https://doi.org/10.1007/s00392-025-02625-4
1Universitätsmedizin der Johannes Gutenberg-Universität Mainz Centrum für Thrombose und Hämostase Mainz, Deutschland; 2Universitätspital Zürich Zürich, Schweiz; 3Universitätsmedizin der Johannes Gutenberg-Universität Mainz Zentrum für Kardiologie Mainz, Deutschland; 4Herz- und Diabeteszentrum NRW Allgemeine und Interventionelle Kardiologie/Angiologie Bad Oeynhausen, Deutschland; 5Universitätsmedizin Greifswald Greifswald, Deutschland; 6Klinikum Esslingen Esslingen am Neckar, Deutschland; 7Universitätsklinikum Essen Essen, Deutschland; 8Klinikum Würzburg Mitte gGmbH Innere Abteilung Würzburg, Deutschland; 9Universitätsmedizin der Johannes Gutenberg-Universität Mainz Kardiologie 1, Zentrum für Kardiologie Mainz, Deutschland; 10Herzzentrum der Universität zu Köln Klinik III für Innere Medizin Köln, Deutschland; 11Leiden University Medical Center Leiden, Niederlande
Objective: To assess the performance of the 2019 ESC guidelines-recommended follow-up algorithm after acute PE.
Methods: In a prospective cohort study, consecutive unselected survivors of acute PE underwent comprehensive 3-month follow-up, including clinical assessment, laboratory examination, echocardiography, and cardiopulmonary exercise testing (CPET). The echocardiographic probability of pulmonary hypertension (PH) was determined according to the criteria of the European Guidelines, while presence of cardiopulmonary limitation on CPET included ventilatory inefficiency and insufficient cardiocirculatory reserve. Besides independently adjudicated chronic thromboembolic PH (CTEPH) over two-year follow-up, post-PE impairment (PPEI) was prospectively defined as combined echocardiographic with clinical, functional, and laboratory abnormalities.
Results: Of 530 patients, 437 (82.5%) presented with dyspnea or functional limitation (84% of 437), or risk factors for CTEPH (61% of 437) and were eligible for echocardiography at 3-month follow-up as per current guideline recommendations. Of these, 101 (23.1%) had high echocardiographic PH probability, or intermediate probability with cardiopulmonary limitation on CPET, natriuretic peptides, or CTEPH risk factors, thus qualifying for V/Q scan according to current guidelines’ recommendations; these included 9/12 confirmed CTEPH cases. Only 2.2% and 2.6% of patients formally not needing echocardiography showed high echocardiographic PH probability and severe cardiopulmonary limitation on CPET, respectively. Of patients fulfilling the guideline indications for echocardiography, the majority had low echocardiographic PH probability (329/437; 75.3%). Of patients with low echocardiographic probability who also underwent CPET, 50% showed mild to severe cardiopulmonary limitation. Overall, 141 more patients would qualify for a V/Q scan on the basis of CPET results, NT-proBNP elevation and risk factors of CTEPH. In addition, 54% of patients with PPEI and 3/12 patients with confirmed CTEPH were found within the ‘low-probability’ population, based on echocardiography only. To identify enhancing factors that would drive further exercise testing in patients with low echocardiographic probability we investigated factors independently associated with severe cardiopulmonary limitation on CPET but low echocardiographic probability of PH. These revealed the presence and severity of dyspnoea at 3 months, a high- or intermediate-risk vs a low-risk PE index event, low body mass index, and active cancer at baseline as possible factors for reduced cardiopulmonary capacity in patients with low echocardiographic probability of PH. The results of the study are summarized in Figure 1.
Conclusion: Currently recommended algorithms primarily identify patients at the upper end of the PE sequelae spectrum. CPET may be necessary for timely recognition of patients at risk or those with milder forms of long-term post-PE impairment.