Incomplete thrombus resolution occurs in 25-50% of patients after acute PE despite adequate anticoagulation. Persistent obstruction of the pulmonary arteries and accompanying secondary microvasculopathy may cause progressive increase of pulmonary artery pressure leading to chronic thromboembolic pulmonary hypertension (CTEPH). An active screening algorithm was suggested in the 2019 ESC/ERS guidelines on pulmoanary embolis (PE), and recommended to apply echocardiography 3 to 6 months after PE diagnosis in all patients with persistent dyspnoea or predisposing conditions for CTEPH. Since at 50% of PE survicors report dyspone, this indicates high load for need for echocardiograpy.
For this newsletter we selected the InShape II study which was a prospective international single-arm management study with consecutive patients managed according to a screening algorithm starting three months after acute PE. All patienst were clinicaly evaluated for CTEPH proability. When this ‘CTEPH prediction score’ indicated high pre-test probability or symptoms were present, the ‘CTEPH rule-out criteria’ were applied, consisting of ECG and NT-proBNP levels. If ecg showed RV strain or NTproBNP was elevated echocardiography was performed. In consecutive 424 patients according to the algorithm, CTEPH was considered absent in 81% patients, while only 81 patients (19%) referred for echocardiography. During two-year follow-up CTEPH incidence was 3.1% (13/424). Of note only one patient in whom echocardiography was deemed unnecessary by InShape algorithm was eventually diagnosed with CTEPH, indicating an algorithm failure rate of 0.29% (95%CI 0-1.6%). Results of the InShape II study potentially provide an alternative to the “echocardiographic based” follow-up algorithm limiting the need for echocardiography. Moreover, algorhythm with ecg and NtproBNp assay can be easily applied even in primary care setting facilitating early CTEPH diagnosis.
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