. A simple and sensitive way for CTEPH screening in patients with acute pulmonary embolism is recommended.

Incidence and risk factors of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism: a systematic review and meta-analysis of cohort studies

“…Several patient-specific, CTEPH-specific and radiological factors were proved to be relevant to an increased risk of CTEPH. Of the studies that were included, 6 studies performed a multivariate analysis (2,5,(14)(15)(16)21), and the study by Guérin et al and the study by Coquoz et al just reported unadjusted risk factors (1,23). Previous/recurrent PE or previous VTE (1,2,14,16) and right heart dysfunction at presentation (1,5,14,21) were evaluated as risk factors in more than three studies.…”

“…First, our analysis didn't include abstracts, reviews, and conference proceedings, because it's difficult to assess quality from incomplete data. Second, our analysis included the latest 4 studies published in 2016 (5,14,15,22) and 1 study published in 2018 (23). Third, the data from China were also included into our meta-analysis (14,15,21).…”

2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS)

“…Screening for possible CTEPH was performed at 6, 12, and 24 months using a stepwise algorithm that included a phone-based dyspnoea survey, TTE, right heart catheterization, and radiological confirmation of CTEPH. Of 508 patients assessed for CTEPH screening over 2 years, CTEPH incidence following PE was 3.7 per 1000 patient-years, with a 2 year cumulative incidence of 0.79% [441]. In Germany, the incidence of CTEPH in 2016 was estimated at 5.7 per million adult population [442].…”

Chronic thromboembolic pulmonary hypertension – still evolving

“…Another prospective, multicentre, observational screening survey in Switzerland, for the detection of CTEPH included patients with acute PE from 2009 to 2016. In this study CTEPH incidence following PE was 3.7 per 1,000 patient-years, with a 2 year cumulative incidence of 0.79% 38 . The potential risk of error is mostly due to referral bias, lack of early signs and symptoms, and challenges in the differentiation of acute PE symptoms and pre-existing CTEPH 39,40 .…”