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Original Research |

Functional and Exercise Limitations After a First Episode of Pulmonary Embolism: Results of the ELOPE prospective cohort study

Susan R. Kahn, MD, MSc; Andrew M. Hirsch, MD; Arash Akaberi, MSc; Paul Hernandez, MD; David R. Anderson, MD; Philip S. Wells, MD, MSc; Marc Rodger, MD, MSc; Susan Solymoss, MD; Michael J. Kovacs, MD; Lawrence Rudski, MD; Avi Shimony, MD; Carole Dennie, MD; Christopher Rush, MD; William H. Geerts, MD; Shawn D. Aaron, MD; John T. Granton, MD
Author and Funding Information

Summary of conflict of interest: Dr. Hirsch has been a consultant on advisory boards and speaker for Actelion and Bayer. Dr. Hernandez has participated on medical advisory boards, conducted CME activities and/or industry-sponsored clinical research for the following companies: Actelion, Almirall, AstraZeneca, Boehringer Ingelheim, CSL Behring , GlaxoSmithKline, Grifols, Merck, Novartis, Pfizer, and Roche. Dr. Wells has received fees from Bayer Healthcare, Itreas and Daiichi Sankyo and grant support from Pfizer/BMS. Dr. Rudski has stock holdings in GE. Dr. Granton has been involved in studies funded by Actelion, Bayer, United therapeutics, Ikaria and Gilead, has received funding for an industry / CIHR grant from Pfizer, and his institution’s foundation receives support from Bayer and Actelion. No conflicts for the other authors.

Funding: Canadian Institutes of Health Research (MOP-93627)

Prior abstract presentation: “Post-Pulmonary Embolism Syndrome" after a First Episode of PE: Results of the E.L.O.P.E. Study. Oral Presentation, 57th Annual Meeting of American Society of Hematology, December 5-8, 2015, Orlando, FL. Blood 2015;126(23):650.

Study registration number: (www.clinicaltrials.gov) NCT01174628

1Department of Medicine, Jewish General Hospital, Montreal, Canada

2Center for Clinical Epidemiology, Lady Davis Institute, Montreal, Canada

3Department of Medicine, Dalhousie University, Halifax, Canada

4Department of Medicine, The University of Ottawa, and the Ottawa Hospital Research Institute, Ottawa, Canada

5Department of Medicine, University of Ottawa, and the Ottawa Hospital Research Institute, Ottawa, Canada

6Department of Medicine, McGill University, Montreal, Canada

7Department of Medicine, Division of Hematology, Western University, London, Canada

8Department of Cardiology, Ben Gurion University, Beer Sheva, Israel

9Department of Diagnostic Imaging, University of Ottawa, Ottawa, Canada

10Department of Nuclear Medicine, Jewish General Hospital, Montreal, Canada

11Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada

12Division of Respirology, Department of Medicine, University of Toronto, Toronto, Canada

Corresponding author: Susan R. Kahn MD MSc GCBA Centre for Clinical Epidemiology, Jewish General Hospital 3755 Cote Ste. Catherine Rm. H-420, Montreal, Quebec CANADA H3T 1E2


Copyright 2016, . All Rights Reserved.


Chest. 2016. doi:10.1016/j.chest.2016.11.030
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Abstract

Background  We aimed to determine the frequency and predictors of exercise limitation after pulmonary embolism (PE), and to assess its association with health-related quality of life (HRQOL) and dyspnea.

Methods  100 patients with acute PE were recruited at five Canadian hospitals from 2010-2013. Cardiopulmonary exercise testing (CPET) was performed at 1 and 12 months. Quality of life, dyspnea, six-minute walk distance (6MWD), residual clot burden (perfusion (Q) scan; CT pulmonary angiography (CTPA)), cardiac function (echocardiogram) and pulmonary function tests (PFT) were measured during follow-up. The prespecified primary outcome was percent-predicted peak oxygen uptake (VO2 peak) <80% on 1-year CPET.

Results  At 1-year, 40/86 (46.5%) of patients had percent-predicted VO2 peak <80% on CPET, which was associated with significantly worse generic HRQOL, PE-specific HRQOL and dyspnea scores, and significantly reduced 6MWD at 1-year. Predictors of the primary outcome included male sex (relative risk (RR)= 3.2 [95% CI 1.3-8.1]), age (RR 0.98 [0.96-0.99] per 1-year age increase), body mass index (BMI) (RR 1.1 [1.01-1.2] per 1 kg/m2 BMI increase), and smoking history (RR 1.8 [1.1-2.9]), as well as percent-predicted VO2 peak <80% on 1-month CPET (RR 3.8 [1.9-7.2]) and 6MWD at 1-month (RR 0.82 [0.7-0.9] per 30m increased walking distance). Baseline or residual clot burden were not associated with the primary outcome. Mean PFT and echocardiogram (pulmonary artery pressure, right and left ventricular systolic function) results at 1 year were similarly within normal limits in exercise limited and non-exercise limited patients.

Conclusions  Almost half of PE patients have exercise limitation at 1 year which adversely influences HRQOL, dyspnea and walking distance. CPET or 6MWD testing at 1-month may help to identify patients with a higher risk of exercise limitation at 1-year after PE. Based on our results, we believe that deconditioning that occurs after acute PE could underlie this exercise limitation, but cannot exclude that this may have been present pre-PE.


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