455. The Long-Term Management Of Patients With Pulmonary Embolism with Dr. Soophia Naydenov

CardioNerds (Amit and Dan), Billy Joe Mullinax, and Saahil Jumkhawala discuss the long term management of pulmonary embolism with Dr. Soophia Naydenov. The episode focuses on the approach to patients who struggle with persistent symptoms like dyspnea and fatigue even after completing the acute phase of anticoagulation. This spectrum of disease, ranging from mild post-PE impairment to chronic thromboembolic pulmonary hypertension (CTEPH), requires a structured follow-up. The discussion covers the critical importance of identifying CTEPH early, the necessary timelines for follow-up, and the appropriate objective screening tools and invasive testing to guide patient care toward full functional recovery. Audio editing by CardioNerds academy intern, Grace Qiu.

Dr. Dinu Balanescu and Dr. Billy-Joe Mullinax are Co-chairs for the CardioNerds PE Series, developed in collaboration with the PERT Consortium.

Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.

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Acronyms

PE: Pulmonary Embolism

PERT: Pulmonary Embolism Response Team

CTEPH: Chronic Thromboembolic Pulmonary Hypertension

QL: Quality of Life

VTE: Venous Thromboembolism

DASH: D-dimer, Age, Sex, History of non-provoked PE (a risk score)

CPET: Cardiopulmonary Exercise Testing

PFTs: Pulmonary Function Tests

VQ Scan: Ventilation-Perfusion Scan

DOACs: Direct Oral Anticoagulants

TPA: Tissue Plasminogen Activator (Thrombolytics)

ECMO: Extracorporeal Membrane Oxygenation

Pearls:

Post-PE "Syndrome" is a Spectrum: It is more accurately a spectrum of disease (sequelae of PE) rather than a single syndrome, ranging from mild fatigue/dyspnea to the most severe form, CTEPH.

Structured Follow-up is Mandatory: All PE survivors need a structured follow-up, typically with checkpoints at 3, 6, 12, and 16–24 months, with the primary goal being to detect CTEPH, the deadliest, yet potentially curable, disease on the spectrum.

Screening Should Be Objective and Practical: When screening for persistent symptoms, use objective assessment tools like the Post-VTE Functional Status (PVFS) scale or the Modified Medical Research Council (MMR-C) scale, as highly comprehensive but cumbersome tools (like the PE Quality of Life questionnaire) may not be practical for routine clinical use. Recurrence Risk Scores Aid in Anticoagulation Duration: Simple scores like the DASH score or the HERDO2 score (for women) can provide guidance when considering the continuation versus discontinuation of anticoagulation after the initial treatment phase.

Invasive Testing for Persistent Symptoms: If a patient remains symptomatic at the 6-month mark despite normal non-invasive testing (chest X-ray, ECG, PFTs, six-minute walk, echo, VQ scan, CPET), consider invasive testing such as Right Heart Catheterization (RHC) at rest or with exercise, or an invasive CPET.

Notes:

Notes drafted by Saahil Jumkhawala.

1. The Spectrum of Post-PE Disease

The term "post-PE syndrome" should be used with caution, as it refers to a spectrum of disease rather than a single entity.

This spectrum includes symptoms (sequelae) that exist in a patient's life following an incidental PE event that they did not have before.

On one extreme is Chronic Thromboembolic Pulmonary Hypertension (CTEPH):

The definition is clear, but it is the most deadly type, though thankfully rare (2% to 4%).

It involves a residual clot and pulmonary hypertension identifiable at rest.

In the middle is Chronic Thromboembolic Disease (CTED):

Patients may have residual defects seen on a VQ or CT scan, but they do not have pulmonary hypertension.

On the other side is a milder disease, which can include fatigue, dyspnea, or a patient's perceived impairment, where the definition