Angiogenesis in Chronic Thromboembolic Pulmonary Hypertension: A Janus-Faced Player?



pte pulmonary thromboembolism :: Article Creator

Deep Venous Thrombosis - PCI Information

Deep Venous Thrombosis (DVT) is common due to the phenomenon of Virchow's Triad. Therefore, it is very important to closely monitor for DVT, especially in first year following SCI or any time patient is admitted to hospital. Secondary complication of DVT can result in Pulmonary Thromboembolism (PTE) and death.

Assessment

  • Patients with a SCI often present atypically or with an unreliable physical examination. The standard of care is now to initiate subcutaneous low molecular weight heparin for prophylaxis following SCI. Venous Doppler ultrasounds are commonly performed for screening.
  • If there is concern for a PTE, either a CT Angiogram, spiral CT scan, or nuclear ventilation/perfusion scan can be performed to diagnose with a chest x-ray

    • Treatment Considerations

  • For acute DVT/PTE, subcutaneous low molecular weight heparin is used initially with the transition to oral Warfarin if there are no contraindications. The duration of anticoagulation may be increased based on an individual's risk factors. Continued reassessment of the timing of appropriate addition of anticoagulation in this setting is warranted. Inferior Vena Cava filter is indicated when anticoagulation is contraindicated. The inferior vena cava filter is NOT a substitute for thromboprophylaxis.
  • Treatment of DVT is for at least 3 months
  • Treatment of PTE is for at least 6 months
  • Monitor for upper extremity DVT
  • Always recheck Doppler ultrasound after discontinuation of prophylaxis and treatment

    • ResourceVenous Thromboembolism (VTE)PM&R Knowledge NOW Topics from American Academy of Physical Medicine and Rehabilitation


    CTEPH Predictors Following Pulmonary Embolism

    Risk for chronic thromboembolic pulmonary hypertension (CTEPH) after pulmonary embolism (PE) is associated with gender, delayed PE diagnosis, hypoxemia, heart load, D-dimer levels, and PE etiology. These findings were published in the Journal of the American Heart Association.

    One of the most serious post-PE syndromes is CTEPH. A large variation in the rate of CTEPH has been reported and risk factors are not well understood.

    The Contemporary Management and Outcomes in Patients With Venous Thromboembolism (COMMAND VTE) Registry-2 is a large cohort that recruited patients in Japan. In this study, patients (N=5197) with acute symptomatic venous thromboembolism between 2015 and 2020 at 31 sites were evaluated for CTEPH after acute PE (n=2787). The primary outcomes were the incidence of and risk factors for CTEPH.

    Following a diagnosis of acute PE, the cumulative rates of CTEPH increased from 1.0% at 180 days to 1.7% at 1 year, 2.0% at 2 years, 2.3% at 3 years, and 2.4% at 4 and 5 years.

    "

    Several independent risk factors for CTEPH were identified, which could be useful for screening a high-risk population for CTEPH after acute PE.

    The patients with (n=48) and without (n=2739) CTEPH comprised 77.1% and 56.3% women (P =.004), their mean ages were 65.2±15.0 and 66.6±15.4 years, and they had a BMI of 23.4±4.4 and 23.8±4.7, respectively.

    At PE, patients who went on to develop CTEPH were more likely to have unprovoked PE (79.2% vs 40.2%; P <.001), to present with hypoxemia (70.8% vs 44.0%; P <.001), they had higher right heart load (91.7% vs 40.5%; P <.001), and they had lower D-dimer levels (median, 6.0 vs 11.4 mg/mL; P <.001) compared with patients who did not develop CTEPH.

    Most patients with CTEPH (97.9%) were diagnosed within 3 years of PE. A total of 7 patients with CTEPH died, due to malignant diseases (n=4), infection (n=1), chronic obstructive pulmonary disease (n=1), and unknown reasons (n=1). The survival rates after CTEPH were 95.7%, 93.5%, 88.4%, 85.0%, 85.0%, and 72.9% at years 1 through 6, respectively.

    Risk for CTEPH was associated with right heart load (adjusted hazard ratio [aHR], 9.28; 95% CI, 3.19-27.00; P <.001), unprovoked PE (aHR, 2.77; 95% CI, 1.22-6.30; P =.02), hypoxemia (aHR, 2.52; 95% CI, 1.26-5.04; P =.009), female gender (aHR, 2.09; 1.05-4.14; P =.04), per day delay in diagnosis from symptom onset (aHR, 1.04; 95% CI, 1.01-1.07; P =.01), and D-dimer levels per 1 mg/mL (aHR, 0.96; 95% CI, 0.92-0.99; P =.02).

    This study was limited by the lack of diversity in the study cohort, which may limit the generalizability of these findings.

    The study authors concluded, "In this large real-world VTE registry in the DOAC [direct oral anticoagulation] era, the cumulative detection of CTEPH after acute PE was 2.3% at 3 years. Several independent risk factors for CTEPH were identified, which could be useful for screening a high-risk population for CTEPH after acute PE."

    Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors' disclosures.

    This article originally appeared on The Cardiology Advisor





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