External validation of a simple non-invasive algorithm to rule out chronic thromboembolic pulmonary hypertension after acute pulmonary embolism. Issue 5 (May 2015)

• Record Type: Journal Article
• Authors: Klok, F.A.; Tesche, C.; Rappold, L.; Dellas, C.; Hasenfuß, G.; Huisman, M.V.; Konstantinides, S.; Lankeit, M.
• Is Part Of: Thrombosis research. Volume 135:Issue 5(2015)
• Page Start: 796
• Page End: 801
• Publication Date: 2015-05
• Subjects: Pulmonary embolism -- Pulmonary hypertension -- NT-proBNP -- ECG -- Screening -- Echocardiography; Thrombosis -- Periodicals; 616.135
• DOI: 10.1016/j.thromres.2014.12.009
• Languages: English
• ISSNs: 0049-3848

Abstract

Abstract: Purpose: International guidelines do not provide strong recommendations on the duration and intensity of follow-up after acute pulmonary embolism (PE), nor on screening-programs for chronic thromboembolic pulmonary hypertension (CTEPH). We aimed to address this gab by performing an external validation of the easy "CTEPH rule-out-criteria" based on a normal NT-proBNP level and the absence of 3 ECG characteristics. Methods: 134 patients underwent clinical follow-up 6 months after PE. Predefined transthoracic echocardiographic (TTE) criteria were used to categorize patients as "PH unlikely" or "PH possible/likely". The latter patients underwent further (invasive) diagnostic procedures to confirm and classify the diagnosis of pulmonary hypertension. NT-proBNP and ECGs, both assessed at the day of echocardiography, were evaluated post-hoc. Results: Sixty-three patients (47%) scored none of the "CTEPH rule-out criteria" positive, of whom 61 had normal TTE (97%). Twenty-five patients (19%) were categorized by TTE as "PH possible/likely"; of those, 6 were diagnosed with CTEPH. The sensitivity of rule-out criteria for CTEPH was 100% (95%CI 56-100%; 6/6 patients identified), and for "PH possible/likely" on TTE 92% (95%CI 74-99%; 23/25 patients identified): 2 asymptomatic patients with estimated systolic pulmonary arterial pressure of 36 mmHg and 38 mmHg, respectively, who remained stable during further 2-year follow-up, were not identified. Inter-observer agreement for the adjudication of the ECG characteristics was excellent (kappa-statistic 0.97). Conclusions: In this external validation cohort, we confirmed the diagnostic accuracy and reproducibility of the "CTEPH rule-out criteria". These results provide a solid ground for future outcome trials applying this algorithm. Highlights: The CTEPH rule-out criteria consist of a simple ECG reading and NT-proBNP assessment The CTEPH rule-out criteria were shown to have a high sensitivity (100%) for CTEPH The CTEPH rule-out criteria were highly reproducible (kappa statistic 0.97) Validation of the CTEPH rule-out criteria in an outcome study is still required