Chronic thromboembolic pulmonary hypertension after pulmonary embolism is associated with high morbidity and mortality. Understanding the incidence of chronic thromboembolic pulmonary hypertension ...after pulmonary embolism is important for evaluating the need for screening but is also a subject of debate because of different inclusion criteria among previous studies. We determined the incidence of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism and the utility of a screening program for this disease.
We conducted a cohort screening study in an unselected series of consecutive patients (n=866) diagnosed with acute pulmonary embolism between January 2001 and July 2007. All patients who had not been previously diagnosed with pulmonary hypertension (PH) and had survived until study inclusion were invited for echocardiography. Patients with echocardiographic suspicion of PH underwent complete work-up for chronic thromboembolic pulmonary hypertension, including ventilation-perfusion scintigraphy and right heart catheterization.
After an average follow-up of 34 months of all 866 patients, PH was diagnosed in 19 patients by routine clinical care and in 10 by our screening program; 4 patients had chronic thromboembolic pulmonary hypertension, all diagnosed by routine clinical care. The cumulative incidence of chronic thromboembolic pulmonary hypertension after all cause pulmonary embolism was 0.57% (95% confidence interval CI 0.02-1.2%) and after unprovoked pulmonary embolism 1.5% (95% CI 0.08-3.1%).
Because of the low incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism and the very low yield of the echocardiography based screening program, wide scale implementation of prolonged follow-up including echocardiography of all patients with pulmonary embolism to detect chronic thromboembolic pulmonary hypertension does not seem to be warranted.
Abstract Background Our aim was to construct a diagnostic model for ruling out chronic thromboembolic pulmonary hypertension (CTEPH) in symptomatic patients after acute pulmonary embolism (PE) that ...is based on simple, non-invasive tests. Methods Plasma levels of various CTEPH associated biomarkers and conventional ECG criteria for right ventricular pressure overload were assessed in 82 consecutive patients with confirmed CTEPH and 160 consecutive patients with a history of PE who were suspected to have CTEPH, but in whom this disease was ruled out. Results ECG criteria of right ventricular hypertrophy were detected more frequently in patients with CTEPH (77%) than in the patients without CTEPH (11%, Odds ratio 26, 95% confidence interval CI 13–53). Also, clotting factor FVIII activity and the levels of N-terminal-pro-brain-type natriuretic peptide (NT-pro-BNP), Growth Differentiation Factor-15, C-reactive protein and urate, but not D-dimer level, were higher in patients with CTEPH. A diagnostic model including ECG criteria and NT-pro-BNP levels had a sensitivity of 94% (95% CI 86-98%) and a specificity of 65% (95% CI 56-72%). The area under the receiver-operator-characteristic curve was 0.80 (95% CI 0.74-0.85) for the diagnosis of CTEPH. Even with high disease prevalences of up to 10%, the negative predictive value of this model proved to be very high (99%, 95% CI 97-100%). Conclusions Ruling out CTEPH in patients after acute PE seems to be safe without additional diagnostic testing in absence of ECG criteria indicative of right ventricular hypertrophy and a normal NT-pro-BNP level.
Summary Background The exact prevalence and etiology of exertional dyspnea in the clinical course of acute pulmonary embolism (PE) have not yet been established. Methods A large cohort of consecutive ...patients diagnosed with acute PE was subjected to a dyspnea questionnaire and invited for cardiopulmonary work-up including the 6-min walk test, spirometry and echocardiography. The prevalence, severity, determinants and underlying diseases of exertional dyspnea were evaluated. Results Of the registered 877 patients, 259 (30%) had died and 11 (1.3%) were excluded for geographical reasons. From the remaining 607 patients, 217 reported exertional dyspnea (36%; 95% CI 32–40%) 3.6 ± 1.7 years after the PE. In 76% this dyspnea had developed or worsened after the acute PE. 421 patients completed the cardiopulmonary work-up. Cardiopulmonary comorbidity (OR 12; 95% CI 6.5–20), advanced age (OR 1.02 per year; 95% CI 1.01–1.03), higher BMI (OR 1.06 per kg/m2 ; 95% CI 1.01–1.1) and a smoking history (OR 1.6; 95% CI 1.02–2.6) were identified as independent predictors of exertional dyspnea. A pre-defined dyspnea explaining diagnosis could be established in all patients with exertional dyspnea. In only 4 patients, this diagnosis was directly correlated to the acute PE. Increased severity of dyspnea was associated with decreased exercise performance ( p < 0.001) and a higher number of dyspnea-related diagnoses ( p < 0.001). Conclusion Exertional dyspnea is a frequent symptom in the long term clinical course of acute PE. More severe dyspnea results in decreased exercise capacity and increased burden of cardiopulmonary comorbidity. This dyspnea is likely to be unrelated to the past thromboembolic event in the vast majority of patients.
Background: Traditionally, patients with pulmonary embolism (PE) are initially treated in the hospital with low molecular weight heparin (LMWH). The results of a few small non‐randomized studies ...suggest that, in selected patients with proven PE, outpatient treatment is potentially feasible and safe. Objective: To evaluate the efficacy and safety of outpatient treatment according to predefined criteria in patients with acute PE. Patients and Methods: A prospective cohort study of patients with objectively proven acute PE was conducted in 12 hospitals in The Netherlands between 2008 and 2010. Patients with acute PE were triaged with the predefined criteria for eligibility for outpatient treatment, with LMWH (nadroparin) followed by vitamin K antagonists. All patients eligible for outpatient treatment were sent home either immediately or within 24 h after PE was objectively diagnosed. Outpatient treatment was evaluated with respect to recurrent venous thromboembolism (VTE), including PE or deep vein thrombosis (DVT), major hemorrhage and total mortality during 3 months of follow‐up. Results: Of 297 included patients, who all completed the follow‐up, six (2.0%; 95% confidence interval CI 0.8–4.3) had recurrent VTE (five PE 1.7% and one DVT 0.3%). Three patients (1.0%, 95% CI 0.2–2.9) died during the 3 months of follow‐up, none of fatal PE. Two patients had a major bleeding event, one of which was fatal intracranial bleeding (0.7%, 95% CI 0.08–2.4). Conclusion: Patients with PE selected for outpatient treatment with predefined criteria can be treated with anticoagulants on an outpatient basis. (Dutch Trial Register No 1319; http://www.trialregister.nl/trialreg/index.asp).
Background: Even though quality of life (QoL) has become a key component of medical care, there is no instrument available that specifically measures QoL after pulmonary embolism (PE). Recently, the ...Pulmonary Embolism Quality of Life (PEmb‐QoL) Questionnaire has been developed to address this gap. Objective: To evaluate the validity of the PEmb‐QoL questionnaire. Methods: We distributed the PEmb‐QoL questionnaire and the Short Form‐36 (SF‐36) questionnaire twice among consecutive subjects with a history of objectively confirmed acute PE. Internal consistency reliability, test‐retest reliability, convergent validity and criterion validity, and correlations between the PEmb‐QoL and clinical patient characteristics were assessed using standard‐scale construction techniques. Results: Ninety participants completed the questionnaires twice. Internal consistency was adequate (Cronbach’s α 0.62–0.94), as well as test‐retest reliability (intra‐class correlation coefficients: 0.78–0.94). Furthermore, correlation between the PEmb‐QoL questionnaire and the SF‐36 questionnaire supported convergent validity. Age, obesity, cardiopulmonary comorbidity, centrally located PE and a family history of venous thromboembolism were shown to be independent determinants of disease‐specific QoL. Conclusion: The PEmb‐QoL questionnaire is a reliable instrument to specifically assess QoL following PE, which is helpful in the identification of patients with decreased QoL following acute PE.
Altered sleep characteristics during polysomnography and actigraphy in patients previously treated for nonfunctioning macroadenoma are associated with impaired subjective sleep quality.
Context and ...Objective:
Fatigue and excessive sleepiness have been reported after treatment of nonfunctioning pituitary macroadenomas (NFMA). Because these complaints may be caused by disturbed nocturnal sleep, we evaluated objective sleep characteristics in patients treated for NFMA.
Design:
We conducted a controlled cross-sectional study.
Subjects and Methods:
We studied 17 patients (8 women; mean age, 54 yr) in remission of NFMA during long-term follow-up (8 yr; range, 1–18 yr) after surgery (n = 17) and additional radiotherapy (n = 5) without comorbidity except for hypopituitarism and 17 controls matched for age, gender, and body mass index. Sleep was assessed by nocturnal polysomnography, sleep and diurnal movement patterns by actigraphy, and quality of life and subjective sleep characteristics by questionnaires.
Results:
Compared to controls, patients had reduced sleep efficiency, less rapid eye movement sleep, more N1 sleep, and more awakenings in the absence of excessive apnea or periodic limb movements. Actigraphy revealed a longer sleep duration and profound disturbances in diurnal movement patterns, with more awakenings at night and less activity during the day. Patients scored higher on fatigue and reported impaired quality of life.
Conclusion:
Patients previously treated for NFMA suffer from decreased subjective sleep quality, disturbed distribution of sleep stages, and disturbed circadian movement rhythm. These observations indicate that altered sleep characteristics may be a factor contributing to impaired quality of life and increased fatigue in patients treated for NFMA.
Abstract Background There is a lack of information on long term complications of patients with pulmonary embolism (PE), including chronic complaints of dyspnea. Methods Consecutive patients with a ...prior diagnosis of acute PE and an age and gender matched control group with no medical history of PE were presented with a questionnaire, designed to establish the presence, severity and possible causes of dyspnea in the clinical course of PE. Results The questionnaire was taken in 48 PE-survivors 40 ± 7.4 months after PE; 27 patients (56%) had complaints of dyspnea. Sixteen (35%) were categorized as NYHA class II, 6 (13%) as class III and 5 (10%) as class IV. Overall, 19 patients (70%) had new or worsened complaints after PE. The study included 61 controls. Corrected for gender, age and medical history, the control group was significantly less dyspnoeic compared to the PE survivors ( p < 0.001). Corrected for gender and age, patients were 4 times more often in NYHA class II (OR 3.6 95%CI 1.4–9.7) and 7-fold more often in NYHA class III or IV (OR 6.5 95%CI 1.7–24), both compared to control subjects. Conclusion A large percentage of patients with prior PE have persistent complaints of dyspnea at long term follow-up. The majority of them developed new or worsened dyspnea after the thrombo-embolic event. In comparison to a control population without a medical history of VTE, PE patients were overall significantly more dyspnoeic. An explanation for this phenomenon needs to be studied in further functional work-up of these patients.
Purpose
Tumors in the carotid bodies may interfere with their function as peripheral chemoreceptors. An altered control of ventilation may predispose to sleep-disordered breathing. This study aimed ...to assess whether patients with unilateral or bilateral carotid body tumors (uCBT or bCBT, respectively) or bilateral CBT resection (bCBR) display sleep-disordered breathing and to evaluate the global contribution of the peripheral chemoreceptor to the hypercapnic ventilatory response.
Methods
Eight uCBT, eight bCBT, and nine bCBR patients and matched controls underwent polysomnography. The peripheral chemoreflex drive was assessed using euoxic and hyperoxic CO
2
rebreathing tests. Daytime sleepiness and fatigue were assessed with the Epworth Sleepiness Scale and the Multidimensional Fatigue Index.
Results
All patient groups reported significant fatigue-related complaints, but no differences in excessive daytime sleepiness (EDS) were found. The apnea/hypopnea index (AHI) did not differ significantly between patient groups and controls. Only in bCBT patients, a trend towards a higher AHI was observed, but this did not reach significance (
p
= 0.06). No differences in the peripheral chemoreflex drive were found between patients and controls.
Conclusions
Patients with (resection of) CBTs have more complaints of fatigue but are not at risk for EDS. The presence or resection of CBTs is neither associated with an altered peripheral chemoreflex drive nor with sleep-disordered breathing.
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