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de Jong CMM, Boon GJAM, Le YNJ, Barco S, Siegerink B, Klok FA. The Post-Venous Thromboembolism Functional Status Scale: From Call to Action to Application in Research, Extension to COVID-19 Patients, and Its Use in Clinical Practice. Semin Thromb Hemost 2023; 49:764-773. [PMID: 36940713 DOI: 10.1055/s-0043-1764467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2023]
Abstract
A broad spectrum of long-term sequelae may be present in venous thromboembolism (VTE) survivors, affecting their quality of life and functioning. To monitor recovery and improve the prognosis of patients with persistent functional limitations, the development of a new outcome measure that could better capture the consequences of VTE was an unmet need. Starting as a call to action, the Post-VTE Functional Status (PVFS) scale was developed to meet this need. The PVFS scale is an easy-to-use clinical tool to measure and quantify functional outcomes after VTE by focusing on key aspects of daily life. As the scale was considered useful in coronavirus disease 2019 (COVID-19) patients as well, the Post-COVID-19 Functional Status (PCFS) scale was introduced early in the pandemic after slight adaptation. The scale has been well incorporated into both the VTE and COVID-19 research communities, contributing to the shift of focus toward patient-relevant functional outcomes. Psychometric properties have been evaluated, mainly for the PCFS scale but recently also for the PVFS scale, including validation studies of translations, showing adequate validity and reliability. In addition to serving as outcome measure in studies, guidelines and position papers recommend using the PVFS and PCFS scale in clinical practice. As broad use of the PVFS and PCFS scale in clinical practice is valuable to capture what matters most to patients, widespread implementation is a crucial next step. In this review, we discuss the development of the PVFS scale and introduction in VTE and COVID-19 care, the incorporation of the scale in research, and its application in clinical practice.
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Affiliation(s)
- Cindy M M de Jong
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Gudula J A M Boon
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Y N Jenny Le
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Stefano Barco
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Bob Siegerink
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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de Jong CMM, Le YNJ, Boon GJAM, Barco S, Klok FA, Siegerink B. Eight lessons from two-year use of the Post-COVID-19 Functional Status scale. Eur Respir J 2023; 61:13993003.00416-2023. [PMID: 37080570 PMCID: PMC10151454 DOI: 10.1183/13993003.00416-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 04/04/2023] [Indexed: 04/22/2023]
Affiliation(s)
- Cindy M M de Jong
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Y N Jenny Le
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Gudula J A M Boon
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Stefano Barco
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
- Center for Thrombosis and Hemostasis, University Hospital Mainz, Mainz, Germany
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Bob Siegerink
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
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Zhai Z, Boon GJAM, Staring M, van Dam LF, Kroft LJM, Hernández Girón I, Ninaber MK, Bogaard HJ, Meijboom LJ, Vonk Noordegraaf A, Huisman MV, Klok FA, Stoel BC. Automated quantification of the pulmonary vasculature in pulmonary embolism and chronic thromboembolic pulmonary hypertension. Pulm Circ 2023; 13:e12223. [PMID: 37128354 PMCID: PMC10148047 DOI: 10.1002/pul2.12223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 03/30/2023] [Accepted: 03/31/2023] [Indexed: 05/03/2023] Open
Abstract
The shape and distribution of vascular lesions in pulmonary embolism (PE) and chronic thromboembolic pulmonary hypertension (CTEPH) are different. We investigated whether automated quantification of pulmonary vascular morphology and densitometry in arteries and veins imaged by computed tomographic pulmonary angiography (CTPA) could distinguish PE from CTEPH. We analyzed CTPA images from a cohort of 16 PE patients, 6 CTEPH patients, and 15 controls. Pulmonary vessels were extracted with a graph-cut method, and separated into arteries and veins using deep-learning classification. Vascular morphology was quantified by the slope (α) and intercept (β) of the vessel radii distribution. To quantify lung perfusion defects, the median pulmonary vascular density was calculated. By combining these measurements with densities measured in parenchymal areas, pulmonary trunk, and descending aorta, a static perfusion curve was constructed. All separate quantifications were compared between the three groups. No vascular morphology differences were detected in contrast to vascular density values. The median vascular density (interquartile range) was -567 (113), -452 (95), and -470 (323) HU, for the control, PE, and CTEPH group. The static perfusion curves showed different patterns between groups, with a statistically significant difference in aorta-pulmonary trunk gradient between the PE and CTEPH groups (p = 0.008). In this proof of concept study, not vasculature morphology but densities differentiated between patients of three groups. Further technical improvements are needed to allow for accurate differentiation between PE and CTEPH, which in this study was only possible statistically by measuring the density gradient between aorta and pulmonary trunk.
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Affiliation(s)
- Zhiwei Zhai
- Division of Image Processing, Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Gudula J. A. M. Boon
- Department of Medicine ‐ Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Marius Staring
- Division of Image Processing, Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Lisette F. van Dam
- Department of Medicine ‐ Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Lucia J. M. Kroft
- Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Irene Hernández Girón
- Division of Image Processing, Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Maarten K. Ninaber
- Department of PulmonologyLeiden University Medical CenterLeidenThe Netherlands
| | - Harm Jan Bogaard
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Lilian J. Meijboom
- Department of Radiology and Nuclear Medicine, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Menno V. Huisman
- Department of Medicine ‐ Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Frederikus A. Klok
- Department of Medicine ‐ Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Berend C. Stoel
- Division of Image Processing, Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
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Luijten D, Meijer FMM, Boon GJAM, Ende-Verhaar YM, Bavalia R, El Bouazzaoui LH, Delcroix M, Huisman MV, Mairuhu ATA, Middeldorp S, Pruszcyk P, Ruigrok D, Verhamme P, Vonk Noordegraaf A, Vriend JWJ, Vliegen HW, Klok FA. Diagnostic efficacy of ECG-derived ventricular gradient for the detection of chronic thromboembolic pulmonary hypertension in patients with acute pulmonary embolism. J Electrocardiol 2022; 74:94-100. [PMID: 36057190 DOI: 10.1016/j.jelectrocard.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 08/03/2022] [Accepted: 08/19/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Application of the chronic thromboembolic pulmonary hypertension (CTEPH) rule out criteria (manual electrocardiogram [ECG] reading and N-terminal pro-brain natriuretic peptide [NTproBNP] test) can rule out CTEPH in pulmonary embolism (PE) patients with persistent dyspnea (InShape II algorithm). Increased pulmonary pressure may also be identified using automated ECG-derived ventricular gradient optimized for right ventricular pressure overload (VG-RVPO). METHOD A predefined analysis of the InShape II study was performed. The diagnostic performance of the VG-RVPO for the detection of CTEPH and the incremental diagnostic value of the VG-RVPO as new rule-out criteria in the InShape II algorithm were evaluated. RESULTS 60 patients were included; 5 (8.3%) were ultimately diagnosed with CTEPH. The mean baseline VG-RVPO (at time of PE diagnosis) was -18.12 mV·ms for CTEPH patients and - 21.57 mV·ms for non-CTEPH patients (mean difference 3.46 mV·ms [95%CI -29.03 to 35.94]). The VG-RVPO (after 3-6 months follow-up) normalized in patients with and without CTEPH, without a clear between-group difference (mean Δ VG-RVPO of -8.68 and - 8.42 mV·ms respectively; mean difference of -0.25 mV·ms, [95%CI -12.94 to 12.44]). The overall predictive accuracy of baseline VG-RVPO, follow-up RVPO and Δ VG-RVPO for CTEPH was moderate to poor (ROC AUC 0.611, 0.514 and 0.539, respectively). Up to 76% of the required echocardiograms could have been avoided with VG-RVPO criteria replacing the InShape II rule-out criteria, however at cost of missing up to 80% of the CTEPH diagnoses. CONCLUSION We could not demonstrate (additional) diagnostic value of VG-RVPO as standalone test or as on top of the InShape II algorithm.
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Affiliation(s)
- Dieuwke Luijten
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Fleur M M Meijer
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Gudula J A M Boon
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Yvonne M Ende-Verhaar
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Roisin Bavalia
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Marion Delcroix
- Department of Pneumology, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Albert T A Mairuhu
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, the Netherlands
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Piotr Pruszcyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warszawa, Poland
| | - Dieuwertje Ruigrok
- Department of Pulmonology, Amsterdam UMC, VU University Medical Centre, Amsterdam, the Netherlands
| | - Peter Verhamme
- Department of Cardiovascular Sciences, Centre for Molecular and Vascular Biology, University Hospitals Leuven, Leuven, Belgium
| | - Anton Vonk Noordegraaf
- Department of Pulmonology, Amsterdam UMC, VU University Medical Centre, Amsterdam, the Netherlands
| | - Joris W J Vriend
- Department of Cardiology, Haga Teaching Hospital, The Hague, the Netherlands
| | - Hubert W Vliegen
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
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Boon GJAM, van den Hout WB, Barco S, Bogaard HJ, Delcroix M, Huisman MV, Konstantinides SV, Meijboom LJ, Nossent EJ, Symersky P, Vonk Noordegraaf A, Klok FA. A model for estimating the health economic impact of earlier diagnosis of chronic thromboembolic pulmonary hypertension. ERJ Open Res 2021; 7:00719-2020. [PMID: 34853780 PMCID: PMC8628742 DOI: 10.1183/23120541.00719-2020] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 06/14/2021] [Indexed: 11/06/2022] Open
Abstract
Background Diagnostic delay of chronic thromboembolic pulmonary hypertension (CTEPH)
exceeds 1 year, contributing to higher mortality. Health economic
consequences of late CTEPH diagnosis are unknown. We aimed to develop a
model for quantifying the impact of diagnosing CTEPH earlier on survival,
quality-adjusted life-years (QALYs) and healthcare costs. Material and methods A Markov model was developed to estimate lifelong outcomes, depending on the
degree of delay. Data on survival and quality of life were obtained from
published literature. Hospital costs were assessed from patient records
(n=498) at the Amsterdam UMC – VUmc, which is a Dutch CTEPH
referral center. Medication costs were based on a mix of standard medication
regimens. Results For 63-year-old CTEPH patients with a 14-month diagnostic delay of CTEPH
(median age and delay of patients in the European CTEPH Registry), lifelong
healthcare costs were estimated at EUR 117 100 for a mix of treatment
options. In a hypothetical scenario of maximal reduction of current delay,
improved survival was estimated at a gain of 3.01 life-years and 2.04 QALYs.
The associated cost increase was EUR 44 654, of which 87% was
due to prolonged medication use. This accounts for an incremental
cost–utility ratio of EUR 21 900/QALY. Conclusion Our constructed model based on the Dutch healthcare setting demonstrates a
substantial health gain when CTEPH is diagnosed earlier. According to Dutch
health economic standards, additional costs remain below the deemed
acceptable limit of EUR 50 000/QALY for the particular disease
burden. This model can be used for evaluating cost-effectiveness of
diagnostic strategies aimed at reducing the diagnostic delay. This constructed model based on the Dutch healthcare setting can be used
for evaluating cost-effectiveness of diagnostic strategies aimed at reducing
the diagnostic delay of chronic thromboembolic pulmonary hypertensionhttps://bit.ly/35yXPM3
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Affiliation(s)
- Gudula J A M Boon
- Dept of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Wilbert B van den Hout
- Dept of Biomedical Data Science - Medical Decision Making, Leiden University Medical Center, Leiden, the Netherlands
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Centre of the Johannes Gutenberg University, Mainz, Germany.,Clinic of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Harm Jan Bogaard
- Dept of Pulmonary Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Marion Delcroix
- Dept of Pneumology, University Hospitals Leuven, Leuven, Belgium
| | - Menno V Huisman
- Dept of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Centre of the Johannes Gutenberg University, Mainz, Germany.,Dept of Cardiology, Democritus University of Thrace, Xanthi, Greece
| | - Lilian J Meijboom
- Dept of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Esther J Nossent
- Dept of Pulmonary Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Petr Symersky
- Dept of Cardiac Surgery, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Anton Vonk Noordegraaf
- Dept of Pulmonary Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Frederikus A Klok
- Dept of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.,Center for Thrombosis and Hemostasis, University Medical Centre of the Johannes Gutenberg University, Mainz, Germany
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Boon GJAM, Jairam PM, Groot GMC, van Rooden CJ, Ende-Verhaar YM, Beenen LFM, Kroft LJM, Bogaard HJ, Huisman MV, Symersky P, Vonk Noordegraaf A, Meijboom LJ, Klok FA. Identification of chronic thromboembolic pulmonary hypertension on CTPAs performed for diagnosing acute pulmonary embolism depending on level of expertise. Eur J Intern Med 2021; 93:64-70. [PMID: 34294517 DOI: 10.1016/j.ejim.2021.07.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/30/2021] [Accepted: 07/08/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Expert reading often reveals radiological signs of chronic thromboembolic pulmonary hypertension (CTEPH) or chronic PE on computed tomography pulmonary angiography (CTPA) performed at the time of acute pulmonary embolism (PE) presentation preceding CTEPH. Little is known about the accuracy and reproducibility of CTPA reading by radiologists in training in this setting. OBJECTIVES To evaluate 1) whether signs of CTEPH or chronic PE are routinely reported on CTPA for suspected PE; and 2) whether CTEPH-non-expert readers achieve comparable predictive accuracy to CTEPH-expert radiologists after dedicated instruction. METHODS Original reports of CTPAs demonstrating acute PE in 50 patients whom ultimately developed CTEPH, and those of 50 PE who did not, were screened for documented signs of CTEPH. All scans were re-assessed by three CTEPH-expert readers and two CTEPH-non-expert readers (blinded and independently) for predefined signs and overall presence of CTEPH. RESULTS Signs of chronic PE were mentioned in the original reports of 14/50 cases (28%), while CTEPH-expert radiologists had recognized 44/50 (88%). Using a standardized definition (≥3 predefined radiological signs), moderate-to-good agreement was reached between CTEPH-non-expert readers and the experts' consensus (k-statistics 0.46; 0.61) at slightly lower sensitivities. The CTEPH-non-expert readers had moderate agreement on the presence of CTEPH (κ-statistic 0.38), but both correctly identified most cases (80% and 88%, respectively). CONCLUSIONS Concomitant signs of CTEPH were poorly documented in daily practice, while most CTEPH patients were identified by CTEPH-non-expert readers after dedicated instruction. These findings underline the feasibility of achieving earlier CTEPH diagnosis by assessing CTPAs more attentively.
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Affiliation(s)
- Gudula J A M Boon
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
| | - Pushpa M Jairam
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Gerie M C Groot
- Department of Radiology, Medical Center Gelderse Vallei, Ede, the Netherlands
| | | | - Yvonne M Ende-Verhaar
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Ludo F M Beenen
- Department of Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Harm Jan Bogaard
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Petr Symersky
- Department of Cardiothoracic Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Lilian J Meijboom
- Department of Radiology and Nuclear Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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Boon GJAM, Janssen SMJ, Barco S, Bogaard HJ, Ghanima W, Kroft LJM, Meijboom LJ, Ninaber MK, Nossent EJ, Spruit MA, Symersky P, Vliegen HW, Noordegraaf AV, Huisman MV, Siegerink B, Abbink JJ, Klok FA. Efficacy and safety of a 12-week outpatient pulmonary rehabilitation program in Post-PE Syndrome. Thromb Res 2021; 206:66-75. [PMID: 34419865 DOI: 10.1016/j.thromres.2021.08.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 08/11/2021] [Accepted: 08/12/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND The Post-Pulmonary Embolism Syndrome (PPES) comprises heterogeneous entities, including chronic thromboembolic disease with/without pulmonary hypertension (CTEPH/CTEPD), and deconditioning. OBJECTIVES To assess underlying physiological determinants of PPES, and efficacy and safety of rehabilitation training in these patients. METHODS 56 consecutive PE patients with persistent dyspnea and/or functional limitations despite ≥3 months of anticoagulation underwent standardized diagnostic work-up including exercise testing as part of routine practice. All diagnostic (imaging and cardiopulmonary function) tests were interpreted by a core group of experienced clinicians. A subgroup of patients without CTEPH or other treatable conditions was referred for a 12-week personalized rehabilitation program, studying changes in physical condition and patient-reported outcome measures. RESULTS Persistent vascular occlusions were observed in 21/56 patients (38%) and CTEPH was confirmed in ten (18%). Regarding those without CTEPH, impaired cardiopulmonary responses were evident in 18/39 patients with available CPET data (46%), unrelated to chronic thrombi. Rehabilitation was completed by 27 patients after excluding 29 (patients with CTEPH or treatable comorbidities, refusal, ineligibility, or training elsewhere). Training intensity, PE-specific quality of life (PEmb-QoL) and fatigue (CIS) improved with a median difference of 20 W (p = 0.001), 3.9 points (p < 0.001) and 16 points (p = 0.003), respectively. Functional status (Post-VTE Functional Status Scale) improved ≥1 grade in 18 (67%) patients, and declined in one (3.7%). CONCLUSIONS Our findings suggest that abnormal cardiopulmonary responses to exercise are common in patients with PPES and are not limited to those with chronic thrombi. Offering pulmonary rehabilitation to patients not treated otherwise seems safe and promising.
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Affiliation(s)
- Gudula J A M Boon
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany; Clinic of Angiology, University Hospital of Zurich, Zurich, Switzerland
| | - Harm Jan Bogaard
- Department of Pulmonology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Waleed Ghanima
- Departments of Oncology, Medicine and Research, Østfold Hospital Trust, Kalnes, Norway; Institute of Clinical Research, University of Oslo, Oslo, Norway
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Lilian J Meijboom
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Maarten K Ninaber
- Department of Pulmonology, Leiden University Medical Center, Leiden, the Netherlands
| | - Esther J Nossent
- Department of Pulmonology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Martijn A Spruit
- Department of Research and Development, CIRO+, Horn, the Netherlands; NUTRIM School of Nutrition and Translational Research in Metabolism, Faculty of Health, Medicine and Life Sciences, Maastricht, the Netherlands; Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Petr Symersky
- Department of Cardiac Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Hubert W Vliegen
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Bob Siegerink
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
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8
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Braams NJ, Boon GJAM, de Man FS, van Es J, den Exter PL, Kroft LJM, Beenen LFM, Huisman MV, Nossent EJ, Boonstra A, Vonk Noordegraaf A, Ruigrok D, Klok FA, Bogaard HJ, Meijboom LJ. Evolution of CT findings after anticoagulant treatment for acute pulmonary embolism in patients with and without an ultimate diagnosis of chronic thromboembolic pulmonary hypertension. Eur Respir J 2021; 58:13993003.00699-2021. [PMID: 34112733 DOI: 10.1183/13993003.00699-2021] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/13/2021] [Indexed: 01/18/2023]
Abstract
INTRODUCTION The pulmonary arterial morphology of patients with pulmonary embolism (PE) is diverse and it is unclear how the different vascular lesions evolve after initiation of anticoagulant treatment. A better understanding of the evolution of computed tomography pulmonary angiography (CTPA) findings after the start of anticoagulant treatment may help to better identify those PE patients prone to develop chronic thromboembolic pulmonary hypertension (CTEPH). We aimed to assess the evolution of various thromboembolic lesions on CTPA over time after the initiation of adequate anticoagulant treatment in individual acute PE patients with and without an ultimate diagnosis of CTEPH. METHODS We analysed CTPA at diagnosis of acute PE (baseline) and at follow-up in 41 patients with CTEPH and 124 patients without an ultimate diagnosis of CTEPH, all receiving anticoagulant treatment. Central and segmental pulmonary arteries were scored by expert chest radiologists as normal or affected. Lesions were further subclassified as 1) central thrombus, 2) total thrombotic occlusion, 3) mural thrombus, 4) web or 5) tapered pulmonary artery. RESULTS Central thrombi resolved after anticoagulant treatment, while mural thrombi and total thrombotic occlusions either resolved or evolved into webs or tapered pulmonary arteries. Only patients with an ultimate diagnosis of CTEPH exhibited webs and tapered pulmonary arteries on the baseline scan. Moreover, such lesions always persisted after follow-up. CONCLUSIONS Webs and tapered pulmonary arteries at the time of PE diagnosis strongly indicate a state of chronic PE and should raise awareness for possible CTEPH, particularly in patients with persistent dyspnoea after anticoagulant treatment for acute PE.
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Affiliation(s)
- Natalia J Braams
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Gudula J A M Boon
- Dept of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frances S de Man
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Josien van Es
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Paul L den Exter
- Dept of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Lucia J M Kroft
- Dept of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ludo F M Beenen
- Dept of Radiology, Amsterdam UMC, AMC, Amsterdam, The Netherlands
| | - Menno V Huisman
- Dept of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Esther J Nossent
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Anco Boonstra
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Anton Vonk Noordegraaf
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Dieuwertje Ruigrok
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Frederikus A Klok
- Dept of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Harm Jan Bogaard
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands .,H.J. Bogaard and L.J. Meijboom are co-last authors and contributed equally to this work
| | - Lilian J Meijboom
- Dept of Radiology and Nuclear Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,H.J. Bogaard and L.J. Meijboom are co-last authors and contributed equally to this work
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9
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Boon GJAM, Ende-Verhaar YM, Bavalia R, El Bouazzaoui LH, Delcroix M, Dzikowska-Diduch O, Huisman MV, Kurnicka K, Mairuhu ATA, Middeldorp S, Pruszczyk P, Ruigrok D, Verhamme P, Vliegen HW, Vonk Noordegraaf A, Vriend JWJ, Klok FA. Non-invasive early exclusion of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism: the InShape II study. Thorax 2021; 76:1002-1009. [PMID: 33758073 DOI: 10.1136/thoraxjnl-2020-216324] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 02/09/2021] [Accepted: 02/23/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND The current diagnostic delay of chronic thromboembolic pulmonary hypertension (CTEPH) after pulmonary embolism (PE) is unacceptably long, causing loss of quality-adjusted life years and excess mortality. Validated screening strategies for early CTEPH diagnosis are lacking. Echocardiographic screening among all PE survivors is associated with overdiagnosis and cost-ineffectiveness. We aimed to validate a simple screening strategy for excluding CTEPH early after acute PE, limiting the number of performed echocardiograms. METHODS In this prospective, international, multicentre management study, consecutive patients were managed according to a screening algorithm starting 3 months after acute PE to determine whether echocardiographic evaluation of pulmonary hypertension (PH) was indicated. If the 'CTEPH prediction score' indicated high pretest probability or matching symptoms were present, the 'CTEPH rule-out criteria' were applied, consisting of ECG reading and N-terminalpro-brain natriuretic peptide. Only if these results could not rule out possible PH, the patients were referred for echocardiography. RESULTS 424 patients were included. Based on the algorithm, CTEPH was considered absent in 343 (81%) patients, leaving 81 patients (19%) referred for echocardiography. During 2-year follow-up, one patient in whom echocardiography was deemed unnecessary by the algorithm was diagnosed with CTEPH, reflecting an algorithm failure rate of 0.29% (95% CI 0% to 1.6%). Overall CTEPH incidence was 3.1% (13/424), of whom 10 patients were diagnosed within 4 months after the PE presentation. CONCLUSIONS The InShape II algorithm accurately excluded CTEPH, without the need for echocardiography in the overall majority of patients. CTEPH was identified early after acute PE, resulting in a substantially shorter diagnostic delay than in current practice.
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Affiliation(s)
- Gudula J A M Boon
- Department of Thrombosis and Hemostasis, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | - Yvonne M Ende-Verhaar
- Department of Thrombosis and Hemostasis, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | - Roisin Bavalia
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Marion Delcroix
- Department of Pneumology, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Olga Dzikowska-Diduch
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warszawa, Poland
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | - Katarzyna Kurnicka
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warszawa, Poland
| | - Albert T A Mairuhu
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Piotr Pruszczyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warszawa, Poland
| | - Dieuwertje Ruigrok
- Department of Pulmonology, Amsterdam UMC, VU University Medical Centre, Amsterdam, The Netherlands
| | - Peter Verhamme
- Department of Cardiovascular Sciences, Centre for Molecular and Vascular Biology, University Hospitals Leuven, Leuven, Belgium
| | - Hubert W Vliegen
- Department of Cardiology, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonology, Amsterdam UMC, VU University Medical Centre, Amsterdam, The Netherlands
| | - Joris W J Vriend
- Department of Cardiology, Haga Teaching Hospital, The Hague, The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
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10
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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.
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Affiliation(s)
- Gudula J A M Boon
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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11
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van Dam LF, Kroft LJM, Boon GJAM, Huisman MV, Ninaber MK, Klok FA. Computed tomography pulmonary perfusion imaging and 3-months clinical outcomes after acute pulmonary embolism. Thromb Res 2020; 199:32-34. [PMID: 33387875 DOI: 10.1016/j.thromres.2020.12.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 12/10/2020] [Accepted: 12/14/2020] [Indexed: 12/23/2022]
Affiliation(s)
- Lisette F van Dam
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Gudula J A M Boon
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Maarten K Ninaber
- Department of Pulmonology, Leiden University Medical Center, Leiden, the Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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12
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Boon GJAM, Bogaard HJ, Klok FA. Essential aspects of the follow-up after acute pulmonary embolism: An illustrated review. Res Pract Thromb Haemost 2020; 4:958-968. [PMID: 32864549 PMCID: PMC7443426 DOI: 10.1002/rth2.12404] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/13/2020] [Accepted: 05/15/2020] [Indexed: 12/31/2022] Open
Abstract
Care for patients with acute pulmonary embolism (PE) involves more than determination of the duration of anticoagulant therapy. After choosing the optimal initial management strategy based on modern risk stratification schemes, patients require focused attention aimed at prevention of major bleeding, identification of underlying (malignant) disease, prevention of cardiovascular disease, and monitoring for long-term complications. The most frequent complication of PE is the so-called "post-PE syndrome," a phenomenon of permanent functional limitations after PE occurring in up to 50% of patients. The post-PE syndrome is caused by persistent deconditioning, anxiety, and/or ventilatory or circulatory impairment as a result of acute PE. The most severe and most feared presentation of the post-PE syndrome is chronic thromboembolic pulmonary hypertension (CTEPH), a deadly disease if it remains untreated. While CTEPH may be successfully treated with pulmonary endarterectomy, balloon pulmonary angioplasty, and/or pulmonary hypertension drugs, the major challenge is to diagnose CTEPH at an early stage. Poor awareness for the post-PE syndrome and in particular for CTEPH, high prevalence of persistent symptoms after PE and inefficient application of diagnostic tests in clinical practice all contribute to an unacceptable diagnostic delay and underdiagnosis. Its consequences are dire: increased mortality in patients with CTEPH, and excess health care costs, higher prevalence of depression, more unemployment and poorer quality of life in patients with post-PE syndrome in general. In this review, we provide an overview of the incidence and impact of the post-PE syndrome, and illustrate the clinical presentation, optimal diagnostic strategy as well as therapeutic options.
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Affiliation(s)
- Gudula J. A. M. Boon
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Harm Jan Bogaard
- Department of Pulmonary DiseasesInstitute for Cardiovascular Research (ICaR‐VU)Amsterdam University Medical Centerlocation VUmcAmsterdamThe Netherlands
| | - Frederikus A. Klok
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
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13
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Klok FA, Boon GJAM, Barco S, Endres M, Geelhoed JJM, Knauss S, Rezek SA, Spruit MA, Vehreschild J, Siegerink B. The Post-COVID-19 Functional Status scale: a tool to measure functional status over time after COVID-19. Eur Respir J 2020; 56:13993003.01494-2020. [PMID: 32398306 PMCID: PMC7236834 DOI: 10.1183/13993003.01494-2020] [Citation(s) in RCA: 284] [Impact Index Per Article: 71.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 05/06/2020] [Indexed: 12/31/2022]
Abstract
Since the outbreak of the coronavirus disease 2019 (COVID-19) pandemic, most attention has focused on containing transmission of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and addressing the surge of critically ill patients in acute care settings. Indeed, as of 29 April 2020, over 3 million confirmed cases have been accounted for globally [1]. In the coming weeks and months, emphasis will gradually involve also post-acute care of COVID-19 survivors. It is anticipated that COVID-19 may have a major impact on physical, cognitive, mental and social health status, also in patients with mild disease presentation [2]. Previous outbreaks of coronaviruses have been associated with persistent pulmonary function impairment, muscle weakness, pain, fatigue, depression, anxiety, vocational problems, and reduced quality of life to various degrees [3–5]. An ordinal tool is proposed to measure the full spectrum of functional outcomes following COVID-19. This “Post-COVID-19 Functional Status (PCFS) scale” can be used for tracking functional status over time as well as for research purposes.https://bit.ly/3cofGaa
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Affiliation(s)
- Frederikus A Klok
- Dept of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands .,Center for Thrombosis and Haemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Gudula J A M Boon
- Dept of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Stefano Barco
- Center for Thrombosis and Haemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.,Clinic of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Matthias Endres
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Dept of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Samuel Knauss
- Dept of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Spencer A Rezek
- Institute of Therapies and Rehabilitation, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Martijn A Spruit
- Dept of Research and Development, CIRO+, Horn, The Netherlands.,Dept of Respiratory Medicine, Maastricht University Medical Center (MUMC+), NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands.,REVAL Rehabilitation Research Center, BIOMED Biomedical Research Institute, Faculty of Rehabilitation Sciences, Hasselt University, Diepenbeek, Belgium
| | - Jörg Vehreschild
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Dept I for Internal Medicine, Cologne, Germany.,German Centre for Infection Research (DZIF), partner site Bonn-Cologne, Cologne, Germany.,Dept of Internal Medicine, Hematology/Oncology, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Bob Siegerink
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Dept of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
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14
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Boon GJAM, van der Putten K, van Hattem JM, Heidt J. Answer to Photoquiz Does it bite? Neth J Med 2020; 78:215. [PMID: 32641556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- G J A M Boon
- Departments of Intensive Care, Tergooi Hospital, Hilversum, the Netherlands
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15
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Boon GJAM, van der Putten K, van Hattem JM, Heidt J. Does it bite? Neth J Med 2020; 78:214. [PMID: 32641555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- G J A M Boon
- Department of Intensive Care, Tergooi Hospital, Hilversum, the Netherlands
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16
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Boon GJAM, van Rein N, Bogaard HJ, Ende-Verhaar YM, Huisman MV, Kroft LJM, van der Meer FJM, Meijboom LJ, Symersky P, Noordegraaf AV, Klok FA. Correction: Quality of initial anticoagulant treatment and risk of CTEPH after acute pulmonary embolism. PLoS One 2020; 15:e0234298. [PMID: 32484829 PMCID: PMC7266560 DOI: 10.1371/journal.pone.0234298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
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17
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Boon GJAM, van Rein N, Bogaard HJ, Ende-Verhaar YM, Huisman MV, Kroft LJM, van der Meer FJM, Meijboom LJ, Symersky P, Vonk Noordegraaf A, Klok FA. Quality of initial anticoagulant treatment and risk of CTEPH after acute pulmonary embolism. PLoS One 2020; 15:e0232354. [PMID: 32343741 PMCID: PMC7188241 DOI: 10.1371/journal.pone.0232354] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 04/13/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The pathophysiology of chronic thromboembolic pulmonary hypertension (CTEPH) is not fully understood. Poor-quality anticoagulation may contribute to a higher risk of CTEPH after acute pulmonary embolism (PE), partly explaining the transition from acute PE to CTEPH. We assessed the association between the time in therapeutic range (TTR) of vitamin-K antagonist (VKA) treatment and incidence of CTEPH after a PE diagnosis. METHODS Case-control study in which the time spent in, under and above therapeutic range was calculated in 44 PE patients who were subsequently diagnosed with CTEPH (cases). Controls comprised 150 consecutive PE patients in whom echocardiograms two years later did not show pulmonary hypertension. All patients were treated with VKA for at least 6 months after the PE diagnosis. Time in (TTR), under and above range were calculated. Mean differences between cases and controls were estimated by linear regression. RESULTS Mean TTR during the initial 6-month treatment period was 72% in cases versus 78% in controls (mean difference -6%, 95%CI -12 to -0.1), mainly explained by more time above the therapeutic range in the cases. Mean difference of time under range was 0% (95%CI -6 to 7) and 2% (95CI% -3 to 7) during the first 3 and 6 months, respectively. In a multivariable model, adjusted odds ratios (ORs) for CTEPH were around unity considering different thresholds for 'poor anticoagulation', i.e. TTR <50%, <60% and <70%. CONCLUSION Subtherapeutic initial anticoagulation was not more prevalent among PE patients diagnosed with CTEPH than in those who did not develop CTEPH.
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Affiliation(s)
- Gudula J. A. M. Boon
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Nienke van Rein
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Harm Jan Bogaard
- Department of Pulmonary Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Yvonne M. Ende-Verhaar
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Menno V. Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Lucia J. M. Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Felix J. M. van der Meer
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Lilian J. Meijboom
- Department of Radiology and Nuclear medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Petr Symersky
- Department of Cardiac Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonary Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Frederikus A. Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
- * E-mail:
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18
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Boon GJAM, Barco S, Bertoletti L, Ghanima W, Huisman MV, Kahn SR, Noble S, Prandoni P, Rosovsky RP, Sista AK, Siegerink B, Klok FA. Measuring functional limitations after venous thromboembolism: Optimization of the Post-VTE Functional Status (PVFS) Scale. Thromb Res 2020; 190:45-51. [PMID: 32298840 DOI: 10.1016/j.thromres.2020.03.020] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 03/25/2020] [Accepted: 03/27/2020] [Indexed: 12/24/2022]
Abstract
INTRODUCTION We recently proposed a scale for assessment of patient-relevant functional limitations following an episode of venous thromboembolism (VTE). Further development of this post-VTE functional status (PVFS) scale is still needed. METHODS Guided by the input of VTE experts and patients, we refined the PVFS scale and its accompanying manual, and attempted to acquire broad consensus on its use. RESULTS A Delphi analysis was performed involving 53 international VTE experts with diverse scientific and clinical backgrounds. In this process, the number of scale grades of the originally proposed PVFS scale was reduced and descriptions of the grades were improved. After these changes, a consensus was reached on the number/definitions of the grades, and method/timing of the scale assessment. The relevance and potential impact of the scale was confirmed in three focus groups totaling 18 VTE patients, who suggested additional changes to the manual, but not to the scale itself. Using the improved manual, the κ-statistics between PVFS scale self-reporting and its assessment via the structured interview was 0.75 (95%CI 0.58-1.0), and 1.0 (95%CI 0.83-1.0) between independent raters of the recorded interview of 16 focus groups members. CONCLUSION We improved the PVFS scale and demonstrated broad consensus on its relevance, optimal grades, and methods of assessing among international VTE experts and patients. The interobserver agreement of scale grade assignment was shown to be good-to-excellent. The PVFS scale may become an important outcome measure of functional impairment for quality of patient care and in future VTE trials.
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Affiliation(s)
- G J A M Boon
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - S Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany; Clinic of Angiology, University Hospital of Zurich, Zurich, Switzerland
| | - L Bertoletti
- Service de Médecine Vasculaire et Thérapeutique, CHU de St-Étienne, Saint-Étienne, France; INSERM UMR 1059 and CIC 1408, Université Jean-Monnet, Saint-Étienne, France
| | - W Ghanima
- Department of Oncology, Østfold Hospital Trust, Kalnes, Norway; Department Medicine and Research, Østfold Hospital Trust, Kalnes, Norway
| | - M V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - S R Kahn
- Division of Clinical Epidemiology, Department of Medicine, Jewish General Hospital, Montreal, QC, Canada
| | - S Noble
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
| | - P Prandoni
- Arianna Foundation on Anticoagulation, Bologna, Italy
| | - R P Rosovsky
- Department of Medicine, Hematology/Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - A K Sista
- Department of Radiology, New York University School of Medicine, New York, NY, United States
| | - B Siegerink
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - F A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands; Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany.
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19
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Klok FA, Meijboom LJ, Kroft LJM, Beenen LFM, Boon GJAM, Middeldorp S, Huisman MV, Bogaard HJ, Vonk Noordegraaf A, Ende-Verhaar YM. P1625Identification of chronic thromboembolic pulmonary hypertension on standard computed tomography pulmonary angiography for suspected acute pulmonary embolism. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.p1625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- F A Klok
- Leiden University Medical Center, Leiden, Netherlands
| | - L J Meijboom
- VU University Medical Center, Amsterdam, Netherlands
| | - L J M Kroft
- Leiden University Medical Center, Leiden, Netherlands
| | - L F M Beenen
- Academic Medical Center of Amsterdam, Amsterdam, Netherlands
| | - G J A M Boon
- Leiden University Medical Center, Leiden, Netherlands
| | - S Middeldorp
- Academic Medical Center of Amsterdam, Amsterdam, Netherlands
| | - M V Huisman
- Leiden University Medical Center, Leiden, Netherlands
| | - H J Bogaard
- VU University Medical Center, Amsterdam, Netherlands
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20
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Boon GJAM, Ruurda JP, Bogte A, van Hillegersberg R, Minderhoud IM, Heidt J. Sudden subcutaneous emphysema and dysphagia in a 46-year-old woman. Neth J Med 2018; 76:302. [PMID: 30152397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- G J A M Boon
- Department of Intensive Care, Tergooi Hospital, Hilversum, the Netherlands
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