What is the recommended follow-up imaging for patients with pulmonary embolism (PE)?

Recommended Follow-up Imaging for Pulmonary Embolism

Follow-up imaging is not routinely recommended for asymptomatic patients after pulmonary embolism (PE), but should be considered in patients with persistent symptoms or risk factors for chronic thromboembolic pulmonary hypertension (CTEPH). 1

Assessment After Initial Treatment

Routine Follow-up Imaging

• Follow-up imaging is not routinely needed in asymptomatic PE 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 (CTPA) follow-up is not recommended for asymptomatic patients after completing appropriate anticoagulation therapy 1

Follow-up for Symptomatic Patients

• After acute PE, patients should not be lost to follow-up and should be assessed for:
  • Signs of VTE recurrence
  • Bleeding complications of anticoagulation
  • Persistent or new-onset dyspnea
  • Functional limitations 1
• For patients reporting persistent symptoms (dyspnea, poor physical performance), implement a staged diagnostic workup to:
  • Exclude CTEPH or chronic thromboembolic disease
  • Detect and treat comorbidities
  • Address deconditioning 1

When to Consider Follow-up Imaging

Indications for Imaging

• Persistent or worsening dyspnea after completing anticoagulation therapy 1
• Poor physical performance or exercise intolerance 1
• Patients with risk factors for development of CTEPH, including:
  • Advanced age
  • Cardiac or pulmonary comorbidity
  • Higher body mass index
  • History of smoking
  • Higher systolic pulmonary arterial pressure at diagnosis
  • Right ventricular dysfunction at diagnosis
  • Residual pulmonary vascular obstruction at discharge 1

Recommended Imaging Modalities

• CTPA remains the first-line imaging modality for follow-up assessment when indicated 1, 2
• V/Q (ventilation-perfusion) scanning is an alternative in patients with contraindications to CTPA, such as:
  • Allergy to iodine contrast
  • Renal failure 1, 3
• Echocardiography may be useful to assess for right ventricular dysfunction and pulmonary hypertension in symptomatic patients 1

Special Considerations

Recurrent PE Suspicion

• For patients with suspected recurrent PE, CTPA is the recommended initial imaging modality 1, 2
• In centers where V/Q scintigraphy is readily available, it remains a valid option for patients with contraindications to CTPA 1

High-Risk Patients

• For patients with risk factors for CTEPH, a lower threshold for follow-up imaging should be maintained 1
• Up to 47% of PE patients may have reduced maximal aerobic capacity at one year, indicating the importance of appropriate follow-up 1

Clinical Approach to Follow-up

1. Assess for symptoms at 3-6 months after PE diagnosis
2. For asymptomatic patients with no risk factors: no routine imaging needed
3. For symptomatic patients or those with risk factors: consider appropriate imaging based on clinical presentation
4. Implement appropriate care including exercise rehabilitation, treatment of comorbidity, and modification of risk factors 1

Remember that the primary goals of follow-up after PE are to provide appropriate care to patients with persisting symptoms and to ensure early detection of CTEPH to refer the patient for further diagnostic workup and specific treatment 1.