Chronic thromboembolic pulmonary hypertension is an uncommon complication of COVID-19: UK national surveillance and observational screening cohort studies

Abstract

Background: Pulmonary embolism (PE) is a well-recognised complication of coronavirus disease 2019 (COVID-19) infection, and chronic thromboembolic pulmonary disease with and without pulmonary hypertension (CTEPD/CTEPH) are potential life-limiting consequences. At present the burden of CTEPD/CTEPH is unclear and optimal and cost-effective screening strategies yet to be established.

Methods: We evaluated the CTEPD/CTEPH referral rate to the UK national multidisciplinary team (MDT) during the 2017-2022 period to establish the national incidence of CTEPD/CTEPH potentially attributable to COVID-19-associated PE with historical comparator years. All individual cases of suspected CTEPH were reviewed by the MDT for evidence of associated COVID-19. In a separate multicentre cohort, the risk of developing CTEPH following hospitalisation with COVID-19 was calculated using simple clinical parameters at a median of 5 months post-hospital discharge according to existing risk scores using symptoms, ECG and N-terminal pro-brain natriuretic peptide.

Results: By the second year of the pandemic, CTEPH diagnoses had returned to the pre-pandemic baseline (23.1 versus 27.8 cases per month; p=0.252). Of 334 confirmed CTEPD/CTEPH cases, four (1.2%) patients were identified to have CTEPH potentially associated with COVID-19 PE, and a further three (0.9%) CTEPD without PH. Of 1094 patients (mean age 58 years, 60.4% male) hospitalised with COVID-19 screened across the UK, 11 (1.0%) were at high risk of CTEPH at follow-up, none of whom had a diagnosis of CTEPH made at the national MDT.

Conclusion: A priori risk of developing CTEPH following COVID-19-related hospitalisation is low. Simple risk scoring is a potentially effective way of screening patients for further investigation.

Summary of the background, methods and results of the study, highlighting the two complementary national datasets. COVID-19: coronavirus disease 2019; PE: pulmonary embolism; CTEPH: chronic thromboembolic pulmonary hypertension; PHOSP-COVID: Post-Hospitalisation COVID-19; D-12: Dyspnea-12; NT-proBNP: N-terminal pro-brain natriuretic peptide. Servier Medical Art material used under CC BY 4.0 licence: https://creativecommons.org/licenses/by/4.0

FIGURE 1

Flowchart showing the decision-making process to associate coronavirus disease 2019 (COVID-19) infection with subsequent chronic thromboembolic pulmonary hypertension (CTEPH). MDT: multidisciplinary team; PH: pulmonary hypertension; PE: pulmonary embolism.

FIGURE 2

Illustration of the proportion of chronic thromboembolic pulmonary disease (CTEPD) referrals potentially related to coronavirus disease 2019 (COVID-19). CTEPH: chronic thromboembolic pulmonary hypertension; PE: pulmonary embolism.

FIGURE 3

Flowchart showing the sequential assessment of patients at 3 months post-hospitalisation with coronavirus disease 2019 by Dyspnea-12 (D-12) score, ECG and N-terminal pro-brain natriuretic peptide (NT-proBNP) to risk stratify into very-low-, low-, intermediate- and high-risk categories. ^#: ECG criteria: rSR′ or rSr′ pattern in lead V1; and/or R:S >1 in lead V1 with R >0.5 mV; and/or QRS axis >90°.