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4. Symptom-related screening programme for early
detection of chronic thromboembolic pulmonary
hypertension after acute pulmonary embolism: the
SYSPPE study
Thorax Volume 79, Issue 2
The presentation content has been taken from BMJ Journals
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Thorax
5. Symptom-related screening programme for early detection of chronic
thromboembolic pulmonary hypertension after acute pulmonary embolism: the
SYSPPE study
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Speaker: Dr. Rizwan Ali Tunio
MBBS, FCPS Pulmonology-AKUH
HOD and Assistant Professor of Pulmonology
Department Chandka Medical College
Shaheed Mohtarma Benazir Bhutto Medical University, Larkana
6. Introduction:
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Definition of Chronic Thromboembolic Pulmonary Hypertension:
• Precapillary PH caused by persistent fibrotic occlusions in the pulmonary arteria tree
• Occurs after at least 3 months of anticoagulant treatment post-pulmonary embolism
Incidence and Prevalence:
• Estimated cumulative incidence of CTEPH is 0.1%–9.1% in the first 2 years after PE
• Prevalence increased from 3.2 per million inhabitants in 2007 to 22.5 in 2018
• Varied prevalence in different countries (e.g., 1.7 in Spain, 1.75 in the UK, 3.7 in Switzerland,
and 5.7 in Germany)
Challenges in Diagnosis:
• High prevalence of post-PE syndrome, leading to dyspnea in up to 50% of survivors
• Diagnosis complexity due to symptom similarity with acute PE and lack of validated
screening protocols
• Average time to diagnosis in specialized centers is reported to be 14 months from
symptom onset
7. Introduction:
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Importance of Early Diagnosis:
• Early detection crucial for better prognosis, lower perioperative mortality, and treatable
states
• Delayed diagnosis associated with worse outcomes in CTEPH
Current Screening Practices:
• Routine screening with imaging tests not recommended due to low CTEPH incidence
• Focused efforts on symptom-related screening in patients with suggestive symptoms are
considered more practical
The objective of the Study:
• Evaluate the impact of a symptom-related screening program for early CTEPH detection
in long-time PE survivors
8. Methods:
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• This was a multicentre cohort study of patients diagnosed with acute symptomatic PE
between January 2017 and December 2018 in 16 centers in Spain
• Patients were contacted by phone 2 years after the index PE diagnosis
• Those with dyspnoea corresponding to a New York Heart Association (NYHA)/WHO
scale≥II, visited the outpatient clinic for echocardiography and further diagnostic tests
including right heart catheterisation (RHC)
• The primary outcome was the new diagnosis of CTEPH confirmed by RHC
10. inclusion and Exclusion criteria:
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The main inclusion criteria were:
• (1) age >18year;
• (2) objectively confirmed diagnosis of acute symptomatic PE with or without symptomatic
deep vein thrombosis (DVT),
• (3) ability of subject to understand the study and
• (4) informed consent
Exclusion criteria
• Inability to follow the study procedures, incidental PE, previous confirmed diagnosis of
CTEPH or PH.
• Confirmatory testing for PE consisted of either high probability ventilation-perfusion
scintigraphy or positive CT pulmonary angiography for PE.
11. Results:
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• Out of 1077 patients with acute PE, 646 were included in the symptom screening
• At 2 years, 21.8% (n=141) reported dyspnoea NYHA/WHO scale≥II
• Before the symptom screening protocol, five patients were diagnosed with CTEPH
following routine care
• In patients with NYHA/WHO scale≥II, after symptom screening protocol, the
echocardiographic probability of pulmonary hypertension (PH) was low, intermediate,
and high in 76.6% (n=95), 21.8% (n=27) and 1.6% (n=2), respectively
• After performing additional diagnostic tests in the latter 2 groups, 12 additional
CTEPH cases were confirmed
18. Discussion:
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Study Overview:
• Prospective, multicenter study with 1077 patients with acute symptomatic PE
Key Findings:
• Dedicated phone follow-up post-PE increases CTEPH detection over threefold compared
to routine care
• Symptom-focused screening aligns with 2019 ESC guidelines and is cost-effective
Telemedicine Advantages:
• Phone calls are cheap, easy, and useful, especially in regions lacking dedicated clinics or
post-COVID-19 trends favoring telemedicine
19. Discussion:
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Other Strategies for CTEPH Identification:
• FOCUS study used echocardiography, revealing 2-year cumulative CTEPH incidence of
2.3%
• InShape II study validated an algorithm for early CTEPH exclusion in low-risk patients
• Biomarkers like BNP may enhance screening when combined with symptoms
Study Strengths:
• Well-designed multicenter study in Spain with external validity
• Proposes a cost-effective phone-based diagnostic strategy for CTEPH
• Utilizes a fluid challenge to identify postcapillary PH in group 2
20. Discussion:
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Study Limitations:
• Focus on newly diagnosed CTEPH cases confirmed by RHC as primary objective
• Complex implementation of telephone screening but demonstrates simplicity and
effectiveness
• Potential underestimation of CTEPH cases due to various factors, including limited
diagnostic workup and timing of symptom screening
• Acknowledges the cost-effectiveness of the strategy despite potential inaccuracies
21. Conclusion:
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• The implementation of this simple strategy based on symptom evaluation by phone
diagnosed more than doubled the number of CTEPH cases
• Dedicated follow-up algorithms for PE survivors help diagnosing CTEPH earlier
