Risk factors and prediction model for chronic thromboembolic pulmonary hypertension in acute pulmonary embolism patients with right heart dysfunction on CT or echocardiography

Risk factors and prediction model for chronic thromboembolic pulmonary hypertension in acute pulmonary embolism patients with right heart dysfunction on CT or echocardiography | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Risk factors and prediction model for chronic thromboembolic pulmonary hypertension in acute pulmonary embolism patients with right heart dysfunction on CT or echocardiography Shuangping Li, Shenshen Huang, Wei Wang, Pengfei Gao, YUxuan Feng, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3938961/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective The aim of our study was to investigate the risk factors for chronic thromboembolic pulmonary hypertension (CTEPH) in acute pulmonary embolism patients with right heart dysfunction via computed tomography (CT) or echocardiography. Method : Our study was a retrospective cohort study. A total of 506 patients diagnosed with pulmonary embolism at the First Affiliated Hospital of Henan University of Science and Technology between January 2018 and June 2023 were included, and 128 patients were ultimately included. The patients were divided into 33 suspected CTEPH patients and 95 non CTEPH patients. Multivariate logistic regression was used to analyse the risk factors for suspected CTEPH, and nomogram models were constructed according to the risk factors. ROC curves were used to analyse the predictive value of risk factors and the model for suspected CTEPH patients. Results : The incidence of suspected CTEPH was 25.8% in acute pulmonary embolism patients with right heart dysfunction 3 to 6 months after PE diagnosis. No CTEPH occurred in patients treated after thrombolytic therapy. The time from symptom onset to treatment (OR, 1.20), sPESI score ≥ 1 (OR, 7.82), and baseline peak velocity of tricuspid regurgitation (OR, 4.17) were risk factors for suspected CTEPH in haemodynamically stable patients (p < 0.05). A prediction model was established based on these three variables. The AUC of the prediction model for suspected CTEPH was 0.905, which has high predictive value. Conclusion : The incidence of suspected CTEPH is higher in patients with acute pulmonary embolism and right heart dysfunction according to CT or echocardiography. To improve the awareness of the diagnosis of acute pulmonary embolism, more active treatment and follow-up for patients with risk factors may reduce the incidence of CTEPH. PE CTEPH risk factors early screening Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Acute pulmonary embolism (APE) survivors are at risk of multiple long-term complications, and half of these patients do not fully recover from an acute episode and have chronic functional limitations[ 1 ]. This may be related to incomplete dissolution of the thrombus, incomplete recovery of heart size and function, and permanent changes in pulmonary artery haemodynamics[ 2 – 4 ]. Among the disease spectrum of postpulmonary embolism syndrome, chronic thromboembolic disease (CTED) and chronic thromboembolic pulmonary hypertension (CTEPH) are the most serious complications[ 5 , 6 ]. Previous studies have shown that the incidence of CTEPH is 2–4%[ 7 – 9 ]. CTEPH is characterized by thrombofibrosis and secondary microvascular remodelling, leading to persistent pulmonary artery obstruction and resulting in increased pulmonary vascular resistance and pulmonary hypertension (PH). Studies have shown that the majority of patients with CTEPH can be diagnosed within 4 months after PE diagnosis[ 10 ]. The current median time to diagnosis of CTEPH is approximately 10 months after the patient becomes symptomatic and 13.1 months after the patient becomes symptomatic [ 11 ], and it is clear that delayed diagnosis of CTEPH is common. Identifying the risk factors for CTEPH can improve the early prediction of CTEPH occurrence, help formulate a treatment plan for pulmonary embolism, improve the early screening rate of CTEPH, and reduce the incidence of CTEPH. Possible risk factors for CTEPH include hypothyroidism, malignant tumours, recurrent venous thromboembolism, massive PE, positive antiphospholipid antibody, elevated coagulation factor VIII, non-O blood type, and splenectomy[ 12 ]. However, risk factors for predicting CTEPH incidence are not comprehensive, and the risk factors still need to be further explored. One study reported that patients with acute pulmonary embolism with right heart dysfunction on CT or echocardiography were more likely to develop CTEPH, and 81% of CTEPH patients had signs of right heart dysfunction during acute pulmonary embolism[ 13 ]. CTEPH was diagnosed by right heart catheterization (RHC). For screening pulmonary hypertension, echocardiography is the preferred test because it can provide an estimate of pulmonary artery pressure[ 14 ]. The purpose of our study was to investigate the risk factors for suspected pulmonary hypertension 3–6 months after anticoagulation therapy in PE patients with right heart dysfunction via CT or echocardiography to help doctors make treatment decisions about APE to reduce the occurrence of CTEPH and improve the early screening and diagnosis rate of CTEPH. Materials and methods A total of 506 patients with APE were diagnosed at the First Affiliated Hospital of Henan University of Science and Technology from January 2018 to June 2023. The inclusion criteria were as follows: 1. Pulmonary embolism was diagnosed by CT pulmonary angiography (CTPA) or ventilation/perfusion (V/Q) lung scans; 2. Echocardiography or CTPA indicated signs of right heart dysfunction; and 3. Within 30 days from the onset of symptoms to the diagnosis of PE. The exclusion criteria were as follows: 1. Patients with no signs of right heart dysfunction on imaging; 2. Death in hospital; 3. Patients with no 3–6 month follow-up records or incomplete follow-up data; 4. Potential pulmonary hypertension or CTEPH, severe left heart failure (LVEF ≤ 40%); and 5. Patients who had incomplete data. Definition The diagnostic criteria for right ventricular dysfunction according to echocardiography included the following: (1) right ventricular (RV) end-diastolic diameter > 30 mm, (2) reduced range of right ventricular free wall motion, (3) tricuspid regurgitation peak velocity (TRPV) > 2.6 m/s, and (4) tricuspid annulus plane systolic excursion (TAPSE) < 17 mm)[ 15 ]. The diagnostic criterion for right ventricular dysfunction according to CTPA was right ventricular dilation found at the four visceral levels. The criterion for diagnosing PH by echocardiography was a TRPV > 2.8 m/s[ 16 ]. Suspected CTEPH was defined when the patient was treated with anticoagulation agents for more than 3 months, if the echocardiography results indicated pulmonary hypertension, and the CTPA or V/Q pulmonary scan indicated chronic thrombosis. The diagnostic criterion for CTEPH was right heart catheterization, for which the mean pulmonary artery pressure (mPAP) was ≥ 25 mmHg and the pulmonary artery wedge pressure (PAWP) was ≤ 15 mmHg. Data collection All clinical data were collected from inpatient and outpatient medical records. The baseline data included sex, age, time from symptom onset to treatment, risk stratification of pulmonary embolism, treatment mode, complications, echocardiography markers, NT-proBNP, troponin, heart rate, systolic blood pressure, oxygen saturation, respiratory rate, and simplified pulmonary embolism severity index score (sPESI). Follow-up data included patient symptoms and echocardiography indicator data. If the patient's echocardiography indicated PH, CTPA or V/Q lung scan was performed. Statistical methods All the statistical analyses were performed using SPSS 23.0 and R software (version 4.2.2; R Foundation for Statistical Computing, Vienna, Austria). For descriptive statistics, categorical variables are expressed as numbers (percentages), and continuous variables are expressed as the mean ± standard deviation. When the two groups were compared, the χ2 test or Fisher’s exact test was used for categorical variables, Student’s t test was used for continuous variables with a normal distribution, and the Wilcoxon rank sum test was used for variables with a nonnormal distribution. Variables with p values < 0.05 in the univariate analysis were included in the multivariate logistic regression analysis. By executing the rms package in R (version 4.2.2), a nomogram model was constructed using meaningful factors from the multivariate logistic regression analysis. The rmda package was employed for decision curve analysis (DCA). The C-index and calibration curve were used to verify the accuracy of the nomogram model. ROC curves were drawn to evaluate the predictive value of risk factors and prediction models for suspected CTEPH. A P value < 0.05 was considered to indicate statistical significance. Results This retrospective cohort study included 506 patients diagnosed with PE at the First Affiliated Hospital of Henan University of Science and Technology from January 2018 to June 2023. Forty-five patients had incomplete hospital data; 235 patients had no signs of right heart dysfunction; 28 patients died in the hospital; 16 patients had potential pulmonary hypertension; 11 patients had potential severe left heart failure; 7 patients had chronic pulmonary embolism; 26 patients did not return to the hospital for follow-up 3–6 months after discharge; and 10 patients had incomplete follow-up data. Overall, 128 APE patients with right heart dysfunction on CT or echocardiography were included, including 12 patients with haemodynamic instability and 116 patients with haemodynamic stability. At the 3–6 month follow-up, 33 patients (25.8%) were diagnosed with suspected CTEPH, 4 of these patients were confirmed by right heart catheterization. 95 patients (74.2%) were not diagnosed with CTEPH. Among the 33 suspected CTEPH patients, 27 (81.8%) had symptoms of dyspnoea. CTPA confirmed that thromboembolism was still present in all suspected CTEPH patients; for 23 (69.7%) of these patients, thromboembolism was less than before; and for 10 (30.3%) patients, thromboembolism did not significantly change compared with the first time. The enrolment flow chart is shown in Fig. 1 . Comparison of baseline data between suspected CTEPH patients and patients without CTEPH Comparison of baseline data between suspected CTEPH patients and non CTEPH patients. There were significant differences in thrombolytic therapy, time from onset of symptoms to treatment, sPESI score and TRPV (p < 0.05). There were no statistically significant differences between the two groups in terms of sex, age, type of oral anticoagulant drug, heart rate, RV end-diastolic diameter, RV/LV end-diastolic diameter, TAPSE, troponin, NT-proBNP, comorbidity, or history of VTE (p > 0.05). Notably, 20 patients who underwent thrombolytic therapy all without CTEPH and 33 patients with suspected CTEPH at follow-up were haemodynamically stable and without thrombolytic therapy. The data are shown in Table 1 . Table 1 Comparison of baseline data between patients with suspected CTEPH and without CTEPH Without CTEPH(n = 95) Suspected CTEPH(n = 33) X2 value/T value P value Male, n(%) 47(49.5) 20(60.1) 1.22 0.27 Age 66.27 ± 13.16 69.63 ± 15.99 1.19 0.23 Thrombolytic therapy, n(%) 20(21.1) 0(0) 8.23 0.004 NOAC, n(%) 62(65.2) 20(60.6) 0.23 0.63 Time from onset of symptoms to time of treatment (days) 4.30 ± 4.14 13.06 ± 9.40 7.29 < 0.001 Cerebral infarction, n(%) 16(16.8) 4(12.1) 0.41 0.52 Diabetes, n(%) 9(9.5) 4(12.1) 0.19 0.66 Hypertension, n(%) 42(44.2) 15(45.5) 0.01 0.90 Active tumour, n(%) 8(8.4) 5(15.1) 1.21 0.27 VTE history, n(%) 10(10.5) 2(6.1) 0.16 0.68 sPESI score ≥ 1, n(%) 42(44.2) 23(69.7) 6.36 0.01 RV end-diastolic diameter ≥ 30 mm, n(%) 36(37.8) 11(33.3) 0.21 0.64 RV/LV end-diastolic diameter ≥ 0.9, n(%) 9(9.4) 3(9.1) 0.004 0.94 TAPSE < 17 mm, n(%) 24(23.2) 10(30.3) 0.32 0.57 TRPV(m/s) 3.15 ± 0.53 3.68 ± 0.51 4.95 < 0.001 Lactic acid(mmol/L) 1.91 ± 1.28 1.74 ± 0.62 0.72 0.47 Troponin elevated, n(%) 41(43.2) 9(27.3) 2.59 0.11 NT-proBNP elevated, n(%) 84(88.4) 30(90.1) 0.16 0.69 NOAC new oral anticoagulant; VTE venous thromboembolism; sPESI simplified pulmonary embolism severity index; RV right ventricular; RV/LV right ventricular/left ventricular; TAPSE tricuspid annulus plane systolic excursion; TRPV tricuspid regurgitation peak velocity Risk factors for suspected CTEPH in APE patients with right heart dysfunction on CT or echocardiography Sex, time from symptom onset to treatment, sPESI score and TRPV were included in the multivariate logistic regression analysis, which showed that the time from symptom onset to treatment (OR, 1.213), sPESI score (OR, 4.628) and TRPV (OR, 5.115) were risk factors for suspected CTEPH. Shown in Table 2 . Table 2 Analysis of risk factors for suspected CTEPH in APE patients with right heart dysfunction via CT or echocardiography B SE P value Exp(B) 95%CI Male 0.660 0.560 0.239 1.936 (0.645,5.806) Time from onset of symptoms to time of treatment 0.193 0.047 0.000 1.213 (1.106,1.329) TRPV(m/s) 1.632 0.565 0.004 5.115 (1.690,15.478) sPESI score 1.532 0.589 0.009 4.628 (1.460,14.674) TRPV tricuspid regurgitation peak velocity; sPESI simplified pulmonary embolism severity index Comparison of suspected CTEPH versus without CTEPH in haemodynamically stable APE patients The time from symptom onset to treatment, arterial oxygen saturation ≤ 90%, sPESI score ≥ 1 point, and TRPV were significantly different between the two groups (p < 0.05). There were no significant differences in sex, age, thrombolytic therapy, type of oral anticoagulant, heart rate, RV end-diastolic diameter, RV/LV end-diastolic diameter, TAPSE, troponin, NT-proBNP, comorbidities, or history of VTE (p > 0.05). Shown in Table 3 . Table 3 Comparison of patients with suspected CTEPH and without CTEPH at baseline for haemodynamically stable pulmonary embolism Without CTEPH(n = 83) Suspected CTEPH(n = 33) X2 value/T value P value Male, n(%) 41(49.5) 20(60.1) 1.19 0.27 Age 66.48 ± 12.98 69.63 ± 15.99 1.10 0.27 Thrombolytic therapy, n(%) 8(9.6) 0(0) 2.08 0.14 NOAC, n(%) 52(62.6) 20(60.6) 0.04 0.83 Time from onset of symptoms to time of treatment (days) 4.78 ± 4.22 13.06 ± 9.40 6.55 < 0.001 sPESI score ≥ 1, n(%) 30(36.1) 23(69.7) 10.71 0.001 Heart rate ≥ 110 times/min, n(%) 12(14.5) 9(27.2) 2.62 0.11 Oxygen saturation ≤ 90%, n(%) 10(12.1) 9(27.2) 3.99 0.04 RV end-diastolic diameter ≥ 30 mm, n(%) 29(34.9) 11(33.3) 0.02 0.87 RV/LV end-diastolic diameter ≥ 0.9, n(%) 7(8.4) 3(9.1) 0.02 0.86 TAPSE < 17 mm,n(%) 16(19.2) 10(30.3) 1.65 0.19 TRPV(m/s) 3.16 ± 0.54 3.68 ± 0.51 4.70 < 0.001 Troponin elevated, n(%) 38(45.78) 9(27.27) 3.35 0.06 NT-proBNP elevated, n(%) 73(87.95) 30(90.1) 0.20 0.64 Cerebral infarction, n(%) 15(18.1) 4(12.1) 0.61 0.43 Diabetes, n(%) 8(9.6) 4(12.1) 0.003 0.95 Hypertension, n(%) 37(44.5) 15(45.5) 0.007 0.93 Active tumour, n(%) 7(8.4) 5(15.1) 0.53 0.46 VTE history, n(%) 10(12.1) 2(6.1) 0.38 0.53 NOAC new oral anticoagulant; VTE venous thromboembolism; sPESI simplified pulmonary embolism severity index; RV right ventricular; RV/LV right ventricular/left ventricular; TAPSE tricuspid annulus plane systolic excursion; TRPV tricuspid regurgitation peak velocity Risk factors and prediction model for suspected CTEPH in patients with haemodynamically stable APE Sex, time from symptom onset to treatment, sPESI score and TRPV were included in the multivariate logistic regression analysis, which showed that the time from symptom onset to treatment (OR, 1.200), sPESI score (OR, 7.836), and TRPV (OR, 4.176) were risk factors for suspected CTEPH, as shown in Table 4 . ROC curves were generated for the time from symptom onset to treatment, the sPESI score, and the TRPV for predicting suspected CTEPH in patients with haemodynamically stable pulmonary embolism (Fig. 2 ). The AUC of the time from symptom onset to treatment was 0.793; when the optimal cut-off value was 8 days, the sensitivity was 60.6%, and the specificity was 85.5%. The AUC for TRPV was 0.755; when the optimal cut-off value was 3.4 m/s, the sensitivity and specificity were 78.8% and 66.3%, respectively. The AUC of the sPESI was 0.698; when the sPESI was ≥ 1, the sensitivity and specificity were 75.8% and 63.9%, respectively. Establishment and prediction efficiency of prediction model A prediction model was established based on these three variables. A nomogram was constructed based on the prediction model (Fig. 3 ). The Hosmer–Lemeshow goodness of fit test showed a good fit between the nomogram prediction probability and the actual probability (Fig. 4 ). The ROC curve of the prediction model had an AUC of 0.905, indicating that the model has high predictive value (Fig. 5 ). DCA showed that prediction model had high clinical assessment efficacy for the prediction of suspected CTEPH in patients with haemodynamically stable APE (Fig. 6 ) . Table 4 Analysis of risk factors for suspected CTEPH in patients with haemodynamically stable pulmonary embolism B SE P value Exp(B) 95%CI Male 0.599 0.571 0.294 1.821 (0.595,5.575) Time from onset of symptoms to time of treatment (days) 0.183 0.047 0.001 1.200 (1.094,1.317) TRPV(m/s) 1.429 0.577 0.013 4.176 (1.347,12.944) sPESI score 2.059 0.633 0.001 7.836 (2.266,27.092) TRPV tricuspid regurgitation peak velocity; sPESI simplified pulmonary embolism severity index . Discussion CTEPH is a serious long-term complication after acute pulmonary embolism. CTEPH occurs infrequently after PE, so diagnostic evaluation of CTEPH is not recommended for all PE survivors[ 17 ], however, screening and diagnostic evaluation of CTEPH, such as persistent dyspnoea and risk factors for CTEPH, are recommended for patients who are clinically suspected to have CTEPH. Several studies have shown that patients with pulmonary embolism and right heart dysfunction are more likely to have CTEPH [ 17 , 18 ]. The initial treatment of acute pulmonary embolism also has a certain impact on the occurrence of residual right heart dysfunction and CTEPH. Similarly, compared with anticoagulation therapy alone, MATUSOV Y [ 19 ]reported that reperfusion therapy for intermediate- to high-risk pulmonary embolism was significantly beneficial for short-term and long-term right heart recovery and reduced the occurrence of CTEPH. In the European CTEPH registration study, the average diagnostic delay from the first symptom to diagnosis was 14 months [ 20 ], and delays in diagnosis and treatment of CTEPH significantly affect patient prognosis. The 2019 ESC Guidelines for the Diagnosis and Management of pulmonary embolism recommend CTEPH screening for patients with acute pulmonary embolism after 3–6 months[ 15 ]. In our study, APE patients with right heart dysfunction on CT or echocardiography were continuously included, and risk factors for suspected CTEPH were investigated according to the 3–6 month follow-up. These findings could help make treatment decisions for acute pulmonary embolism to reduce the adverse prognosis caused by acute pulmonary embolism and improve the early screening rate and diagnosis rate of CTEPH. Our study is the first to investigate risk factors for early onset of suspected CTEPH in a subgroup of APE patients with right heart dysfunction via CT or echocardiography. In our study, among 128 patients with acute pulmonary embolism with right ventricular dysfunction indicated by imaging, 33 patients were found to develop suspected CTEPH at 3–6 months of follow-up, for an incidence rate of 25.8%. Among pulmonary embolisms that were haemodynamically stable, the incidence rate of suspected CTEPH was 28.4%. Only 5 patients in our study had no elevated biomarkers for right heart dysfunction, and 96% of patients had intermediate- to high-risk pulmonary embolism. KLOK F A et al. reported that 25% of patients with submassive pulmonary embolism still had right ventricular dysfunction or possible CTEPH at the 6-month follow-up [ 21 ]; the conclusion of our study was similar to that previously reported. All 20 patients were treated after initial thrombolytic therapy without CTEPH during follow-up. ASL FS et al. also showed that none of the patients with haemodynamic instability or reperfusion therapy were diagnosed with CTEPH during follow-up[ 17 ]. However, in patients with haemodynamically stable pulmonary embolism, there was no significant difference in treatment method between the groups (p > 0.05), which was consistent with the conclusions reached in previous studies [ 22 ] and may be related to less thrombolytic therapy in patients with stable haemodynamics. In the present study, the application of catheter-directed thrombolysis (CDT) in patients with intermediate-high risk pulmonary embolism was conducive to the recovery of right heart function and pulmonary artery pressure and to reducing CTEPH incidence[ 23 , 24 ]. Our study screened out the risk factors that may cause CTEPH and conducted more active treatment in APE patients with risk factors to reduce the occurrence of CTEPH. In our study, it was concluded that the time from symptom onset to treatment, the TRPV, and the sPESI were independent risk factors for CTEPH in patients with right heart dysfunction, as indicated by imaging (p < 0.05). Since all patients with haemodynamic instability are less likely to develop CTEPH after thrombolytic therapy and all patients with suspected CTEPH have haemodynamically stable pulmonary embolism, we separately analysed pulmonary embolism patients with stable haemodynamics. It was also concluded that longer duration from symptom onset to treatment, higher TRPV, and sPESI score ≥ 1 were independent risk factors for suspected CTEPH (p < 0.05). The best cut-off value for predicting suspected CTEPH was 8 days, and the average number of days was 13 days. Previous studies have indicated that a duration from symptom onset to diagnosis of PE greater than 2 weeks is an independent risk factor for CTEPH [ 13 ]. The best cut-off value for the time from symptom onset to treatment was shorter in our study, which may be related to the patients enrolled in our study having acute pulmonary embolism (time from the onset of symptoms to the diagnosis of PE within 30 days). Delayed anticoagulation and thrombolytic therapy can lead to thrombofibrosis and promote the release of inflammatory factors, leading to the occurrence of CTEPH[ 25 ]. Early diagnosis of acute PE can reduce the incidence of CTEPH. LACHANT D et al. [ 26 ] reported that pulmonary artery systolic blood pressure at baseline was associated with the development of CTEPH. An estimated baseline pulmonary artery systolic blood pressure > 50 mmHg was associated with the persistence of pulmonary hypertension and RV dysfunction[ 27 ]. We also concluded that the TRPV at baseline was a risk factor for suspected CTEPH in haemodynamically stable pulmonary embolism patients. The optimal cut-off value was 3.4 m/s, the sensitivity was 78.8%, and the specificity was 66.3%. A previous study showed that an RV/LV > 1 was a risk factor for CTEPH [ 17 ], which was not confirmed in our study. Our study concluded that an sPESI score ≥ 1 at baseline was an independent risk factor for suspected CTEPH. When the sPESI score was ≥ 1, the sensitivity was 75.8%, and the specificity was 63.9%. At present, studies on the application of the sPESI for predicting the long-term prognosis of pulmonary embolism, especially for patients with CTEPH, are rare. VALERIO L et al.[ 7 ] reported that patients with pulmonary embolism and an sPESI score ≥ 1 are more likely to develop post pulmonary embolism syndrome. In our study, when combined with the time from symptom to treatment, the TRPV, and sPESI scores were used to predict suspected CTEPH at 3–6 months in patients with haemodynamically stable pulmonary embolism, and the AUC was 0.905, indicating high predictive value. Our study has several limitations. First, our study was a retrospective single-centre cohort study. The potential CTEPH population was screened through symptoms, echocardiography and CTPA during follow-up, but only 4 patients were confirmed to have CTEPH by right cardiac catheterization; not all patients were confirmed to have CTEPH by right cardiac catheterization and the true occurrence of CTEPH was unknown. However, we recommend echocardiography inspection for pulmonary embolism patients with right heart dysfunction indicated by imaging after 3 months of anticoagulation therapy to reduce missed diagnoses in CTEPH patients. Second, although we tried to exclude patients who had underlying RV dysfunction preceding acute hospitalization, we cannot rule out the possibility that some patients had underlying undiagnosed pulmonary hypertension or right heart disease. Therefore, prospective studies with large sample sizes are needed to verify our conclusions. Conclusion Our study concluded that a longer duration from symptom onset to treatment, a higher TRPV, and an sPESI ≥ 1 were associated with an increased risk of CTEPH. Improving the diagnostic level of acute pulmonary embolism, more active treatment and more follow-up for patients with risk factors may reduce the incidence of CTEPH. Abbreviations CTEPH chronic thromboembolic pulmonary hypertension CTED chronic thromboembolic disease PE pulmonary embolism APE acute pulmonary embolism VTE venous thromboembolism PH pulmonary hypertension CT computed tomography CTPA computed tomography pulmonary angiography ROC receiver operating characteristic OR odds ratio AUC area under the curve RHC right heart catheterization V/Q ventilation/perfusion LVEF left ventricle ejection fraction RV right ventricular RV/LV right ventricular/left ventricular TRPV tricuspid regurgitation peak velocity TAPSE tricuspid annulus plane systolic excursion mPAP mean pulmonary artery pressure PAWP pulmonary artery wedge pressure sPESI simplified pulmonary embolism severity index NOAC new oral anticoagulant CDT catheter-directed thrombolysis NT-proBNP N terminal pro B type natriuretic peptide Declarations Author contributions LSP, MYM and HSS contributed to design this study. LSP ，WW and FYX contributed to collect data. LSP analyzed the results and wrote the manuscript. LSP，GPF and MYM provided overall supervision and critically revised the manuscript. All authors read and approved the final manuscript. Funding We have not received any funding for this research. Institutional Review Board Statement The experiment was approved by the Ethics Committee of the First Afliated Hospital of Henan University of Science and Technology. This study used routinely collected data extracted anonymously from patient charts and was granted a waiver from obtaining informed consent by the Ethics Committee of the First Afliated Hospital of Henan University of Science and Technology and the research content and process of this project comply with the international and national ethical requirements for biomedical research, and meet the medical ethical requirements stipulated in the preliminary rules of ethical review measures for biomedical research involving human. 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Uberoi, Catheter-directed therapies for the treatment of high risk (massive) and intermediate risk (submassive) acute pulmonary embolism. Cochrane Database Syst Rev, 2022. 8(8): p. CD013083. Yu, Y., et al., Incidence and risk factors of chronic thromboembolic pulmonary hypertension in patients with diagnosis of pulmonary embolism for the first time in real world. Clin Respir J, 2018. 12(11): p. 2551-2558. Lachant, D., et al., Clinical and imaging outcomes after intermediate- or high-risk pulmonary embolus. Pulm Circ, 2020. 10(3): p. 2045894020952019. Barco, S., et al., Incomplete echocardiographic recovery at 6 months predicts long-term sequelae after intermediate-risk pulmonary embolism. A post-hoc analysis of the Pulmonary Embolism Thrombolysis (PEITHO) trial. Clin Res Cardiol, 2019. 108(7): p. 772-778. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3938961","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":272412151,"identity":"a30e7b38-8c02-4c0e-9eea-f00d43c68ff5","order_by":0,"name":"Shuangping Li","email":"","orcid":"","institution":"Henan University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Shuangping","middleName":"","lastName":"Li","suffix":""},{"id":272412152,"identity":"908d8f12-4e3f-48fe-bc53-fd3c3e5c9da4","order_by":1,"name":"Shenshen Huang","email":"","orcid":"","institution":"Henan University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Shenshen","middleName":"","lastName":"Huang","suffix":""},{"id":272412153,"identity":"2f56712e-e4f5-4db4-af4f-e200f7c685bc","order_by":2,"name":"Wei Wang","email":"","orcid":"","institution":"First Affiliated Hospital of Henan University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Wei","middleName":"","lastName":"Wang","suffix":""},{"id":272412154,"identity":"f9478e2f-807a-464f-a143-c9b7e6ef62ce","order_by":3,"name":"Pengfei Gao","email":"","orcid":"","institution":"First Affiliated Hospital of Henan University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Pengfei","middleName":"","lastName":"Gao","suffix":""},{"id":272412155,"identity":"9fd343d8-e7ba-40e4-93f8-b77116a860fe","order_by":4,"name":"YUxuan Feng","email":"","orcid":"","institution":"Henan University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"YUxuan","middleName":"","lastName":"Feng","suffix":""},{"id":272412156,"identity":"1b6ab29c-bb50-4809-ad2d-c04f589a3959","order_by":5,"name":"Yimin Mao","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyElEQVRIiWNgGAWjYDACZgaGAwwVEjz2xxuADOK1nLGQYzhzgFgtIMDYUmHMcCOBSNUGx7kTDxc2SCQ2znz+8HBBDYM8vxgBywwO8244PHOHRGKzdI7B4RnHGAxnziZgHVgL7xmJxDbpHIbDPGwMCQa3idLSJpHYI3n8wWGefyRoMZaQALHbiNAiCdLCc0ZCzoAH6BfePgnCfuE7f3bzZ56KOh4D9uOPP/N8s5HnlyagReEAKl8Cv3IQkG8grGYUjIJRMApGOgAA1rpGlcKt5OcAAAAASUVORK5CYII=","orcid":"","institution":"First Affiliated Hospital of Henan University of Science and Technology","correspondingAuthor":true,"prefix":"","firstName":"Yimin","middleName":"","lastName":"Mao","suffix":""}],"badges":[],"createdAt":"2024-02-08 06:01:52","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3938961/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3938961/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":51134807,"identity":"8e5d856e-95bd-4cf6-98e9-8e492a27b899","added_by":"auto","created_at":"2024-02-14 18:26:56","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":21045,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart of APE patients with right heart dysfunction according to CT or echocardiography\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3938961/v1/67347fe9b5614bd9b272d810.png"},{"id":51134802,"identity":"b2480146-0104-4779-82d9-8548f842a349","added_by":"auto","created_at":"2024-02-14 18:26:55","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":52093,"visible":true,"origin":"","legend":"\u003cp\u003eROC curve of the time from symptom onset to treatment, sPESI score, and TRPV for predicting suspected CTEPH in patients with haemodynamically stable pulmonary embolism\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-3938961/v1/9ab13adbbd514f1ef0b44848.png"},{"id":51134813,"identity":"5e4d9895-bef9-4dc5-b87a-ec8ea7c222da","added_by":"auto","created_at":"2024-02-14 18:26:59","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":41388,"visible":true,"origin":"","legend":"\u003cp\u003eNomogram of the risk of suspected CTEPH in haemodynamically stable pulmonary embolism patients\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-3938961/v1/9cbe8920859f452f2271e375.png"},{"id":51134804,"identity":"fec5e8db-3169-4712-992b-12fecd99f35e","added_by":"auto","created_at":"2024-02-14 18:26:56","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":276279,"visible":true,"origin":"","legend":"\u003cp\u003eCalibration curve of the model.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-3938961/v1/60a7773ad6c4c2b0a0693e50.png"},{"id":51134806,"identity":"aec801c7-7fc5-4617-a9b4-2c07abfea223","added_by":"auto","created_at":"2024-02-14 18:26:56","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":120188,"visible":true,"origin":"","legend":"\u003cp\u003eROC curve of the prediction model\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-3938961/v1/9a5206014f55627acdb1aff3.png"},{"id":51134808,"identity":"b62138fa-61d1-4870-962a-26137c370648","added_by":"auto","created_at":"2024-02-14 18:26:57","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":160347,"visible":true,"origin":"","legend":"\u003cp\u003eDCA of the prediction model\u003c/p\u003e","description":"","filename":"floatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-3938961/v1/12a42480cf6b4091a8ef5eb2.png"},{"id":51520190,"identity":"20d7bf9f-6a71-4d42-adb8-6184c063b6a5","added_by":"auto","created_at":"2024-02-23 03:09:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":907113,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3938961/v1/26e468ee-25c6-4381-966d-f51b5674ebf9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Risk factors and prediction model for chronic thromboembolic pulmonary hypertension in acute pulmonary embolism patients with right heart dysfunction on CT or echocardiography","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAcute pulmonary embolism (APE) survivors are at risk of multiple long-term complications, and half of these patients do not fully recover from an acute episode and have chronic functional limitations[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This may be related to incomplete dissolution of the thrombus, incomplete recovery of heart size and function, and permanent changes in pulmonary artery haemodynamics[\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Among the disease spectrum of postpulmonary embolism syndrome, chronic thromboembolic disease (CTED) and chronic thromboembolic pulmonary hypertension (CTEPH) are the most serious complications[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Previous studies have shown that the incidence of CTEPH is 2\u0026ndash;4%[\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. CTEPH is characterized by thrombofibrosis and secondary microvascular remodelling, leading to persistent pulmonary artery obstruction and resulting in increased pulmonary vascular resistance and pulmonary hypertension (PH). Studies have shown that the majority of patients with CTEPH can be diagnosed within 4 months after PE diagnosis[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The current median time to diagnosis of CTEPH is approximately 10 months after the patient becomes symptomatic and 13.1 months after the patient becomes symptomatic [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], and it is clear that delayed diagnosis of CTEPH is common. Identifying the risk factors for CTEPH can improve the early prediction of CTEPH occurrence, help formulate a treatment plan for pulmonary embolism, improve the early screening rate of CTEPH, and reduce the incidence of CTEPH. Possible risk factors for CTEPH include hypothyroidism, malignant tumours, recurrent venous thromboembolism, massive PE, positive antiphospholipid antibody, elevated coagulation factor VIII, non-O blood type, and splenectomy[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, risk factors for predicting CTEPH incidence are not comprehensive, and the risk factors still need to be further explored. One study reported that patients with acute pulmonary embolism with right heart dysfunction on CT or echocardiography were more likely to develop CTEPH, and 81% of CTEPH patients had signs of right heart dysfunction during acute pulmonary embolism[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. CTEPH was diagnosed by right heart catheterization (RHC). For screening pulmonary hypertension, echocardiography is the preferred test because it can provide an estimate of pulmonary artery pressure[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The purpose of our study was to investigate the risk factors for suspected pulmonary hypertension 3\u0026ndash;6 months after anticoagulation therapy in PE patients with right heart dysfunction via CT or echocardiography to help doctors make treatment decisions about APE to reduce the occurrence of CTEPH and improve the early screening and diagnosis rate of CTEPH.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eA total of 506 patients with APE were diagnosed at the First Affiliated Hospital of Henan University of Science and Technology from January 2018 to June 2023. The inclusion criteria were as follows: 1. Pulmonary embolism was diagnosed by CT pulmonary angiography (CTPA) or ventilation/perfusion (V/Q) lung scans; 2. Echocardiography or CTPA indicated signs of right heart dysfunction; and 3. Within 30 days from the onset of symptoms to the diagnosis of PE. The exclusion criteria were as follows: 1. Patients with no signs of right heart dysfunction on imaging; 2. Death in hospital; 3. Patients with no 3\u0026ndash;6 month follow-up records or incomplete follow-up data; 4. Potential pulmonary hypertension or CTEPH, severe left heart failure (LVEF\u0026thinsp;\u0026le;\u0026thinsp;40%); and 5. Patients who had incomplete data.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDefinition\u003c/h2\u003e \u003cp\u003eThe diagnostic criteria for right ventricular dysfunction according to echocardiography included the following: (1) right ventricular (RV) end-diastolic diameter\u0026thinsp;\u0026gt;\u0026thinsp;30 mm, (2) reduced range of right ventricular free wall motion, (3) tricuspid regurgitation peak velocity (TRPV)\u0026thinsp;\u0026gt;\u0026thinsp;2.6 m/s, and (4) tricuspid annulus plane systolic excursion (TAPSE)\u0026thinsp;\u0026lt;\u0026thinsp;17 mm)[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The diagnostic criterion for right ventricular dysfunction according to CTPA was right ventricular dilation found at the four visceral levels. The criterion for diagnosing PH by echocardiography was a TRPV\u0026thinsp;\u0026gt;\u0026thinsp;2.8 m/s[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Suspected CTEPH was defined when the patient was treated with anticoagulation agents for more than 3 months, if the echocardiography results indicated pulmonary hypertension, and the CTPA or V/Q pulmonary scan indicated chronic thrombosis. The diagnostic criterion for CTEPH was right heart catheterization, for which the mean pulmonary artery pressure (mPAP) was \u0026ge;\u0026thinsp;25 mmHg and the pulmonary artery wedge pressure (PAWP) was \u0026le;\u0026thinsp;15 mmHg.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eAll clinical data were collected from inpatient and outpatient medical records. The baseline data included sex, age, time from symptom onset to treatment, risk stratification of pulmonary embolism, treatment mode, complications, echocardiography markers, NT-proBNP, troponin, heart rate, systolic blood pressure, oxygen saturation, respiratory rate, and simplified pulmonary embolism severity index score (sPESI). Follow-up data included patient symptoms and echocardiography indicator data. If the patient's echocardiography indicated PH, CTPA or V/Q lung scan was performed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical methods\u003c/h2\u003e \u003cp\u003eAll the statistical analyses were performed using SPSS 23.0 and R software (version 4.2.2; R Foundation for Statistical Computing, Vienna, Austria). For descriptive statistics, categorical variables are expressed as numbers (percentages), and continuous variables are expressed as the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation. When the two groups were compared, the χ2 test or Fisher\u0026rsquo;s exact test was used for categorical variables, Student\u0026rsquo;s t test was used for continuous variables with a normal distribution, and the Wilcoxon rank sum test was used for variables with a nonnormal distribution. Variables with p values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 in the univariate analysis were included in the multivariate logistic regression analysis. By executing the rms package in R (version 4.2.2), a nomogram model was constructed using meaningful factors from the multivariate logistic regression analysis. The rmda package was employed for decision curve analysis (DCA). The C-index and calibration curve were used to verify the accuracy of the nomogram model. ROC curves were drawn to evaluate the predictive value of risk factors and prediction models for suspected CTEPH. A P value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered to indicate statistical significance.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThis retrospective cohort study included 506 patients diagnosed with PE at the First Affiliated Hospital of Henan University of Science and Technology from January 2018 to June 2023. Forty-five patients had incomplete hospital data; 235 patients had no signs of right heart dysfunction; 28 patients died in the hospital; 16 patients had potential pulmonary hypertension; 11 patients had potential severe left heart failure; 7 patients had chronic pulmonary embolism; 26 patients did not return to the hospital for follow-up 3\u0026ndash;6 months after discharge; and 10 patients had incomplete follow-up data. Overall, 128 APE patients with right heart dysfunction on CT or echocardiography were included, including 12 patients with haemodynamic instability and 116 patients with haemodynamic stability. At the 3\u0026ndash;6 month follow-up, 33 patients (25.8%) were diagnosed with suspected CTEPH, 4 of these patients were confirmed by right heart catheterization. 95 patients (74.2%) were not diagnosed with CTEPH. Among the 33 suspected CTEPH patients, 27 (81.8%) had symptoms of dyspnoea. CTPA confirmed that thromboembolism was still present in all suspected CTEPH patients; for 23 (69.7%) of these patients, thromboembolism was less than before; and for 10 (30.3%) patients, thromboembolism did not significantly change compared with the first time. The enrolment flow chart is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eComparison of baseline data between suspected CTEPH patients and patients without CTEPH\u003c/h2\u003e \u003cp\u003eComparison of baseline data between suspected CTEPH patients and non CTEPH patients. There were significant differences in thrombolytic therapy, time from onset of symptoms to treatment, sPESI score and TRPV (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). There were no statistically significant differences between the two groups in terms of sex, age, type of oral anticoagulant drug, heart rate, RV end-diastolic diameter, RV/LV end-diastolic diameter, TAPSE, troponin, NT-proBNP, comorbidity, or history of VTE (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Notably, 20 patients who underwent thrombolytic therapy all without CTEPH and 33 patients with suspected CTEPH at follow-up were haemodynamically stable and without thrombolytic therapy. The data are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of baseline data between patients with suspected CTEPH and without CTEPH\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWithout CTEPH(n\u0026thinsp;=\u0026thinsp;95)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSuspected\u003c/p\u003e \u003cp\u003eCTEPH(n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eX2 value/T value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e47(49.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20(60.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e66.27\u0026thinsp;\u0026plusmn;\u0026thinsp;13.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69.63\u0026thinsp;\u0026plusmn;\u0026thinsp;15.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThrombolytic therapy, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20(21.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNOAC, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e62(65.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20(60.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime from onset of symptoms to time of treatment (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.30\u0026thinsp;\u0026plusmn;\u0026thinsp;4.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.06\u0026thinsp;\u0026plusmn;\u0026thinsp;9.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCerebral infarction, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16(16.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4(12.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9(9.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4(12.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42(44.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15(45.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.90\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActive tumour, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8(8.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5(15.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVTE history, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10(10.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(6.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003esPESI score\u0026thinsp;\u0026ge;\u0026thinsp;1, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42(44.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23(69.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRV end-diastolic diameter\u0026thinsp;\u0026ge;\u0026thinsp;30 mm, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e36(37.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11(33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRV/LV end-diastolic diameter\u0026thinsp;\u0026ge;\u0026thinsp;0.9, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9(9.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(9.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.94\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTAPSE\u0026thinsp;\u0026lt;\u0026thinsp;17 mm, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24(23.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10(30.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTRPV(m/s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.15\u0026thinsp;\u0026plusmn;\u0026thinsp;0.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.68\u0026thinsp;\u0026plusmn;\u0026thinsp;0.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLactic acid(mmol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.91\u0026thinsp;\u0026plusmn;\u0026thinsp;1.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.74\u0026thinsp;\u0026plusmn;\u0026thinsp;0.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTroponin elevated, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41(43.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9(27.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNT-proBNP elevated, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e84(88.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30(90.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eNOAC\u003c/em\u003e new oral anticoagulant; \u003cem\u003eVTE\u003c/em\u003e venous thromboembolism; \u003cem\u003esPESI\u003c/em\u003e simplified pulmonary embolism severity index; \u003cem\u003eRV\u003c/em\u003e right ventricular; \u003cem\u003eRV/LV\u003c/em\u003e right ventricular/left ventricular; \u003cem\u003eTAPSE\u003c/em\u003e tricuspid annulus plane systolic excursion; \u003cem\u003eTRPV\u003c/em\u003e tricuspid regurgitation peak velocity\u003c/p\u003e \u003cp\u003e \u003cb\u003eRisk factors for suspected CTEPH in APE patients with right heart dysfunction on CT or echocardiography\u003c/b\u003e \u003c/p\u003e \u003cp\u003eSex, time from symptom onset to treatment, sPESI score and TRPV were included in the multivariate logistic regression analysis, which showed that the time from symptom onset to treatment (OR, 1.213), sPESI score (OR, 4.628) and TRPV (OR, 5.115) were risk factors for suspected CTEPH. Shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAnalysis of risk factors for suspected CTEPH in APE patients with right heart dysfunction via CT or echocardiography\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eExp(B)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95%CI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.660\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.560\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.239\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.936\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e(0.645,5.806)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime from onset of symptoms to time of treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.193\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.047\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.213\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e(1.106,1.329)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTRPV(m/s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.632\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.565\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e(1.690,15.478)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003esPESI score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.532\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.589\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.628\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e(1.460,14.674)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eTRPV\u003c/em\u003e tricuspid regurgitation peak velocity; \u003cem\u003esPESI\u003c/em\u003e simplified pulmonary embolism severity index\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eComparison of suspected CTEPH versus without CTEPH in haemodynamically stable APE patients\u003c/h2\u003e \u003cp\u003eThe time from symptom onset to treatment, arterial oxygen saturation\u0026thinsp;\u0026le;\u0026thinsp;90%, sPESI score\u0026thinsp;\u0026ge;\u0026thinsp;1 point, and TRPV were significantly different between the two groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). There were no significant differences in sex, age, thrombolytic therapy, type of oral anticoagulant, heart rate, RV end-diastolic diameter, RV/LV end-diastolic diameter, TAPSE, troponin, NT-proBNP, comorbidities, or history of VTE (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of patients with suspected CTEPH and without CTEPH at baseline for haemodynamically stable pulmonary embolism\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWithout CTEPH(n\u0026thinsp;=\u0026thinsp;83)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSuspected\u003c/p\u003e \u003cp\u003eCTEPH(n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eX2 value/T value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41(49.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20(60.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e66.48\u0026thinsp;\u0026plusmn;\u0026thinsp;12.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69.63\u0026thinsp;\u0026plusmn;\u0026thinsp;15.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThrombolytic therapy, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8(9.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNOAC, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e52(62.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20(60.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime from onset of symptoms to time of treatment (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.78\u0026thinsp;\u0026plusmn;\u0026thinsp;4.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.06\u0026thinsp;\u0026plusmn;\u0026thinsp;9.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003esPESI score\u0026thinsp;\u0026ge;\u0026thinsp;1, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30(36.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23(69.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeart rate\u0026thinsp;\u0026ge;\u0026thinsp;110 times/min, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12(14.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9(27.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOxygen saturation\u0026thinsp;\u0026le;\u0026thinsp;90%, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10(12.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9(27.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRV end-diastolic diameter\u0026thinsp;\u0026ge;\u0026thinsp;30 mm, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29(34.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11(33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.87\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRV/LV end-diastolic diameter\u0026thinsp;\u0026ge;\u0026thinsp;0.9, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7(8.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(9.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTAPSE\u0026thinsp;\u0026lt;\u0026thinsp;17 mm,n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16(19.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10(30.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTRPV(m/s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.16\u0026thinsp;\u0026plusmn;\u0026thinsp;0.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.68\u0026thinsp;\u0026plusmn;\u0026thinsp;0.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTroponin elevated, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38(45.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9(27.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNT-proBNP elevated, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e73(87.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30(90.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCerebral infarction, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15(18.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4(12.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8(9.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4(12.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37(44.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15(45.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActive tumour, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7(8.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5(15.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVTE history, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10(12.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(6.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eNOAC\u003c/em\u003e new oral anticoagulant; \u003cem\u003eVTE\u003c/em\u003e venous thromboembolism; \u003cem\u003esPESI\u003c/em\u003e simplified pulmonary embolism severity index; \u003cem\u003eRV\u003c/em\u003e right ventricular; \u003cem\u003eRV/LV\u003c/em\u003e right ventricular/left ventricular; \u003cem\u003eTAPSE\u003c/em\u003e tricuspid annulus plane systolic excursion; \u003cem\u003eTRPV\u003c/em\u003e tricuspid regurgitation peak velocity\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eRisk factors and prediction model for suspected CTEPH in patients with haemodynamically stable APE\u003c/h2\u003e \u003cp\u003eSex, time from symptom onset to treatment, sPESI score and TRPV were included in the multivariate logistic regression analysis, which showed that the time from symptom onset to treatment (OR, 1.200), sPESI score (OR, 7.836), and TRPV (OR, 4.176) were risk factors for suspected CTEPH, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. ROC curves were generated for the time from symptom onset to treatment, the sPESI score, and the TRPV for predicting suspected CTEPH in patients with haemodynamically stable pulmonary embolism (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The AUC of the time from symptom onset to treatment was 0.793; when the optimal cut-off value was 8 days, the sensitivity was 60.6%, and the specificity was 85.5%. The AUC for TRPV was 0.755; when the optimal cut-off value was 3.4 m/s, the sensitivity and specificity were 78.8% and 66.3%, respectively. The AUC of the sPESI was 0.698; when the sPESI was \u0026ge;\u0026thinsp;1, the sensitivity and specificity were 75.8% and 63.9%, respectively.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eEstablishment and prediction efficiency of prediction model\u003c/h2\u003e \u003cp\u003eA prediction model was established based on these three variables. A nomogram was constructed based on the prediction model (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The Hosmer\u0026ndash;Lemeshow goodness of fit test showed a good fit between the nomogram prediction probability and the actual probability (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The ROC curve of the prediction model had an AUC of 0.905, indicating that the model has high predictive value (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). DCA showed that prediction model had high clinical assessment efficacy for the prediction of suspected CTEPH in patients with haemodynamically stable APE (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e) .\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAnalysis of risk factors for suspected CTEPH in patients with haemodynamically stable pulmonary embolism\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eExp(B)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95%CI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.599\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.571\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.294\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.821\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e(0.595,5.575)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime from onset of symptoms to time of treatment (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.183\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.047\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e(1.094,1.317)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTRPV(m/s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.429\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.577\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.176\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e(1.347,12.944)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003esPESI score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.059\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.633\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7.836\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e(2.266,27.092)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eTRPV\u003c/em\u003e tricuspid regurgitation peak velocity; \u003cem\u003esPESI\u003c/em\u003e simplified pulmonary embolism severity index\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eCTEPH is a serious long-term complication after acute pulmonary embolism. CTEPH occurs infrequently after PE, so diagnostic evaluation of CTEPH is not recommended for all PE survivors[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], however, screening and diagnostic evaluation of CTEPH, such as persistent dyspnoea and risk factors for CTEPH, are recommended for patients who are clinically suspected to have CTEPH. Several studies have shown that patients with pulmonary embolism and right heart dysfunction are more likely to have CTEPH [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The initial treatment of acute pulmonary embolism also has a certain impact on the occurrence of residual right heart dysfunction and CTEPH. Similarly, compared with anticoagulation therapy alone, MATUSOV Y [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]reported that reperfusion therapy for intermediate- to high-risk pulmonary embolism was significantly beneficial for short-term and long-term right heart recovery and reduced the occurrence of CTEPH. In the European CTEPH registration study, the average diagnostic delay from the first symptom to diagnosis was 14 months [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], and delays in diagnosis and treatment of CTEPH significantly affect patient prognosis. The 2019 ESC Guidelines for the Diagnosis and Management of pulmonary embolism recommend CTEPH screening for patients with acute pulmonary embolism after 3\u0026ndash;6 months[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In our study, APE patients with right heart dysfunction on CT or echocardiography were continuously included, and risk factors for suspected CTEPH were investigated according to the 3\u0026ndash;6 month follow-up. These findings could help make treatment decisions for acute pulmonary embolism to reduce the adverse prognosis caused by acute pulmonary embolism and improve the early screening rate and diagnosis rate of CTEPH. Our study is the first to investigate risk factors for early onset of suspected CTEPH in a subgroup of APE patients with right heart dysfunction via CT or echocardiography.\u003c/p\u003e \u003cp\u003eIn our study, among 128 patients with acute pulmonary embolism with right ventricular dysfunction indicated by imaging, 33 patients were found to develop suspected CTEPH at 3\u0026ndash;6 months of follow-up, for an incidence rate of 25.8%. Among pulmonary embolisms that were haemodynamically stable, the incidence rate of suspected CTEPH was 28.4%. Only 5 patients in our study had no elevated biomarkers for right heart dysfunction, and 96% of patients had intermediate- to high-risk pulmonary embolism. KLOK F A et al. reported that 25% of patients with submassive pulmonary embolism still had right ventricular dysfunction or possible CTEPH at the 6-month follow-up [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]; the conclusion of our study was similar to that previously reported. All 20 patients were treated after initial thrombolytic therapy without CTEPH during follow-up. ASL FS et al. also showed that none of the patients with haemodynamic instability or reperfusion therapy were diagnosed with CTEPH during follow-up[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. However, in patients with haemodynamically stable pulmonary embolism, there was no significant difference in treatment method between the groups (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05), which was consistent with the conclusions reached in previous studies [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] and may be related to less thrombolytic therapy in patients with stable haemodynamics. In the present study, the application of catheter-directed thrombolysis (CDT) in patients with intermediate-high risk pulmonary embolism was conducive to the recovery of right heart function and pulmonary artery pressure and to reducing CTEPH incidence[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Our study screened out the risk factors that may cause CTEPH and conducted more active treatment in APE patients with risk factors to reduce the occurrence of CTEPH.\u003c/p\u003e \u003cp\u003eIn our study, it was concluded that the time from symptom onset to treatment, the TRPV, and the sPESI were independent risk factors for CTEPH in patients with right heart dysfunction, as indicated by imaging (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Since all patients with haemodynamic instability are less likely to develop CTEPH after thrombolytic therapy and all patients with suspected CTEPH have haemodynamically stable pulmonary embolism, we separately analysed pulmonary embolism patients with stable haemodynamics. It was also concluded that longer duration from symptom onset to treatment, higher TRPV, and sPESI score\u0026thinsp;\u0026ge;\u0026thinsp;1 were independent risk factors for suspected CTEPH (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The best cut-off value for predicting suspected CTEPH was 8 days, and the average number of days was 13 days. Previous studies have indicated that a duration from symptom onset to diagnosis of PE greater than 2 weeks is an independent risk factor for CTEPH [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The best cut-off value for the time from symptom onset to treatment was shorter in our study, which may be related to the patients enrolled in our study having acute pulmonary embolism (time from the onset of symptoms to the diagnosis of PE within 30 days). Delayed anticoagulation and thrombolytic therapy can lead to thrombofibrosis and promote the release of inflammatory factors, leading to the occurrence of CTEPH[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Early diagnosis of acute PE can reduce the incidence of CTEPH. LACHANT D et al. [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] reported that pulmonary artery systolic blood pressure at baseline was associated with the development of CTEPH. An estimated baseline pulmonary artery systolic blood pressure\u0026thinsp;\u0026gt;\u0026thinsp;50 mmHg was associated with the persistence of pulmonary hypertension and RV dysfunction[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. We also concluded that the TRPV at baseline was a risk factor for suspected CTEPH in haemodynamically stable pulmonary embolism patients. The optimal cut-off value was 3.4 m/s, the sensitivity was 78.8%, and the specificity was 66.3%. A previous study showed that an RV/LV\u0026thinsp;\u0026gt;\u0026thinsp;1 was a risk factor for CTEPH [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], which was not confirmed in our study. Our study concluded that an sPESI score\u0026thinsp;\u0026ge;\u0026thinsp;1 at baseline was an independent risk factor for suspected CTEPH. When the sPESI score was \u0026ge;\u0026thinsp;1, the sensitivity was 75.8%, and the specificity was 63.9%. At present, studies on the application of the sPESI for predicting the long-term prognosis of pulmonary embolism, especially for patients with CTEPH, are rare. VALERIO L et al.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] reported that patients with pulmonary embolism and an sPESI score\u0026thinsp;\u0026ge;\u0026thinsp;1 are more likely to develop post pulmonary embolism syndrome. In our study, when combined with the time from symptom to treatment, the TRPV, and sPESI scores were used to predict suspected CTEPH at 3\u0026ndash;6 months in patients with haemodynamically stable pulmonary embolism, and the AUC was 0.905, indicating high predictive value.\u003c/p\u003e \u003cp\u003eOur study has several limitations. First, our study was a retrospective single-centre cohort study. The potential CTEPH population was screened through symptoms, echocardiography and CTPA during follow-up, but only 4 patients were confirmed to have CTEPH by right cardiac catheterization; not all patients were confirmed to have CTEPH by right cardiac catheterization and the true occurrence of CTEPH was unknown. However, we recommend echocardiography inspection for pulmonary embolism patients with right heart dysfunction indicated by imaging after 3 months of anticoagulation therapy to reduce missed diagnoses in CTEPH patients. Second, although we tried to exclude patients who had underlying RV dysfunction preceding acute hospitalization, we cannot rule out the possibility that some patients had underlying undiagnosed pulmonary hypertension or right heart disease. Therefore, prospective studies with large sample sizes are needed to verify our conclusions.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study concluded that a longer duration from symptom onset to treatment, a higher TRPV, and an sPESI\u0026thinsp;\u0026ge;\u0026thinsp;1 were associated with an increased risk of CTEPH. Improving the diagnostic level of acute pulmonary embolism, more active treatment and more follow-up for patients with risk factors may reduce the incidence of CTEPH.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCTEPH \u0026nbsp;\u0026nbsp;chronic thromboembolic pulmonary hypertension\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCTED \u0026nbsp; \u0026nbsp;chronic thromboembolic disease\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePE \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;pulmonary embolism\u003c/p\u003e\n\u003cp\u003eAPE \u0026nbsp; \u0026nbsp; acute pulmonary embolism \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eVTE \u0026nbsp; \u0026nbsp; venous thromboembolism\u003c/p\u003e\n\u003cp\u003ePH \u0026nbsp; \u0026nbsp; \u0026nbsp;pulmonary hypertension\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCT \u0026nbsp; \u0026nbsp; \u0026nbsp;computed tomography\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCTPA \u0026nbsp; \u0026nbsp;computed tomography pulmonary angiography\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eROC\u0026nbsp; \u0026nbsp; receiver operating characteristic\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOR\u0026nbsp; \u0026nbsp; \u0026nbsp;odds ratio\u003c/p\u003e\n\u003cp\u003eAUC \u0026nbsp; \u0026nbsp;\u0026nbsp;area under the curve\u003c/p\u003e\n\u003cp\u003eRHC \u0026nbsp; \u0026nbsp;\u0026nbsp;right heart catheterization\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eV/Q \u0026nbsp; \u0026nbsp; \u0026nbsp;ventilation/perfusion\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLVEF \u0026nbsp; \u0026nbsp; left\u0026nbsp;ventricle\u0026nbsp;ejection fraction\u003c/p\u003e\n\u003cp\u003eRV \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;right ventricular\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRV/LV\u0026nbsp; \u0026nbsp;right ventricular/left ventricular\u003c/p\u003e\n\u003cp\u003eTRPV \u0026nbsp; \u0026nbsp;tricuspid regurgitation peak velocity\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTAPSE \u0026nbsp;\u0026nbsp;tricuspid annulus plane systolic excursion\u0026nbsp;\u003c/p\u003e\n\u003cp\u003emPAP \u0026nbsp; \u0026nbsp;mean\u0026nbsp;pulmonary artery pressure\u003c/p\u003e\n\u003cp\u003ePAWP \u0026nbsp; \u0026nbsp;pulmonary artery wedge pressure\u003c/p\u003e\n\u003cp\u003esPESI \u0026nbsp; \u0026nbsp;simplified pulmonary embolism severity index\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNOAC \u0026nbsp; new oral anticoagulant\u003c/p\u003e\n\u003cp\u003eCDT \u0026nbsp; \u0026nbsp;\u0026nbsp;catheter-directed thrombolysis\u003c/p\u003e\n\u003cp\u003eNT-proBNP \u0026nbsp;N terminal pro B type natriuretic peptide\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLSP, MYM and HSS contributed to design this study. LSP\u0026nbsp;，WW and FYX contributed to collect data. LSP analyzed the results and wrote the manuscript. LSP，GPF and MYM provided overall supervision and critically revised the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe have not received any funding for this research.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInstitutional Review Board Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe experiment was approved by the Ethics Committee of the First Afliated Hospital of Henan University of Science and Technology. This study used routinely collected data extracted anonymously from patient charts and was granted a waiver from obtaining informed consent by the Ethics Committee of the First Afliated Hospital of Henan University of Science and Technology and the research content and process of this project comply with the international and national ethical requirements for biomedical research, and meet the medical ethical requirements stipulated in the preliminary rules of ethical review measures for biomedical research involving human.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all subjects involved in the study\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere is no any confict of interest among the all authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eden Exter, P.L., et al., Long-term clinical course of acute pulmonary embolism. Blood Rev, 2013. 27(4): p. 185-92.\u003c/li\u003e\n\u003cli\u003eKahn, S.R., et al., Functional and Exercise Limitations After a First Episode of Pulmonary Embolism: Results of the ELOPE Prospective Cohort Study. Chest, 2017. 151(5): p. 1058-1068.\u003c/li\u003e\n\u003cli\u003eKahn, S.R., et al., Quality of Life, Dyspnea, and Functional Exercise Capacity Following a First Episode of Pulmonary Embolism: Results of the ELOPE Cohort Study. Am J Med, 2017. 130(8): p. 990.e9-990.e21.\u003c/li\u003e\n\u003cli\u003eKlok, F.A., et al., The post-PE syndrome: a new concept for chronic complications of pulmonary embolism. Blood Rev, 2014. 28(6): p. 221-6.\u003c/li\u003e\n\u003cli\u003eTeerapuncharoen, K. and R. Bag, Chronic Thromboembolic Pulmonary Hypertension. Lung, 2022. 200(3): p. 283-299.\u003c/li\u003e\n\u003cli\u003eBarco, S., et al., Preexisting Chronic Thromboembolic Pulmonary Hypertension in Acute Pulmonary Embolism. Chest, 2023. 163(4): p. 923-932.\u003c/li\u003e\n\u003cli\u003eValerio, L., et al., Chronic thromboembolic pulmonary hypertension and impairment after pulmonary embolism: the FOCUS study. Eur Heart J, 2022. 43(36): p. 3387-3398.\u003c/li\u003e\n\u003cli\u003eEnde-Verhaar, Y.M., et al., Incidence of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism: a contemporary view of the published literature. Eur Respir J, 2017. 49(2).\u003c/li\u003e\n\u003cli\u003eGall, H., et al., An epidemiological analysis of the burden of chronic thromboembolic pulmonary hypertension in the USA, Europe and Japan. Eur Respir Rev, 2017. 26(143).\u003c/li\u003e\n\u003cli\u003eBoon, G., et al., Non-invasive early exclusion of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism: the InShape II study. Thorax, 2021. 76(10): p. 1002-1009.\u003c/li\u003e\n\u003cli\u003eKerr, K.M., et al., Results From the United States Chronic Thromboembolic Pulmonary Hypertension Registry: Enrollment Characteristics and 1-Year Follow-up. Chest, 2021. 160(5): p. 1822-1831.\u003c/li\u003e\n\u003cli\u003eKim, N.H. and I.M. Lang, Risk factors for chronic thromboembolic pulmonary hypertension. Eur Respir Rev, 2012. 21(123): p. 27-31.\u003c/li\u003e\n\u003cli\u003eKlok, F.A., et al., Derivation of a clinical prediction score for chronic thromboembolic pulmonary hypertension after acute pulmonary embolism. J Thromb Haemost, 2016. 14(1): p. 121-8.\u003c/li\u003e\n\u003cli\u003eKlok, F.A., M. Delcroix and H.J. Bogaard, Chronic thromboembolic pulmonary hypertension from the perspective of patients with pulmonary embolism. J Thromb Haemost, 2018. 16(6): p. 1040-1051.\u003c/li\u003e\n\u003cli\u003eKonstantinides, S.V. and G. Meyer, The 2019 ESC Guidelines on the Diagnosis and Management of Acute Pulmonary Embolism. Eur Heart J, 2019. 40(42): p. 3453-3455.\u003c/li\u003e\n\u003cli\u003eHumbert, M., et al., 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J, 2022. 43(38): p. 3618-3731.\u003c/li\u003e\n\u003cli\u003eAsl, F.S., et al., Incidence and predictors of chronic thromboembolic pulmonary hypertension following first episode of acute pulmonary embolism. Adv Respir Med, 2020. 88(6): p. 539-547.\u003c/li\u003e\n\u003cli\u003eHeld, M., et al., Frequency and characterization of CTEPH and CTEPD according to the mPAP threshold \u0026gt; 20 mm Hg: Retrospective analysis from data of a prospective PE aftercare program. Respir Med, 2023. 210: p. 107177.\u003c/li\u003e\n\u003cli\u003eMatusov, Y., et al., Long term recovery of right ventricular function after treatment of intermediate and high risk pulmonary emboli. Thromb Res, 2023. 225: p. 57-62.\u003c/li\u003e\n\u003cli\u003eDelluc, A., et al., Real-world incidence of cancer following a first unprovoked venous thrombosis: Results from the EPIGETBO study. Thromb Res, 2018. 164: p. 79-84.\u003c/li\u003e\n\u003cli\u003eKlok, F.A., et al., Optimal follow-up after acute pulmonary embolism: a position paper of the European Society of Cardiology Working Group on Pulmonary Circulation and Right Ventricular Function, in collaboration with the European Society of Cardiology Working Group on Atherosclerosis and Vascular Biology, endorsed by the European Respiratory Society. Eur Heart J, 2022. 43(3): p. 183-189.\u003c/li\u003e\n\u003cli\u003eMavromanoli, A.C., et al., Recovery of right ventricular function after intermediate-risk pulmonary embolism: results from the multicentre Pulmonary Embolism International Trial (PEITHO)-2. Clin Res Cardiol, 2023. 112(10): p. 1372-1381.\u003c/li\u003e\n\u003cli\u003eSadeghipour, P., et al., Catheter-Directed Thrombolysis vs Anticoagulation in Patients With Acute Intermediate-High-risk Pulmonary Embolism: The CANARY Randomized Clinical Trial. JAMA Cardiol, 2022. 7(12): p. 1189-1197.\u003c/li\u003e\n\u003cli\u003eHarvey, J.J., S. Huang and R. Uberoi, Catheter-directed therapies for the treatment of high risk (massive) and intermediate risk (submassive) acute pulmonary embolism. Cochrane Database Syst Rev, 2022. 8(8): p. CD013083.\u003c/li\u003e\n\u003cli\u003eYu, Y., et al., Incidence and risk factors of chronic thromboembolic pulmonary hypertension in patients with diagnosis of pulmonary embolism for the first time in real world. Clin Respir J, 2018. 12(11): p. 2551-2558.\u003c/li\u003e\n\u003cli\u003eLachant, D., et al., Clinical and imaging outcomes after intermediate- or high-risk pulmonary embolus. Pulm Circ, 2020. 10(3): p. 2045894020952019.\u003c/li\u003e\n\u003cli\u003eBarco, S., et al., Incomplete echocardiographic recovery at 6 months predicts long-term sequelae after intermediate-risk pulmonary embolism. A post-hoc analysis of the Pulmonary Embolism Thrombolysis (PEITHO) trial. Clin Res Cardiol, 2019. 108(7): p. 772-778.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"PE, CTEPH, risk factors, early screening","lastPublishedDoi":"10.21203/rs.3.rs-3938961/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3938961/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe aim of our study was to investigate the risk factors for chronic thromboembolic pulmonary hypertension (CTEPH) in acute pulmonary embolism patients with right heart dysfunction via computed tomography (CT) or echocardiography.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod\u003c/strong\u003e: Our study was a retrospective cohort study. A total of 506 patients diagnosed with pulmonary embolism at the First Affiliated Hospital of Henan University of Science and Technology between January 2018 and June 2023 were included, and 128 patients were ultimately included. The patients were divided into 33 suspected CTEPH patients and 95 non CTEPH patients. Multivariate logistic regression was used to analyse the risk factors for suspected CTEPH, and nomogram models were constructed according to the risk factors. ROC curves were used to analyse the predictive value of risk factors and the model for suspected CTEPH patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: The incidence of suspected CTEPH was 25.8% in acute pulmonary embolism patients with right heart dysfunction 3 to 6 months after PE diagnosis. No CTEPH occurred in patients treated after thrombolytic therapy. The time from symptom onset to treatment (OR, 1.20), sPESI score ≥ 1 (OR, 7.82), and baseline peak velocity of tricuspid regurgitation (OR, 4.17) were risk factors for suspected CTEPH in haemodynamically stable patients (p \u0026lt; 0.05). A prediction model was established based on these three variables. The AUC of the prediction model for suspected CTEPH was 0.905, which has high predictive value.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: The incidence of suspected CTEPH is higher in patients with acute pulmonary embolism and right heart dysfunction according to CT or echocardiography. To improve the awareness of the diagnosis of acute pulmonary embolism, more active treatment and follow-up for patients with risk factors may reduce the incidence of CTEPH.\u003c/p\u003e","manuscriptTitle":"Risk factors and prediction model for chronic thromboembolic pulmonary hypertension in acute pulmonary embolism patients with right heart dysfunction on CT or echocardiography","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-14 18:26:49","doi":"10.21203/rs.3.rs-3938961/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ed49a95e-f28b-4209-bbf7-3455faf3401b","owner":[],"postedDate":"February 14th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-02-23T03:00:53+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-14 18:26:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3938961","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3938961","identity":"rs-3938961","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}