Survival and restoration of pulmonary perfusion in a long-term follow-up of patients after acute pulmonary embolism

Massimo Miniati, Simonetta Monti, Matteo Bottai, Elvio Scoscia, Carolina Bauleo, Lucia Tonelli, Alba Dainelli, Carlo Giuntini, Massimo Miniati, Simonetta Monti, Matteo Bottai, Elvio Scoscia, Carolina Bauleo, Lucia Tonelli, Alba Dainelli, Carlo Giuntini

Abstract

We followed prospectively 834 consecutive patients (70% inpatients), evaluated for suspected pulmonary embolism, for a median time of 2.1 years (range, 0-4.8 yr), and compared the survival rates in patients with proven pulmonary embolism (n=320) with those without (n=514). In multivariate analysis, we modeled the probability of surviving in patients with pulmonary embolism as a function of the extent of pulmonary vascular obstruction at baseline. Among patients with pulmonary embolism, a scintigraphic follow-up was pursued to assess the restoration of pulmonary perfusion over a 1-year period. We found that massive pulmonary embolism (vascular obstruction>or=50%) is a risk factor for mortality within the first few days after onset but, subsequently, has no significant effect on survival. The adjusted risk of death in patients with massive pulmonary embolism was 8-fold higher than in patients without embolism within the first day after the incident event. By contrast, the adjusted risk of death for patients with minor or moderate pulmonary embolism (vascular obstruction<50%) was no higher than in patients without embolism at any time after onset. Most of the patients who survived a year after pulmonary embolism showed a nearly complete restoration of pulmonary perfusion with a considerable improvement in arterial oxygenation. Four (1%) of the 320 patients with pulmonary embolism at presentation developed chronic thromboembolic pulmonary hypertension. These patients featured persistent large perfusion defects in sequential lung scans. Pulmonary embolism with vascular obstruction>or=50% is a strong, independent predictor of reduced short-term survival. This underscores the need for a prompt diagnosis of the disease. Monitoring the resolution of pulmonary embolism by lung scanning may prove useful in identifying patients with persistent perfusion abnormalities who may be at risk of chronic thromboembolic pulmonary hypertension.

References

    1. Alpert JS, Smith R, Carlson J, Ockene IS, Dexter L, Dalen JE. Mortality in patients treated for pulmonary embolism. JAMA. 1974;229:1606-1613.
    1. Anderson FA Jr, Wheeler HB, Goldberg RJ, Hosmer DW, Patwardhan NA, Jovanovic B, Forcier A, Dalen JE. A population-based perspective on the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism: the Worcester DVT Study. Arch Intern Med. 1991;151:933-938.
    1. Carson JL, Kelley MA, Duff A, Weg JG, Fulkerson WJ, Palevsky HI, Schwartz JS, Thompson BT, Popovich J, Hobbins TE, Spera MA, Alavi A, Terrin ML. The clinical course of pulmonary embolism. N Engl J Med. 1992;326:1240-1245.
    1. Giuntini C, Di Ricco G, Marini C, Melillo E, Palla A. Pulmonary embolism: epidemiology. Chest. 1995;107:3S-9S.
    1. Goldhaber SZ, Visani L, De Rosa M, for ICOPER. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet. 1999;353:1386-1389.
    1. Heit JA, Silverstein MD, Mohr DN, Petterson TM, O'Fallon WM, Melton LJ III. Predictors of survival after deep vein thrombosis and pulmonary embolism. A population-based cohort study. Arch Intern Med. 1999;159:445-453.
    1. Hull RD, Raskob GE, Coates G, Panju AA. Clinical validity of a normal perfusion scan in patients with suspected pulmonary embolism. Chest. 1990;97:23-26.
    1. Kipper MS, Moser KM, Kortman KE, Ashburn WL. Long term follow-up of patients with suspected pulmonary embolism and a normal lung scan. Chest. 1982;82:411-415.
    1. Kniffin WD Jr, Baron JA, Barrett J, Birkmeyer JD, Anderson FA Jr. The epidemiology of diagnosed pulmonary embolism and deep vein thrombosis in the elderly. Arch Intern Med. 1994;154:861-866.
    1. Kucher N, Wallmann D, Windecker S, Meier B, Hess OM. Incremental prognostic value of troponin I and echocardiography in patients with acute pulmonary embolism. Eur Heart J. 2003;24:1651-1656.
    1. Kucher N, Goldhaber SZ. Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism. Circulation. 2003;108:2191-2194.
    1. Kucher N, Rossi E, De Rosa M, Goldhaber SZ. Prognostic role of echocardiography among patients with acute pulmonary embolism and systolic arterial pressure of 90 mmHg or higher. Arch Intern Med. 2005;165:1777-1781.
    1. Meyer G, Collignon MA, Guinet F, Jeffrey AA, Barritault L, Sors H. Comparison of perfusion lung scanning and angiography in the estimation of vascular obstruction in acute pulmonary embolism. Eur J Nucl Med. 1990;17:315-319.
    1. Miniati M, Pistolesi M, Marini C, Di Ricco G, Formichi B, Prediletto R, Allescia G, Tonelli L, Sostman HD, Giuntini C. Value of perfusion lung scan in the diagnosis of pulmonary embolism: results of the Prospective Investigative Study of Acute Pulmonary Embolism Diagnosis (PISA-PED). Am J Respir Crit Care Med. 1996;154:1387-1393.
    1. Miniati M, Prediletto R, Formichi B, Marini C, Di Ricco G, Tonelli L, Allescia G, Pistolesi M. Accuracy of clinical assessment in the diagnosis of pulmonary embolism. Am J Respir Crit Care Med. 1999;159:864-871.
    1. Miniati M, Monti S, Pratali L, Di Ricco G, Marini C, Formichi B, Prediletto R, Michelassi C, Di Lorenzo M, Tonelli L, Pistolesi M. Value of transthoracic echocardiography in the diagnosis of pulmonary embolism: results of a prospective study in unselected patients. Am J Med. 2001;110:528-535.
    1. Miniati M, Monti S, Bottai M. A structured clinical model for predicting the probability of pulmonary embolism. Am J Med. 2003;114:173-179.
    1. Pengo V, Lensing AWA, Prins MH, Marchiori A, Davidson MPH, Tiozzo F, Albanese P, Biasolo A, Pegoraro C, Iliceto S, Prandoni P. Incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism. N Engl J Med. 2004;350:2257-2264.
    1. Schoepf UJ, Kucher N, Kipfmueller F, Quiroz R, Costello P, Goldhaber SZ. Right ventricular enlargement on chest computed tomography: a predictor of early death in acute pulmonary embolism. Circulation. 2004;110:3276-3280.
    1. Siddique RM, Siddique MI, Connors AF Jr, Rimm AA. Thirty-day case-fatality rates for pulmonary embolism in the elderly. Arch Intern Med. 1996;1564:2343-2347.
    1. Silverstein MD, Heit JA, Mohr DN, Petterson TM, O'Fallon WM, Melton LJ III. Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study. Arch Intern Med. 1998;158:585-593.
    1. Simonneau G, Sors H, Charbonnier B, Page Y, Laaban JP, Azarian R, Laurent M, Hirsch JL, Ferrari E, Bosson JL, Mottier D, Beau B, for the THESEE Study Group. A comparison of low-molecular-weight heparin with unfractionated heparin for acute pulmonary embolism. N Engl J Med. 1997;337:663-669.
    1. The Task Force on Diagnosis and Treatment of Pulmonary Arterial Hypertension of the European Society of Cardiology. Guidelines on diagnosis and treatment of pulmonary arterial hypertension. Eur Heart J. 2004;25:2243-2278.
    1. van Beek EJR, Kuijer PMM, Schenk BE, Brandjes DPM, ten Cate JW, Buller HR. A normal perfusion lung scan in patients with clinically suspected pulmonary embolism: frequency and clinical validity. Chest. 1995;108:170-173.
    1. van Beek EJR, Kuijer PMM, Buller HR, Brandjes DPM, Bossuyt PMM, ten Cate JW. The clinical course of patients with suspected pulmonary embolism. Arch Intern Med. 1997;157:2593-2598.
    1. Wartski M, Collignon MA. Incomplete recovery of lung perfusion after 3 months in patients with acute pulmonary embolism treated with antithrombotic agents. THESEE Study Group. Tinzaparin ou Heparin Standard: Evaluation dans l'Embolie Pulmonaire Group. J Nucl Med. 2000;41:1043-1050.

Source: PubMed

スポンサーと協力者

医学的状態

薬物療法

3
購読する