Residual pulmonary vascular obstruction and recurrence after acute pulmonary embolism: a systematic review and meta-analysis of individual participant data

Cost-effectiveness of follow-up algorithms for chronic thromboembolic pulmonary hypertension in pulmonary embolism survivors

Introduction

Achieving an early diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH) in pulmonary embolism (PE) survivors results in better quality of life and survival. Importantly, dedicated follow-up strategies to achieve an earlier CTEPH diagnosis involve costs that were not explicitly incorporated in the models assessing their cost-effectiveness. We performed an economic evaluation of 11 distinct PE follow-up algorithms to determine which should be preferred.

Materials and methods

11 different PE follow-up algorithms and one hypothetical scenario without a dedicated CTEPH follow-up algorithm were included in a Markov model. Diagnostic accuracy of consecutive tests was estimated from patient-level data of the InShape II study (n=424). The lifelong costs per CTEPH patient were compared and related to quality-adjusted life-years (QALYs) for each scenario.

Results

Compared to not performing dedicated follow-up, the integrated follow-up algorithms are associated with an estimated increase of 0.89-1.2 QALYs against an incremental cost-effectiveness ratio (ICER) of EUR 25 700-46 300 per QALY per CTEPH patient. When comparing different algorithms with each other, the maximum differences were 0.27 QALYs and EUR 27 600. The most cost-effective algorithm was the InShape IV algorithm, with an ICER of EUR 26 700 per QALY compared to the next best algorithm.

Conclusion

Subjecting all PE survivors to any of the currently established dedicated follow-up algorithms to detect CTEPH is cost-effective and preferred above not performing a dedicated follow-up, evaluated against the Dutch acceptability threshold of EUR 50 000 per QALY. The model can be used to identify the locally preferred algorithm from an economical point-of-view within local logistical possibilities.

Long-term monitoring and treatment of venous thromboembolic disease: recommendations of the Thromboembolic Disease Group of the Spanish Society of Internal Medicine 2024

Venous thromboembolim (VTE) is a highly prevalent condition that requires long-term monitoring and treatment. This monitoring includes: 1) completing the etiological study and determining the risk of VTE recurrence; 2) establishing the optimal duration of anticoagulant treatment, as well as the type of therapy and its dosage; 3) estimating the risk of bleeding, and 4) identifying the occurrence of chronic complications. This consensus document, prepared by the VTE Group of the Spanish Society of Internal Medicine (SEMI), aims to update and establish consensus recommendations on these aspects. The document focuses on four aspects of management: the first includes risk factors for VTE recurrence after an unprovoked VTE episode and describes the predictive scores of VTE recurrence; the second focuses on risk factors for bleeding; the third provides recommendations for long-term follow-up in VTE, addressing specific considerations for screening chronic thromboembolic pulmonary hypertension and post-thrombotic syndrome of the lower limbs; and the fourth provides guidance on the optimal duration of extended anticoagulant treatment, as well as the type of therapy and its dosage. For each area, an exhaustive literature review was conducted, analyzing the updated VTE clinical guidelines and recent studies. This document is intended to be a guide in the long-term management of VTE based on the most current knowledge.

Dyspnea After an Acute Intermediate-Risk Pulmonary Embolism: A Case-Based Approach to Evaluation and Treatment

Exercise intolerance after acute pulmonary embolism may be caused by residual pulmonary vascular obstruction, which presents as chronic thromboembolic pulmonary disease with or without pulmonary hypertension. We present a case highlighting a systematic approach to evaluating functional limitations due to residual pulmonary vascular obstruction, emphasizing the utility of cardiopulmonary exercise testing.

Prognostic Value of Neutrophil/Lymphocyte Ratio for Pulmonary Embolism: A Meta-Analysis and External Validation

BACKGROUND

Prognostic value of neutrophil/lymphocyte ratio (NLR) for pulmonary embolism (PE) has been reported in several retrospective studies. The purpose of this investigation was to perform a pooled analysis and external validation of predictive value of NLR.

METHODS

PubMed, Embase, and Cochrane databases were searched from inception to November 5, 2022. A random effects model was used. Grade was used to evaluate the certainty of evidence. External validation was conducted in clinical cohorts before and after a propensity scoring matching (PSM). Covariates include basic clinical characteristics, such as age, gender, etc. The value of NLR in prediction model was also evaluated.

RESULTS

A total of 15 studies comprising 5,874 patients were included. Pooled risk ratio of NLR was 2.33 (95% confidence interval [CI]: 1.97-2.75), with an area under the curve of 0.78 (95% CI: 0.74-0.81), a sensitivity of 0.75 (95% CI: 0.71-0.79), a specificity of 0.67 (95% CI: 0.61-0.73), and a median cut-off value of 5.7. Grade of Recommendations Assessment Development and Evaluation (GRADE) certainty analysis showed the quality of the evidence was moderate. Before (n = 336) and after (n = 152) propensity scoring matching, risk ratio of NLR was 2.69 (95% CI: 1.04-6.97) and 6.58 (95% CI: 1.99-17.75). A prediction model consisting of NLR, age, D-dimer, and simplified PE severity index had an area under the curve of 0.809 (95% CI: 0.738-0.88), a sensitivity of 0.638 (95% CI: 0.511-0.745), and a specificity of 0.851 (95% CI: 0.709-0.917). Net reclassification index (12%, P = 0.035) and integrated discrimination improvement (17%, P = 0.022) indicated an improvement caused by NLR.

CONCLUSIONS

Prognostic value of NLR for PE was confirmed by meta-analysis and validated in an independent cohort, deserving further clinical application.

Association between pre-treatment computed tomography findings and post-treatment persistent decrease in lung perfusion blood volume

The purpose of this study was to evaluate pre-treatment CT findings in patients with acute pulmonary embolism (PE) and determine the imaging findings associated with residual hypoperfused segments in post-treatment lung perfused blood volume (LPBV). We evaluated 91 patients with acute PE who underwent dual-energy CT before and after treatment. The location of thrombi (proximal or distal) and patency of the pulmonary artery (occlusive or non-occlusive) were recorded using pre-treatment computed tomography pulmonary angiography (CTPA). Residual hypoperfusion was defined as a perfusion-decreased area seen in both the pre- and post-treatment LPBVs. The association of the location of the thrombus and vascular patency of pre-treatment CTPA with residual hypoperfusion on a segmental and patient basis was examined. In the segment-based analysis, the proportion of residual hypoperfusion in the proximal group was significantly higher than that in the peripheral group (33/125 [26.4%] vs. 9/87 [10.3%], P = 0.004). Patient-based analysis also showed that the proportion of residual hypoperfusion in patients with pre-treatment proximal thrombus was significantly higher than those without (16/42 [38.1%] vs. 3/25 (12.0%); P = 0.022). Pre-treatment vascular patency was not significantly associated with residual hypoperfusion (P > 0.05). Therefore, careful follow-up is necessary, especially in patients with proximal thrombi.

Anticoagulation Management Post Pulmonary Embolism

Pulmonary embolus (PE) carries a significant impending morbidity and mortality, especially in intermediate and high-risk patients, and the choice of initial anticoagulation that allows for therapeutic adjustment or manipulation is important. The preferred choice of anticoagulation management includes direct oral anticoagulants. Vitamin K antagonists and low-molecular-weight heparin are preferred in special populations or selected patients such as breastfeeding mothers, those with end-stage renal disease, or obese patients, among others. This article reviews the primary and longer-term considerations for anticoagulation management in patients with PE and highlights special patient populations and risk factor considerations.

Status and Future Directions for Balloon Pulmonary Angioplasty in Chronic Thromboembolic Pulmonary Disease With and Without Pulmonary Hypertension: A Scientific Statement From the American Heart Association

Balloon pulmonary angioplasty continues to gain traction as a treatment option for patients with chronic thromboembolic pulmonary disease with and without pulmonary hypertension. Recent European Society of Cardiology guidelines on pulmonary hypertension now give balloon pulmonary angioplasty a Class 1 recommendation for inoperable and residual chronic thromboembolic pulmonary hypertension. Not surprisingly, chronic thromboembolic pulmonary hypertension centers are rapidly initiating balloon pulmonary angioplasty programs. However, we need a comprehensive, expert consensus document outlining critical concepts, including identifying necessary personnel and expertise, criteria for patient selection, and a standardized approach to preprocedural planning and establishing criteria for evaluating procedural efficacy and safety. Given this lack of standards, the balloon pulmonary angioplasty skill set is learned through peer-to-peer contact and training. This document is a state-of-the-art, comprehensive statement from key thought leaders to address this gap in the current clinical practice of balloon pulmonary angioplasty. We summarize the current status of the procedure and provide a consensus opinion on the role of balloon pulmonary angioplasty in the overall care of patients with chronic thromboembolic pulmonary disease with and without pulmonary hypertension. We also identify knowledge gaps, provide guidance for new centers interested in initiating balloon pulmonary angioplasty programs, and highlight future directions and research needs for this emerging therapy.