Regular Article| Volume 131, ISSUE 5, e191-e195, May 2013

Factors Associated with elevated Pulmonary Arterial Pressure Levels on the Echocardiographic Assessment in Patients with Prior Pulmonary Embolism

Published:February 27, 2013DOI:



      Factors associated with the detection of raised systolic pulmonary artery pressure (sPAP) levels in patients with a prior episode of pulmonary embolism (PE) are not well known.


      We used the RIETE Registry database to identify factors associated with the finding of sPAP levels ≥50 mm Hg on trans-thoracic echocardiography, in 557 patients with a prior episode of acute, symptomatic PE.


      Sixty-two patients (11.1%; 95% CI: 8.72–14.1) had sPAP levels ≥50 mm Hg. These patients were more likely women, older, and more likely had chronic lung disease, heart failure, renal insufficiency or leg varicosities than those with PAP levels <50 mm Hg. During the index PE event, they more likely had recent immobility, and more likely presented with hypoxemia, increased sPAP levels, atrial fibrillation, or right bundle branch block. On multivariate analysis, women aged ≥70 years (hazard ratio [HR]: 2.0; 95% CI: 1.0–3.7), chronic heart or chronic lung disease (HR: 2.4; 95% CI: 1.3–4.4), atrial fibrillation at PE presentation (HR: 2.8; 95% CI: 1.3–6.1) or varicose veins (HR: 1.8; 95% CI: 1.0–3.3) were all associated with an increased risk to have raised sPAP levels. Chronic heart disease, varicose veins, and atrial fibrillation were independent predictors in women, while chronic heart disease, atrial fibrillation, a right bundle branch block or an S1Q3T3 pattern on the electrocardiogram were independent predictors in men.


      Women aged ≥70 years more likely had raised sPAP levels than men after a PE episode. Additional variables influencing this risk seem to differ according to gender.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Thrombosis Research
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Park B.
        • Messina L.
        • Dargon P.
        • Huang W.
        • Ciocca R.
        • Anderson F.A.
        Recent trends in clinical outcomes and resource utilization for pulmonary embolism in the United States: findings from the nationwide inpatient sample.
        Chest. 2009; 136: 983-990
        • Hurdman J.
        • Condliffe R.
        • Elliot C.A.
        • Davies C.
        • Hill C.
        • Wild J.M.
        • et al.
        ASPIRE registry: assessing the Spectrum of Pulmonary hypertension Identified at a REferral centre.
        Eur Respir J. 2012; 39: 945-955
        • Cohen A.T.
        • Agnelli G.
        • Anderson F.A.
        • Arcelus J.I.
        • Bergqvist D.
        • Brecht J.G.
        • et al.
        The number of VTE events and associated morbidity and mortality.
        Thromb Haemost. 2007; 98: 756-764
        • Condliffe R.
        • Kiely D.G.
        • Gibbs J.S.
        • Corris P.A.
        • Peacock A.J.
        • Jenkins D.P.
        Improved outcomes in medically and surgically treated chronic thromboembolic pulmonary hypertension.
        Am J Respir Crit Care Med. 2008; 177: 1122-1127
        • Rich J.D.
        • Shah S.J.
        • Swamy R.S.
        • Kamp A.
        • Rich S.
        Inaccuracy of Doppler echocardiographic estimates of pulmonary artery pressures in patients with pulmonary hypertension: implications for clinical practice.
        Chest. 2011; 139: 988-993
        • Simonneau G.
        • Robbins I.M.
        • Beghetti M.
        • Channick R.N.
        • Delcroix M.
        • Denton C.P.
        • et al.
        Updated clinical classification of pulmonary hypertension.
        J Am Coll Cardiol. 2009; 30;54: S43-S54
        • Jiménez D.
        • Aujesky D.
        • Moores L.
        • Gómez V.
        • Lobo J.L.
        • Uresandi F.
        • et al.
        Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism.
        Arch Intern Med. Aug. 9 2010; 170: 1383-1389
        • Laporte S.
        • Mismetti P.
        • Décousus H.
        • Uresandi F.
        • Otero R.
        • Lobo J.L.
        • et al.
        Clinical predictors for fatal pulmonary embolism in 15,520 patients with venous thromboembolism: findings from the Registro Informatizado de la Enfermedad TromboEmbolica venosa (RIETE) Registry.
        Circulation. Apr. 1 2008; 117: 1711-1716
        • Otero R.
        • Trujillo-Santos J.
        • Cayuela A.
        • Rodríguez C.
        • Barron M.
        • Martín J.J.
        • et al.
        Haemodynamically unstable pulmonary embolism in the RIETE Registry: systolic blood pressure or shock index?.
        Eur Respir J. Dec. 2007; 30: 1111-1116
        • Monreal M.
        • Muñoz-Torrero J.F.
        • Naraine V.S.
        • Jiménez D.
        • Soler S.
        • Rabuñal R.
        • et al.
        Pulmonary embolism in patients with chronic obstructive pulmonary disease or congestive heart failure.
        Am J Med. Oct. 2006; 119: 851-858
        • Galiè N.
        • Hoeper M.M.
        • Humbert M.
        • Torbicki A.
        • Vachiery J.L.
        • Barbera J.A.
        • et al.
        Guidelines for the diagnosis and treatment of pulmonary hypertension.
        Eur Respir J. 2009; 34: 1219-1263
        • Umar S.
        • Rabinovitch M.
        • Eghbali M.
        Estrogen paradox in pulmonary hypertension: current controversies and future perspectives.
        Am J Respir Crit Care Med. 2012; 186: 125-131
        • Jamieson S.W.
        • Kapelanski D.P.
        Pulmonary endarterectomy.
        Curr Probl Surg. 2000; 36: 165-252
        • Tanabe N.
        • Kimura A.
        • Amamo S.
        • Okada O.
        • Kasahara Y.
        • Tatsumi K.
        Association of clinical features with HLA in chronic pulmonary thromboembolism.
        Eur Respir J. 2005; 25: 131-138
        • Ribeiro A.
        • Lindmarker P.
        • Johnsson H.
        Pulmonary embolism: one-year follow-up with echocardiography Doppler and five-year survival analysis.
        Circulation. 1999; 99: 1325-1330
        • Fisher M.R.
        • Forfia P.R.
        • Chamera E.
        • Housten-Harris T.
        • Champion H.C.
        • Girgis R.E.
        • et al.
        Accuracy of Doppler echocardiography in the hemodynamic assessment of pulmonary hypertension.
        Am J Respir Crit Care Med. 2009; 179: 615-621
        • Perrot M.
        • Fadel E.
        • McRae K.
        • Tan K.
        • Slinger P.
        • Paul N.
        Evaluation of persistent pulmonary hypertension after acute pumonary embolism.
        Chest. 2007; 132: 780-785
        • Pengo V.
        • Lensing A.W.
        • Prins M.H.
        • Marchiori A.
        • Davidson B.L.
        • Tiozzo F.
        • et al.
        Incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism.
        N Engl J Med. 2004; 350: 2257-2264
        • Riedel M.
        • Stanek V.
        • Widimsky J.
        • Prerovsky I.
        Long-term follow-up of patients with pulmonary trhomboembolism: late prognosis and evolution of hemodynamic and respiratory data.
        Chest. 1982; 81: 151-158
        • Douketis J.
        • Tosetto S.
        • Msrcucci M.
        • Baglin T.
        • Cosmi B.
        • Cushman M.
        • et al.
        Risk of recurrence after venous thromboembolism in men and woman: patient level meta-analysis.
        BMJ. 2011; 342: d813
        • Gabler N.B.
        • French B.
        • Strom B.L.
        • Liu Z.
        • Palevsky H.I.
        • Taichman D.B.
        • et al.
        Race and sex differences in response to endothelin receptor antagonists for pulmonary arterial hypertension.
        Chest. 2012; 141: 20-26
        • Lahm T.
        • Crisostomo P.R.
        • Markel T.A.
        • Wang M.
        • Weil B.R.
        • Novotny N.M.
        • et al.
        The effects of estrogen on pulmonary artery vasoreactivity and hypoxic pulmonary vasoconstriction: potential new clinical implications for an old hormone.
        Crit Care Med. 2008; 36: 2174-2183
        • Resta T.C.
        • Knaggy N.L.
        • Walker B.R.
        Estradiol-induced attenuation of pulmonary hypertension is not associated with altered eNOS expression.
        Am J Physiol Lung Cell Mol Physiol. 2001; 280: L88-L97
        • Scorza R.
        • Caronni M.
        • Bazzi S.
        • Nador F.
        • Beretta L.
        • Antonioli R.
        • et al.
        Post-menopause is the main risk factor for developing isolated pulmonary hypertension in systemic sclerosis.
        Ann N Y Acad Sci. 2002; 966: 238-246
        • Austin E.D.
        • Cogan J.D.
        • West J.D.
        Alterations in estrogen metabolism: implications for higher penetrance of familial pulmonary arterial hypertension in females.
        Eur Respir J. 2009; 34: 1093-1099
        • Roberts K.E.
        • Fallon M.B.
        • Krowka M.J.
        Genetic risk factors for portopulmonary hypertension in patients with advanced liver disease.
        Am J Respir Crit Care Med. 2009; 179: 835-842
        • Sweeney L.B.
        • Voelkel N.F.
        Estrogen exposure in women with pulmonary arterial hypertension.
        Am J Respir Crit Care Med. 2009; 179: A4870
        • Tofovic S.
        Estrogens and development of Pulmonary Hypertension: Interection of estradiol metabolism and pulmonary vascular disease.
        J Cardiovasc Pharmacol. 2010; 56: 696-708