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Durrington C, Hurdman JA, Elliot CA, Maclean R, Van Veen J, Saccullo G, De-Foneska D, Swift AJ, Smitha R, Hill C, Thomas S, Dwivedi K, Alabed S, Wild JM, Charalampopoulos A, Hameed A, Rothman AMK, Watson L, Hamilton N, Thompson AAR, Condliffe R, Kiely DG. Systematic pulmonary embolism follow-up increases diagnostic rates of chronic thromboembolic pulmonary hypertension and identifies less severe disease: results from the ASPIRE Registry. Eur Respir J 2024; 63:2300846. [PMID: 38302154 PMCID: PMC7615743 DOI: 10.1183/13993003.00846-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 12/21/2023] [Indexed: 02/03/2024]
Abstract
BACKGROUND Diagnostic rates and risk factors for the subsequent development of chronic thromboembolic pulmonary hypertension (CTEPH) following pulmonary embolism (PE) are not well defined. METHODS Over a 10-year period (2010-2020), consecutive patients attending a PE follow-up clinic in Sheffield, UK (population 554 600) and all patients diagnosed with CTEPH at a pulmonary hypertension (PH) referral centre in Sheffield (referral population estimated 15-20 million) were included. RESULTS Of 1956 patients attending the Sheffield PE clinic 3 months following a diagnosis of acute PE, 41 were diagnosed with CTEPH with a cumulative incidence of 2.10%, with 1.89% diagnosed within 2 years. Of 809 patients presenting with pulmonary hypertension (PH) and diagnosed with CTEPH, 32 were Sheffield residents and 777 were non-Sheffield residents. Patients diagnosed with CTEPH at the PE follow-up clinic had shorter symptom duration (p<0.01), better exercise capacity (p<0.05) and less severe pulmonary haemodynamics (p<0.01) compared with patients referred with suspected PH. Patients with no major transient risk factors present at the time of acute PE had a significantly higher risk of CTEPH compared with patients with major transient risk factors (OR 3.6, 95% CI 1.11-11.91; p=0.03). The presence of three computed tomography (CT) features of PH in combination with two or more out of four features of chronic thromboembolic pulmonary disease at the index PE was found in 19% of patients who developed CTEPH and in 0% of patients who did not. Diagnostic rates and pulmonary endarterectomy (PEA) rates were higher at 13.2 and 3.6 per million per year, respectively, for Sheffield residents compared with 3.9-5.2 and 1.7-2.3 per million per year, respectively, for non-Sheffield residents. CONCLUSIONS In the real-world setting a dedicated PE follow-up pathway identifies patients with less severe CTEPH and increases population-based CTEPH diagnostic and PEA rates. At the time of acute PE diagnosis the absence of major transient risk factors, CT features of PH and chronic thromboembolism are risk factors for a subsequent diagnosis of CTEPH.
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Affiliation(s)
- Charlotte Durrington
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
| | - Judith A Hurdman
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Charlie A Elliot
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Rhona Maclean
- Department of Haematology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Joost Van Veen
- Department of Haematology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Giorgia Saccullo
- Department of Haematology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Duneesha De-Foneska
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Andrew J Swift
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- Department of Radiology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Insigneo Institute, University of Sheffield, Sheffield, UK
- National Institute for Health and Care Research Sheffield Biomedical Research Centre, Sheffield, UK
| | - Rajaram Smitha
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- Department of Radiology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Catherine Hill
- Department of Radiology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Steven Thomas
- Department of Radiology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Krit Dwivedi
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- Department of Radiology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Samer Alabed
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- Department of Radiology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - James M Wild
- Department of Radiology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Insigneo Institute, University of Sheffield, Sheffield, UK
- National Institute for Health and Care Research Sheffield Biomedical Research Centre, Sheffield, UK
| | - Athanasios Charalampopoulos
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Abdul Hameed
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
| | - Alexander M K Rothman
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- National Institute for Health and Care Research Sheffield Biomedical Research Centre, Sheffield, UK
| | - Lisa Watson
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Neil Hamilton
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
| | - A A Roger Thompson
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- National Institute for Health and Care Research Sheffield Biomedical Research Centre, Sheffield, UK
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- National Institute for Health and Care Research Sheffield Biomedical Research Centre, Sheffield, UK
- R. Condliffe and D.G. Kiely contributed equally to this work
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- Insigneo Institute, University of Sheffield, Sheffield, UK
- National Institute for Health and Care Research Sheffield Biomedical Research Centre, Sheffield, UK
- R. Condliffe and D.G. Kiely contributed equally to this work
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Pepke-Zaba J, Howard L, Kiely DG, Sweeney S, Johnson M. Pulmonary Embolism (PE) to Chronic Thromboembolic Pulmonary Disease (CTEPD): Findings from a Survey of UK Physicians. Adv Respir Med 2024; 92:45-57. [PMID: 38247551 PMCID: PMC10801485 DOI: 10.3390/arm92010007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 12/22/2023] [Accepted: 12/22/2023] [Indexed: 01/23/2024]
Abstract
Chronic thromboembolic pulmonary disease (CTEPD) is a complication of pulmonary embolism (PE). We conducted an online survey of UK PE-treating physicians to understand practices in the follow-up of PE and awareness of CTEPD. The physicians surveyed (N = 175) included 50 each from cardiology, respiratory and internal medicine, plus 25 haematologists. Most (89%) participants had local guidelines for PE management, and 65% reported a PE follow-up clinic, of which 69% were joint clinics. Almost half (47%) had a protocol for the investigation of CTEPD. According to participants, 129 (74%) routinely consider a diagnosis of CTEPD and 97 (55%) routinely investigate for CTEPD, with 76% of those 97 participants investigating in patients who are symptomatic at 3 months and 22% investigating in all patients. This survey demonstrated variability in the follow-up of PE and the awareness of CTEPD and its investigation. The findings support the conduct of a national audit to understand the barriers to the timely detection of CTEPD.
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Affiliation(s)
- Joanna Pepke-Zaba
- Pulmonary Vascular Diseases Unit, National Pulmonary Hypertension Service, Royal Papworth Hospital, Cambridge CB2 0AY, UK
| | - Luke Howard
- National Pulmonary Hypertension Service, Hammersmith Hospital, London W12 0HS, UK
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, NIHR Biomedical Research Centre, Sheffield S10 2RX, UK
| | - Shruti Sweeney
- Medical Affairs Department, Janssen-Cilag Ltd., High Wycombe HP12 4EG, UK
| | - Martin Johnson
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow G81 4DY, UK
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Kanwar MK, Cole M, Gauthier-Loiselle M, Manceur AM, Tsang Y, Lefebvre P, Panjabi S, Benza RL. Development and validation of a claims-based model to identify patients at risk of chronic thromboembolic pulmonary hypertension following acute pulmonary embolism. Curr Med Res Opin 2021; 37:1483-1491. [PMID: 34166172 DOI: 10.1080/03007995.2021.1947215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare disease that often follows pulmonary embolism (PE). Screening for CTEPH is challenging, often delaying diagnosis and worsening prognosis. Predictive risk models for CTEPH could help identify at-risk patients, but existing models require multiple clinical inputs. We developed and validated a predictive risk model for CTEPH using health insurance claims that can be used by payers/quality-of-care organizations to screen patients post-PE. METHODS Adult patients newly diagnosed with acute PE (index date) were identified from the Optum De-identified Clinformatics Extended DataMart (January 2007-March 2018; development set) and IBM MarketScan (January 2008-June 2019; validation set) databases. Predictors were identified 12 months before or on the index PE. Risk of "likely CTEPH" was assessed post-PE based on CTEPH-related diagnoses and procedures since the CTEPH diagnosis code (ICD-10-CM: I27.24) was not available until 1 October 2017. Stepwise variable selection was used to build the model using the development set; model validation was subsequently conducted using the validation set. RESULTS The development set included 93,428 patients, of whom 11,878 (12.7%) developed likely CTEPH. Older age (odds ratios [OR] = 1.16-1.49), female (OR = 1.09), unprovoked PE (i.e. without thrombotic factors; OR = 1.14), hypertension (OR = 1.07), osteoarthritis (OR = 1.08), diabetes (OR = 1.07), chronic obstructive pulmonary disease (OR = 1.11), obesity (OR = 1.21) were associated with higher odds of likely CTEPH, and oral anticoagulants with lower odds (OR= 0.50, all p < .01). C-statistic was 0.77 in the development and validation sets. CONCLUSION A claims-based risk model reliably predicted the risk of CTEPH post-PE and could be used to identify high-risk patients who may benefit from focused monitoring.
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Affiliation(s)
- Manreet K Kanwar
- Cardiovascular Institute, Allegheny Health Network, Pittsburgh, PA, USA
| | - Michele Cole
- Actelion Pharmaceuticals US, Inc, a Janssen Pharmaceutical Company of Johnson & Johnson, South San Francisco, CA, USA
| | | | | | - Yuen Tsang
- Actelion Pharmaceuticals US, Inc, a Janssen Pharmaceutical Company of Johnson & Johnson, South San Francisco, CA, USA
| | | | - Sumeet Panjabi
- Actelion Pharmaceuticals US, Inc, a Janssen Pharmaceutical Company of Johnson & Johnson, South San Francisco, CA, USA
| | - Raymond L Benza
- Division of Cardiovascular Diseases, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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CT-Based Biomarkers for Prediction of Chronic Thromboembolic Pulmonary Hypertension After an Acute Pulmonary Embolic Event. AJR Am J Roentgenol 2020; 215:800-806. [PMID: 32809861 DOI: 10.2214/ajr.19.22541] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE. The purpose of this study is to assess CT-based markers predictive of the development of chronic thromboembolic pulmonary hypertension (CTEPH) after acute pulmonary embolism. MATERIALS AND METHODS. Identified from a search of local registries, 48 patients who had CTEPH develop were included in the study group, and 113 patients who had complete resolution of acute pulmonary embolism were included in the control group. Baseline CT scans obtained at the time of the initial pulmonary embolism event were evaluated for the degree of clot-induced vessel obstruction, the quantitative Walsh score, the ratio of the right ventricle diameter to the left ventricle diameter, the right atrium diameter, the pulmonary artery diameter, right heart thrombus, pericardial effusion, lung infarction, and mosaic attenuation. Classification and regression tree analysis was used to create a decision tree. The decision tree was externally validated on an anonymized cohort of 50 control subjects and 50 patients with CTEPH. RESULTS. During univariable analysis, an increase in the degree occlusive clot on initial imaging, a decrease in the Walsh score, absence of pericardial effusion, presence of lung infarction, and the presence of mosaic attenuation were associated with an increased probability of CTEPH development. In the final decision tree, the occlusive nature of the clot remained. Two patients in the cohort used for external validation had nondiagnostic findings and were excluded. The decision process correctly classified 33% (16/48) of patients who had CTEPH develop and 86% (43/50) of patients who did not have CTEPH develop, for an odds ratio of 3.1 (95% CI, 1.1-8.3). CONCLUSION. The presence of an occlusive clot on initial imaging is associated with an increased probability of CTEPH development. Presence of mosaic attenuation and lung infarction may also predict CTEPH development, although additional studies are needed.
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Ramírez P, Otero R, Barberà JA. Pulmonary chronic thromboembolic disease. Arch Bronconeumol 2020; 56:314-321. [PMID: 35373741 DOI: 10.1016/j.arbr.2020.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 10/21/2019] [Indexed: 06/14/2023]
Abstract
Persistent thrombotic lesions are common in patients with pulmonary embolism. These lesions occur on a clinical spectrum, ranging from an asymptomatic course with complete functional recovery to chronic thromboembolic pulmonary hypertension. The concept of chronic thromboembolic disease has emerged in recent years to describe a subgroup of patients with persistent thrombotic lesions who have symptoms on exertion and pulmonary vascular dysfunction, but no pulmonary hypertension at rest. The prevalence of this entity is unknown and the criteria for diagnosing it are not defined. The aim of this article is to analyze post-pulmonary embolism sequelae and review existing evidence on chronic thromboembolic disease, with special emphasis on its diagnosis and therapeutic approach.
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Affiliation(s)
- Purificación Ramírez
- Servicio de Neumología, Hospital Universitario Nuestra Señora de Candelaria, Tenerife, Spain
| | - Remedios Otero
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío-Instituto de Biomedicina de Sevilla (IBiS); CSIC; Universidad de Sevilla, Sevilla, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Joan Albert Barberà
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain; Servicio de Neumología y Alergia Respiratoria, Hospital Clínic-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS); Universidad de Barcelona, Barcelona, Spain.
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Mrozek J, Necasova T, Svoboda M, Simkova I, Jansa P. Prediction Score for persisting perfusion defects after pulmonary embolism. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2019; 164:394-400. [PMID: 31551608 DOI: 10.5507/bp.2019.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 07/02/2019] [Indexed: 11/23/2022] Open
Abstract
AIMS Long-term persistence of perfusion defect after pulmonaryembolism (PE) may lead to the development of chronic thromboembolic pulmonary hypertension. Identification of patients at risk of such a complication using a scoring system would be beneficial in clinical practice. Here, we aimed to derive a score for predicting persistence of perfusion defects after PE. METHODS 83 patients after PE were re-examined 6, 12 and 24 months after the PE episode. Data collected at the time of PE and perfusion status during follow-ups were used for modelling perfusion defects persistence using the Cox proportional hazards model and validated using bootstrap method. RESULTS A simple scoring system utilizing two variables (hemoglobin levels and age at the time of PE) was developed. Patients with hemoglobin levels over 140 g/L who were older than 65 years were at the highest risk of perfusion defects; in patients with the same hemoglobin levels and age <65 years, the risk was reduced by 79%, and by 89% in patients with hemoglobin <140 g/L. CONCLUSION The proposed scoring system may be useful in clinical practice for identifying patients with high risk of persisting perfusion defects, flagging them for closer follow up, thus improving the effectiveness of long-term treatment of patients after PE.
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Affiliation(s)
- Jan Mrozek
- Department of Cardiovascular Diseases, University Hospital Ostrava, 17. listopadu 1790, 708 52 Ostrava-Poruba, Czech Republic
| | - Tereza Necasova
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University Brno, Postovska 68/3, 602 00 Brno, Czech Republic
| | - Michal Svoboda
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University Brno, Postovska 68/3, 602 00 Brno, Czech Republic
| | - Iveta Simkova
- National Institute of Cardiovascular Diseases and Slovak Medical University, Pod Krasnou horkou 7185/1, 831 01 Bratislava - Nove Mesto, Slovak Republic
| | - Pavel Jansa
- Clinical Department of Cardiology and Angiology, 1st Faculty of Medicine, 2nd Medical Department, Charles University, U Nemocnice 499/2, 128 08 Praha 2 - Nove Mesto, Czech Republic
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