Prospective evaluation of right ventricular function and functional status 6 months after acute submassive pulmonary embolism: frequency of persistent or subsequent elevation in estimated pulmonary artery pressure.
BACKGROUND
No published data have systematically documented pulmonary artery pressure over an intermediate time period after submassive pulmonary embolism (PE). The aim of this work was to document the rate of pulmonary hypertension, as assessed noninvasively by estimated right ventricular systolic pressure (RVSP) of >or= 40 mm Hg 6 months after the diagnosis of submassive PE.


METHODS
We enrolled 200 normotensive patients with CT angiography-proven PE and a baseline echocardiogram to estimate RVSP. All patients received therapy with unfractionated heparin initially, but 21 patients later received alteplase in response to circulatory shock or respiratory failure. Patients returned at 6 months for repeat RVSP measurement, and assessments of the New York Heart Association (NYHA) score and 6-min walk distance (6MWD).


RESULTS
Six months after receiving a diagnosis, 162 of 180 survivors (90%) returned for follow-up, including 144 patients who had been treated with heparin (heparin-only group) and 18 patients who had been treated with heparin plus alteplase (heparin-plus-alteplase group). Among the heparin-only patients, the RVSP at diagnosis was >or= 40 mm Hg in 50 of 144 patients (35%; 95% CI, 27% to 43%), compared with 10 of 144 patients at follow-up (7%; 95% CI, 3% to 12%). However, the RVSP at follow-up was higher than the baseline RVSP in 39 of 144 patients (27%; 95% CI, 9% to 35%), and 18 of these 39 patients had a NYHA score of >or= 3 or exercise intolerance (6MWD, < 330 m). Among heparin-plus-alteplase patients, the RVSP was >or= 40 mm Hg in 11 of 18 patients at diagnosis (61%; 95% CI, 36% to 83%), compared with 2 of 18 patients at follow-up (11%; 95% CI, 1% to 35%). The RVSP at follow-up was not higher than at the time of diagnosis in any of the heparin-plus-alteplase patients (95% CI, 0% to 18%).


CONCLUSIONS
Six months after experiencing submassive PE, a significant proportion of patients had echocardiographic and functional evidence of pulmonary hypertension.
Kline
Jeffrey A
JA
Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC. Electronic address: jkline@carolinas.org.
Steuerwald
Michael T
MT
Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC.
Marchick
Michael R
MR
Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC.
Hernandez-Nino
Jackeline
J
Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC.
Rose
Geoffrey A
GA
Carolinas Heart and Vascular Institute, Carolinas Medical Center, Charlotte, NC.
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001794:Blood Pressure; D004298:Dopamine / Q000627:therapeutic use; D004452:Echocardiography; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D005500:Follow-Up Studies; D006493:Heparin / Q000627:therapeutic use; D006801:Humans; D006976:Hypertension, Pulmonary / Q000453:epidemiology*; D008875:Middle Aged; D018579:Patient Selection; D011651:Pulmonary Artery / Q000503:physiopathology*; D011655:Pulmonary Embolism / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000401:mortality / Q000503:physiopathology*; D017741:Survivors; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D016278:Ventricular Function, Right / Q000502:physiology*; D055815:Young Adult
D005343:Fibrinolytic Agents; D006493:Heparin; D010959:Tissue Plasminogen Activator; D004298:Dopamine