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. 2021 Oct;76(10):1002-1009.
doi: 10.1136/thoraxjnl-2020-216324. Epub 2021 Mar 23.

Non-invasive early exclusion of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism: the InShape II study

Gudula J A M Boon  1 , Yvonne M Ende-Verhaar  1 , Roisin Bavalia  2 , Lahassan H El Bouazzaoui  3 , Marion Delcroix  4 , Olga Dzikowska-Diduch  5 , Menno V Huisman  1 , Katarzyna Kurnicka  5 , Albert T A Mairuhu  6 , Saskia Middeldorp  2 , Piotr Pruszczyk  5 , Dieuwertje Ruigrok  7 , Peter Verhamme  8 , Hubert W Vliegen  9 , Anton Vonk Noordegraaf  7 , Joris W J Vriend  10 , Frederikus A Klok  11 ; InShape II study group
Collaborators, Affiliations

Non-invasive early exclusion of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism: the InShape II study

Gudula J A M Boon et al. Thorax. 2021 Oct.

Abstract

Background: The current diagnostic delay of chronic thromboembolic pulmonary hypertension (CTEPH) after pulmonary embolism (PE) is unacceptably long, causing loss of quality-adjusted life years and excess mortality. Validated screening strategies for early CTEPH diagnosis are lacking. Echocardiographic screening among all PE survivors is associated with overdiagnosis and cost-ineffectiveness. We aimed to validate a simple screening strategy for excluding CTEPH early after acute PE, limiting the number of performed echocardiograms.

Methods: In this prospective, international, multicentre management study, consecutive patients were managed according to a screening algorithm starting 3 months after acute PE to determine whether echocardiographic evaluation of pulmonary hypertension (PH) was indicated. If the 'CTEPH prediction score' indicated high pretest probability or matching symptoms were present, the 'CTEPH rule-out criteria' were applied, consisting of ECG reading and N-terminalpro-brain natriuretic peptide. Only if these results could not rule out possible PH, the patients were referred for echocardiography.

Results: 424 patients were included. Based on the algorithm, CTEPH was considered absent in 343 (81%) patients, leaving 81 patients (19%) referred for echocardiography. During 2-year follow-up, one patient in whom echocardiography was deemed unnecessary by the algorithm was diagnosed with CTEPH, reflecting an algorithm failure rate of 0.29% (95% CI 0% to 1.6%). Overall CTEPH incidence was 3.1% (13/424), of whom 10 patients were diagnosed within 4 months after the PE presentation.

Conclusions: The InShape II algorithm accurately excluded CTEPH, without the need for echocardiography in the overall majority of patients. CTEPH was identified early after acute PE, resulting in a substantially shorter diagnostic delay than in current practice.

Keywords: Pulmonary Embolism.

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Conflict of interest statement

Competing interests: GJAMB was supported by the Dutch Heart Foundation (2017T064). MH reports grants from ZonMW Dutch Healthcare Fund, grants and personal fees from Pfizer-BMS, grants and personal fees from Bayer Health Care, grants and personal fees from Daiichi-Sankyo, grants from Leo Pharma, outside the submitted work. SM reports grants and personal fees from Daiichi Sankyo, grants and personal fees from Bayer, personal fees from BMS-Pfizer, personal fees from Boehringer-Ingelheim, personal fees from Portola, personal fees from AbbVie, outside the submitted work. PV reports grants from Bayer, grants from Boehringer, grants from BMS, grants from Daiichi-Sankyo, grants from Pfizer, grants from Leo-Pharma, grants from Sanofi, grants from Anthos Therapeutics, outside the submitted work. AVN reports grants from Netherlands CardioVascular Research Initiative, grants from Netherlands Organization for Scientific Research, other from Johnson & Johnson and Ferrer in the past 3 years, non-financial support from member of scientific advisory board of Morphogen-XI, outside the submitted work. FAK reports research grants from Bayer, Bristol-Myers Squibb, Boehringer-Ingelheim, Daiichi-Sankyo, MSD and Actelion, the Dutch Heart foundation (2017T064) and the Dutch Thrombosis association, all outside the submitted work.

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