Chest
Volume 130, Issue 1, July 2006, Pages 172-175
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Original Research
Incidence of Chronic Thromboembolic Pulmonary Hypertension After a First Episode of Pulmonary Embolism

https://doi.org/10.1378/chest.130.1.172Get rights and content

Study objective

To assess the incidence of chronic thromboembolic pulmonary hypertension (CTPH) after the first episode of objectively confirmed pulmonary embolism (PE).

Design

Prospective cohort study in 12 Italian medical centers.

Patients

Consecutive patients treated with oral anticoagulants for the first episode of PE, either idiopathic or associated with temporary risk factors, were followed up for at least 3 years. Patients were excluded from the study if they had a known persistent risk factor for venous thromboembolism (VTE).

Interventions

At the follow-up visits, patients were evaluated for persistent dyspnea, either at rest or on exertion. All patients who were referred with dyspnea were assessed by transthoracic echocardiography, with evaluation of the systolic and mean pulmonary artery pressures. Patients with evidence of pulmonary hypertension on echocardiography underwent perfusion lung scans and pulmonary angiography to confirm the diagnosis of CTPH.

Results

Overall, 259 patients were included in the study. PE was idiopathic in 135 patients, while it was associated with at least a temporary risk factor for VTE in 124 patients. After an average follow-up period of 46 months, 37 patients were found to have persistent dyspnea that was unexplained in 5 patients. Among these patients, a diagnosis of CTPH was confirmed in two patients with idiopathic PE (0.8% of the overall study population [95% confidence interval (CI), 0.0 to 1.9]; 1.5% of patients with idiopathic PE [95% CI, 0.0 to 3.6]). The diagnosis was made 14 and 22 months, respectively, after the acute PE.

Conclusions

The incidence of CTPH observed in this study was about 1%. CTPH was observed in two patients with idiopathic PE.

Section snippets

Patients

Consecutive patients who experienced a first episode of symptomatic, objectively confirmed PE, either idiopathic or associated with one or more temporary risk factors, were included in the study. For the purpose of this study, recent surgery, trauma with or without bone fracture, oral contraceptives, and prolonged bed rest were considered to be temporary risk factors for VTE. Initial PE was confirmed by pulmonary angiography, spiral CT scan, high-probability lung scan, or an

Materials and Methods

After the episode of acute PE, patients were evaluated every 3 months in the first year and then every 6 months for at least 3 years. In patients who presented with persistent dyspnea, either at rest or on exertion, a medical history was collected and a physical examination was performed to identify the potential causes of dyspnea. The presence of COPD, chronic heart failure, and interstitial lung diseases was confirmed by objective testing. All patients with persistent dyspnea underwent

Results

Overall, 259 patients were included in the study (145 were women; mean [± SD] age, 61 ± 16 years). PE was idiopathic or unprovoked in 135 patients, while in 124 patients it was associated with at least one temporary risk factor. Twenty patients (7.7%) received thrombolytic treatment in the acute phase of PE during the follow-up period. The average follow-up period was 46 months. Twenty-one patients died (8.1%) and 31 patients had a recurrence of VTE (12%), which was a second PE in 15 patients.

Discussion

After an average follow-up period of 46 months (minimum follow-up period, 3 years) of a cohort of patients with a first episode of acute PE, we observed an incidence of symptomatic CTPH of 0.8%. The incidence of symptomatic CTPH in patients with idiopathic PE was 1.5%. These incidences are consistent with those observed in previous studies.12 Furthermore, the 95% upper limit of the CI for the incidence of idiopathic CTPH after PE (3.6) is consistent with the incidence of 3.8% seen in the most

Appendix

Other investigators and sites involved in the study were as follows: Maddalena Miccio, MD, Unita Operativa Medicina d’Urgenza, Ospedale di Cattinara, Trieste, Italy; Davide Imberti, MD, Unita Operativa di Medicina Interna, Ospedale di Piacenza, Piacenza, Italy; Ferdinando Porro, MD, Medicina d’Urgenza, Ospedale Maggiore Policlinico, Milan, Italy; Adriano Bertoldi, MD, Divisione di Chirurgia Vascolare, Ospedale S. Chiara, Trento, Italy; Luigi Ria, MD, Emostasi ed Angiologia Medica, Ospedale

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

A list of other investigators and sites involved in the study is located in the Appendix.

None of the authors has any conflict of interest to disclose.

This study was performed without any external financial support.

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