Pathlight Summer 2016 - (Page 28)

HEALTH MATTERS ASK THE EXPERT Study Reveals Gap between Post-PE Monitoring Recommendations and Reality By Phyllis Hanlon, Contributing Writer R esearch identifies possible gaps between what's recommended to rule out pulmonary hypertension for patients who experience blood clots in their lungs and what actually happens. The Centers for Disease Control and Prevention (CDC) report that between 300,000 and 600,000 Americans experience pulmonary embolism (PE) (i.e., a blockage in an artery in the lung) every year. Previous studies have reported that around 3.8% of patients with a pulmonary embolism go on to develop chronic thromboembolic pulmonary hypertension (CTEPH), a form of pulmonary hypertension (PH), two years after the initial embolism. In spite of the potential for developing serious disease, many patients do not undergo tests, procedures or follow up that could provide early diagnosis and treatment. Victor F. Tapson, MD and colleagues conducted the "first real-world study that documents the use of diagnostic imaging scans in incident pulmonary embolism patients." The INFORM (INvestigating the role oF disease monitORing in incident pulmonary embolism patients using a Managed care claims dataset) study (http://www.ncbi.nlm., funded by Bayer HealthCare Pharmaceuticals, had a threefold objective: * to determine the number of PE patients who show signs and symptoms related to PH; * to determine how many PE patients have a diagnosis of PH; and * to document the overall disease monitoring patterns related to diagnostic tests. CTEPH is a rare and potentially life-threatening disease but, if diagnosed early, it can be treated. However, accurate diagnosis can be challenging since certain symptoms, such as dyspnea (shortness of breath), might be attributed to other conditions. The 2014 guidelines on managing PE from the European Society of Cardiology and the 5th World Symposium on Pulmonary Hypertension issued recommendations for accurate and early diagnosis. The guidelines suggest doing a ventilation-perfusion (V/Q) scan after a PE, particularly when symptoms persist, as a first-line effort to diagnose CTEPH. During the V/Q scan, the patient inhales a radioactive gas. The scan captures images that help in the analysis of airflow in the lung. The patient receives a radioactive material intravenously, which provides images that show if areas of the lung that are receiving air are also receiving blood flow. These pictures enable clinicians to see if there is an embolism or chronic clot in the lung. When the 28 PATHLIGHT // SUMMER 2016 V/Q scan suggests CTEPH might be present, the clinician should do a right heart catheterization to confirm PH and computed tomographic (CT) angiography and/or pulmonary angiography to find the location of the clot or clots. However, these procedures are often not performed after the initial PE, which results in missed or misdiagnosed cases. Dr. Tapson's study evaluated whether these tests were part of patient follow-up after PE. The study examined claims for PE from more than 80 managed care organizations in the LifeLink Health Plan Claims Database, which included diagnoses for inpatients as well as outpatients, procedures and retail and mail-order prescriptions A total of 7,068 patients met the study criteria. Average patient age was 57 years-old and about 53% were female. Forty-five percent were from the Midwest and 30% were from the South; 66% were enrolled in a preferred provider organization. Approximately 52% also had a hypertensive disease and 30% had acute respiratory infections. The most common symptoms noted during the twoyear follow up were shortness of breath (39%) and chest pain (36%). The researchers also assessed malaise/fatigue (30%), abnormal walking (8%) and hemoptysis (1%) (i.e., coughing up blood from the lungs or bronchial tubes due to hemorrhage). The findings showed that 87% of the patients had symptoms suggestive of PH, but only 61% had imaging during the two-year follow-up; 52% had echocardiogram; 23%, CT; 7%, V/Q scan; 1%, right heart catheterization; and 0.3%, pulmonary angiography. Only 12% and 11% of patients experiencing dyspnea and chest pain, respectively, had a V/Q scan after having a PE. Nearly half of patients who had a PE were given no follow-up imaging tests for two years after their initial PE diagnosis.

Table of Contents for the Digital Edition of Pathlight Summer 2016

Message from the Chair
Message from the SLC Chair
Quick Takes
PHenomenal Lives
Family PHocus
A Day in the Life of a PH Physician
Research Corner
GO PHAR Research
Ask the Expert: Post-PE Monitoring
End-of-Life Conversations: Tough Questions & Important Answers
Lantos Highlight
Conference & Leadership Changes
Chapter News
Advocacy PHact or PHiction? Test Your Knowledge of PH Advocacy
Calendar of Events
Question of the Quarter:

Pathlight Summer 2016