Derivation of a clinical prediction score for chronic thromboembolic pulmonary hypertension after acute pulmonary embolism.
Essentials Predicting chronic thromboembolic pulmonary hypertension (CTEPH) after pulmonary embolism is hard. We studied 772 patients with pulmonary embolism who were followed for CTEPH (incidence 2.8%). Logistic regression analysis revealed 7 easily collectable clinical variables that combined predict CTEPH. Our score identifies patients at low (0.38%) or higher (10%) risk of CTEPH.


CONCLUSIONS
Introduction Validated risk factors for the diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH) after acute pulmonary embolism (PE) are currently lacking. Methods This is a post hoc patient-level analysis of three large prospective cohorts with a total of 772 consecutive patients with acute PE, without major cardiopulmonary or malignant comorbidities. All underwent echocardiography after a median of 1.5 years. In cases with signs of pulmonary hypertension, additional diagnostic tests to confirm CTEPH were performed. Baseline demographics and clinical characteristics of the acute PE event were included in a multivariable regression analysis. Independent predictors were combined in a clinical prediction score. Results CTEPH was confirmed in 22 patients (2.8%) by right heart catheterization. Unprovoked PE, known hypothyroidism, symptom onset > 2 weeks before PE diagnosis, right ventricular dysfunction on computed tomography or echocardiography, known diabetes mellitus and thrombolytic therapy or embolectomy were independently associated with a CTEPH diagnosis during follow-up. The area under the receiver operating charateristic curve (AUC) of the prediction score including those six variables was 0.89 (95% confidence interval [CI] 0.84-0.94). Sensitivity analysis and bootstrap internal validation confirmed this AUC. Seventy-three per cent of patients were in the low-risk category (CTEPH incidence of 0.38%, 95% CI 0-1.5%) and 27% were in the high-risk category (CTEPH incidence of 10%, 95% CI 6.5-15%). Conclusion The 'CTEPH prediction score' allows for the identification of PE patients with a high risk of CTEPH diagnosis after PE. If externally validated, the score may guide targeting of CTEPH screening to at-risk patients.
Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.|Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany.
F A
FA
Klok
Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland.
O
O
Dzikowska-Diduch
Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland.
M
M
Kostrubiec
Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands.
H W
HW
Vliegen
Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland.
P
P
Pruszczyk
Clinic of Cardiology and Pneumology, Heart Center, Georg-August University of Göttingen, Göttingen, Germany.
G
G
Hasenfuß
Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
M V
MV
Huisman
Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany.
S
S
Konstantinides
Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany.|Clinic of Cardiology and Pneumology, Heart Center, Georg-August University of Göttingen, Göttingen, Germany.
M
M
Lankeit
D000328:Adult; D000368:Aged; D019540:Area Under Curve; D004452:Echocardiography; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D006976:Hypertension, Pulmonary / Q000150:complications / Q000175:diagnosis* / Q000453:epidemiology; D015994:Incidence; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010045:Outpatients; D011237:Predictive Value of Tests; D011655:Pulmonary Embolism / Q000150:complications / Q000175:diagnosis* / Q000453:epidemiology; D012372:ROC Curve; D012044:Regression Analysis; D012307:Risk Factors; D012680:Sensitivity and Specificity; D013923:Thromboembolism / Q000150:complications / Q000175:diagnosis* / Q000453:epidemiology
decision support techniques; early diagnosis; prognosis; pulmonary embolism; pulmonary hypertension