Chronic thromboembolic pulmonary hypertension in the elderly: outcomes and challenges across a decade of multidisciplinary care in a referral center

Background Chronic pulmonary hypertension (CTEPH) is a rare but severe and disabling condition that may progress to right heart failure and premature mortality if not adequately treated. Managing CTEPH in older adults presents unique challenges due to high prevalence of comorbidities, polypharmacy and potential adverse effects of interventional and pharmacologic therapies. Objectives To provide clinically relevant information based on consolidated experience regarding multidisciplinary management of CTEPH in the older adult population. Methods This registry includes ten years of experience (2015-2025) from hospital 12 de octubre, a national and european reference center for pulmonary hypertension, involving 698 patients diagnosed with CTEPH. All patients underwent multidisciplinary evaluation to determine eligibility for pulmonary endarterectomy (PEA), balloon pulmonary angioplasty (BPA), or medical therapy (MT). Older adults (OA) were define as patients ≥72 years (upper quartile of the cohort), and their characteristics were compared with younger adults (YA). Clinical and hemodynamic outcomes in OA for each treatment modality, as well a long-term survival were analysed over a 5-year follow-up period. Results Of the 698 patients evaluated, 179 were classified as OA (mean age 77±3.6 years). Compared with YA, OA group showed predominance of women (65.9% vs 48.6%, p<0.0001) and higher prevalence of cardiovascular risk factors and comorbidities, including hypertension (72.1% vs 43.1%, p<0.0001), dyslipidemia (70.4% vs 41%, p<0.0001), coronary artery disease (16.7% vs 6.9%) and atrial fibrillation (25.9% vs 11%, p=0.003). OA also exhibited reduced 6-minute walk distance (311±110 vs 380±196 m, p<0.0001), while hemodynamic severity was comparable across age groups (pulmonary vascular resistance 8.0±3.5 vs 8.2±4.5 WU, p=0.5). Interventional procedures (PE, BPA) were the most frequently used therapies in both groups. Among OA, BPA was more common than in the YA group (treatment distribution for OA 27.4% PEA, 48% BPA, 24.6% MT; for YA 54.7% PEA, 36.8% BPA and 8.5% MT; p<0.0001). Clinical and hemodynamic outcomes for all therapeutics strategies in OA cohort showed significant benefit from interventional procedures across all evaluated variables (Table 1). Procedure-related mortality was 4.1% for PEA and 2.3% for BPA. Long –term survival at 1, 3 and 5 years was 92%, 89% and 85% for PEA; 95%, 89% and 85% for BPA and 93%, 86% and 73% for MT (Log-Rank p=0.02). Conclusion In older adults, CTEPH presents a clinical profile characterized by predominance of women and high burden of cardiovascular comorbidities. Interventional therapies – especially BPA- were the most frequently applied and yielded significant clinical and hemodynamic benefits, with excellent long-term survival. Medical therapy should be reserved for patients not candidates for invasive intervention. Optimal therapeutic decision-making requires a multidisciplinary team approachTable 1Figure 1