Chronic Thromboembolism Phenotypes after Acute Pulmonary Embolism: Identification with the SEARCH Algorithm

Rationale Chronic dyspnea and exercise impairment are common after acute pulmonary embolism but poorly characterised. Objectives We performed a prospective observational study to validate an algorithm to diagnose discrete post-pulmonary embolism outcomes, including chronic thromboembolism phenotypes. Methods Six pulmonologists independently reviewed records from 150 consecutive patients three or more months after acute pulmonary embolism who had undergone a stepwise diagnostic algorithm (SEARCH): s ymptom screen, cardiopulmonary e xercise testing, pulmonary a rterial perfusion scans, r esting echocardiography, c onfirmatory imaging, and h emodynamic measurements by rest and exercise right heart catheterisation. Clinical data were reviewed after the first post-pulmonary embolism evaluation and then six months later. Measurements and Main Results Symptomatic recovery was most common and occurred in 66.2% of patients during the final evaluation. Dyspnea without discernable physiological defects occurred in 2.1% and dyspnea from alternative diagnoses in 19.7%. Chronic thromboembolism phenotypes were diagnosed in 12.0% of patients. Chronic thromboembolism with ventilatory inefficiency and/or small stroke volume augmentation during exercise was seen in 6.3%: 2.1% without pulmonary hypertension on right heart catheterisation and 4.2% in whom right heart catheterisation was not performed. Chronic thromboembolic pulmonary hypertension and chronic thromboembolism with exercise-induced pulmonary hypertension occurred in 2.1% and 3.5%, respectively. Krippendorff's alpha among the readers was 0.984 (95% CI: 0.9663, 0.9960), signifying very high diagnostic reliability. No patient developed chronic thromboembolism between the first and final evaluations. Conclusions Dyspnea from chronic thromboembolism is common after acute PE, most of which is not associated with pulmonary hypertension. The SEARCH protocol reliably identifies chronic thromboembolism phenotypes after acute embolism.