The management and follow-up of pulmonary embolism (PE) at a district general hospital: Are we missing CTEPH?

Background : Chronic thromboembolic pulmonary hypertension (CTEPH) is a recognised complication of acute PE with a reported annual incidence of between 2-4%. ERS guidelines recommend a follow up echocardiogram at 3-6 months in any patient demonstrating signs of pulmonary hypertension (PH) or right ventricular dysfunction. The aim of this audit was to assess our current practise. Methods : Retrospective analysis of all new diagnoses of PE from September 2011 to December 2011. Eligible patients were identified using hospital coding databases. Results : 67 patients were identified (35 male, 32 female). Mean age was 73 years (range 27-97). 23.8% (16/67) had an echocardiogram during admission. 68.7% (11/16) demonstrated raised pulmonary pressures (>25mmHg). 45% (5/11) survived to discharge: of these, 40% (2/5) had repeat echocardiograms at follow up. 50% (28/56) of those that survived to discharge were followed up in a medical clinic, 54% (15/28) in a Respiratory clinic. Conclusion : This audit demonstrates that both early and late assessment of PH in patients with acute PE is suboptimal. Furthermore, only a quarter diagnosed with PE are followed up in a Respiratory Clinic. Patients with significant PH, may therefore be missed and potentially denied further invasive treatment, such as pulmonary endarterectomy. Setting up a dedicated PE service would ensure that all patients with PE undergo appropriate and timely investigations. Our trust is seeking approval in order to do this. Our experience is likely to reflect that in other hospitals and by sharing our findings, we hope to encourage other teams to reflect on their local practise.