Follow-up Imaging for Pulmonary Embolism
Assessment After Initial Treatment
- The European Society of Cardiology recommends that follow-up imaging is not routinely needed in asymptomatic pulmonary embolism survivors, as pulmonary arterial bed patency is restored in the majority of patients within the first few months following the acute episode 1
- Routine CT pulmonary angiography follow-up is not recommended for asymptomatic patients after completing appropriate anticoagulation therapy, according to the European Heart Journal 2
- After acute pulmonary embolism, patients should be assessed for signs of venous thromboembolism recurrence, bleeding complications of anticoagulation, persistent or new-onset dyspnea, and functional limitations, as suggested by the European Heart Journal 3
- For patients reporting persistent symptoms, such as dyspnea or poor physical performance, a staged diagnostic workup should be implemented to detect and treat comorbidities, as recommended by the European Heart Journal 3
When to Consider Follow-up Imaging
- The European Heart Journal suggests that follow-up imaging should be considered in patients with persistent or worsening dyspnea after completing anticoagulation therapy 2
- Patients with risk factors for development of chronic thromboembolic pulmonary hypertension, including advanced age, cardiac or pulmonary comorbidity, higher body mass index, history of smoking, higher systolic pulmonary arterial pressure at diagnosis, and right ventricular dysfunction at diagnosis, should be considered for follow-up imaging, as recommended by the European Heart Journal 1, 2, 3
- Residual pulmonary vascular obstruction at discharge is a risk factor for chronic thromboembolic pulmonary hypertension and should be considered for follow-up imaging, according to the European Heart Journal 1, 2
Recommended Imaging Modalities
- The European Heart Journal recommends CT pulmonary angiography as the first-line imaging modality for follow-up assessment when indicated 4
- V/Q scanning is an alternative in patients with contraindications to CT pulmonary angiography, such as allergy to iodine contrast or renal failure, as suggested by the European Heart Journal 5
- Echocardiography may be useful to assess for right ventricular dysfunction and pulmonary hypertension in symptomatic patients, according to the Thorax journal 6
Special Considerations
- For patients with suspected recurrent pulmonary embolism, CT pulmonary angiography is the recommended initial imaging modality, as suggested by the European Heart Journal 7
- Up to 47% of pulmonary embolism patients may have reduced maximal aerobic capacity at one year, indicating the importance of appropriate follow-up, according to the European Heart Journal 2
- The primary goals of follow-up after pulmonary embolism are to provide appropriate care to patients with persisting symptoms and to ensure early detection of chronic thromboembolic pulmonary hypertension, as recommended by the European Heart Journal 1, 2
Follow-Up Care After Pulmonary Embolism
Clinical Follow-Up Timing
- The European Society of Cardiology recommends that all patients require routine clinical evaluation at 3-6 months after the acute pulmonary embolism episode, regardless of symptoms, to assess for signs of venous thromboembolism recurrence, bleeding complications of anticoagulation, persistent or new-onset dyspnea, functional limitations, and occult malignancy, which is a Class I, Level B recommendation 8, 9
- During the clinical evaluation, patients should be assessed for functional limitation or reduced exercise capacity suggesting possible chronic thromboembolic pulmonary hypertension (CTEPH), which is a specific indication for follow-up CT pulmonary angiography 8, 9
When Follow-Up CT Imaging IS Indicated
- The European Society of Cardiology recommends follow-up CT pulmonary angiography only in symptomatic patients, specifically those with persistent or new-onset dyspnea, functional limitation, or risk factors for CTEPH, which includes residual pulmonary vascular obstruction, right ventricular dysfunction, and higher systolic pulmonary arterial pressure 8, 9