Remarks on ‘do low-risk patients really need follow-up after a pulmonary embolism?’: Reassessing the role of structured care in PE management

Dear Editor,

We read with great interest the study by Alexander et al., which questions the need for organised follow-up in patients of low-risk pulmonary embolism (PE) managed as outpatients. ¹ While their conclusions propose that such patients may not need thorough monitoring, further thoughts regarding study design and medical results are necessary.

The authors account that in the first week only 10% of patients received follow-up, with no dedicated PE clinic available. This slight engagement increases concerns about the possible under-detection of non-fatal but problems which are impactful, like concern related to anticoagulation therapy or post-PE syndrome. Study specifies that even patients which are at low-risk may face constant fatigue, dyspnoea or impaired function, despite the absence of chronic thromboembolic pulmonary hypertension (CTEPH). ²

Although Pulmonary Embolism Severity Index (PESI) scores I and II were used to classify maximum outpatients, PESI classes III–V for 28% of patients categorised were also handled outside the hospital. The primary function of PESI to estimate 30-day mortality, not long-standing recovery or functional course. Improvement in PESI scores within the first 48 hours has shown additional prognostic value and may better guide decisions regarding outpatient fitness. ³

Furthermore, the research does not compare follow-up models of structured care vs unstructured care. Without such a comparison, concluding that structured follow-up is unnecessary risks oversimplifying a complex issue. Guidelines from the European Society of Cardiology mention multistep follow-up for patients of PE to screen for CTEPH, perceive recurrence and support psychological recovery and lifestyle. ⁴

Old documentations relying on retrospection has led to missed diagnosis. Furthermore, there was an absence of stranded symptom tracking which also leads to missed diagnoses. Only 34 patients have undergone echocardiography mostly more than a year after index PE. We have also seen that studies like ASPIRE registry show that follow-up improves detection of CTEPH. ⁵ In addition, structured care is linked with better anticoagulation adherence. ⁶

In summary, while Alexander et al. provide reliable practical data, the findings should be used with caution. The study fails to address patients’ experience, long-term results and differences in the values of structured care pathways. Future research should include prospective studies, patient-centred results and comparison of follow-up strategies for the development of more definitive guidelines.

Sincerely,

Sohaib Raza