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Background: Half of people post pulmonary embolism (PE) experience ongoing symptoms such as dyspnoea, anxiety and depression, exercise limitation and fatigue. These symptoms can reduce their quality of life (QoL), psychological wellbeing, and functional capacity. The efficacy of rehabilitation interventions to prevent and manage these symptoms has not been established. The objectives of this review were to synthesise the evidence on interventions targeting QoL, psychological wellbeing, and functional capacity post PE, and to identify intervention characteristics and behaviour change techniques (BCTs) that contribute to successful rehabilitation programmes., Methods: The PRISMA reporting guidelines were followed. Five electronic databases were searched; PubMED, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO. Searching began in November 2023, with the final search run in December 2023. Studies using experimental designs, in adult populations, employing rehabilitation programmes to target patient outcomes post PE were included. The Template of Intervention Description and Replication (TIDieR) 12 item checklist was used to score the description and replicability of the intervention and control conditions and the BCT taxonomy V1 was used to identify BCTs across the included interventions. Data was extracted and a best evidence synthesis was conducted., Results: Of 7321 studies identified, 12 studies (n = 648 participants) met the inclusion criteria; four randomised controlled trials (RCTs), one pilot RCT study and seven prospective cohort studies, all conducted at different timepoints in the disease course, using different selection criteria and with different interventions. Eight of the 12 included studies were evaluated as being of low quality based on the Effective Public Health Practice Project (EPHPP) tool. The mean TIDieR score was six out of 24 for intervention completeness and reporting. Twenty five BCTs were identified across the included studies, three of which were identified in all studies ("Instruction on how to perform the behaviour", "demonstration of the behaviour" and "behaviour practice/ rehearsal"). Overall the best evidence synthesis provided a mixed level of evidence for the effectiveness of rehabilitation interventions post PE. There is a limited level of evidence that rehabilitation has a positive effect on patient perceived QoL and inconsistent evidence that rehabilitation has any effect on psychological wellbeing. There is however, a moderate level of evidence to support the effectiveness of rehabilitation when it comes to improving functional capacity., Conclusion: This review highlights heterogeneity across available studies and provides some evidence supporting rehabilitation programmes to improve functional capacity in people living post PE. However, further research is required to establish their effectiveness for improving QoL and psychological wellbeing. Although a number of BCTs were identified, few of those identified were linked to behaviour change theory. This, combined with limited reporting of components of the rehabilitation interventions, restricted evaluation of their effectiveness., Prospero Registration: PROSPERO 2020 CRD42023459411 Available from: https://www.crd.york.ac.uk/prospero/#recordDetails., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: Patients with venous thromboembolism (VTE) are at risk of psychological consequences. However, as opposed to physical sequelae of VTE, mental health issues are understudied., Objectives: To assess anxiety after VTE and investigate associated clinical characteristics., Methods: We conducted a prospective cohort study, including patients with acute deep vein thrombosis (DVT) and/or pulmonary embolism. Patients with cancer, pregnancy, or puerperium were excluded. Anxiety was assessed with the Patient-Reported Outcome Measurement Information System short form 8a. Standardized T-scores were calculated (reference, 50; SD, 10), with higher values indicating more anxiety. We associated clinical characteristics at baseline with T-scores at 3-month follow-up in a multivariable linear regression model. Patient clusters depending on anxiety trajectories were explored., Results: We included 257 patients (38.5% women) with a median (IQR) age of 54.1 (42.2-63.5) years. While mean (SD) T-scores decreased from baseline to follow-up (51.03 [9.18] to 46.74 [8.89]; P < .001), we observed an increase in 23.7% of all patients. Female sex (T-score change, 3.09; 95% CI, 0.96-5.22), older age until 45 years, and anxiety at baseline were associated with increased T-scores at follow-up. VTE history (-1.55; 95% CI, -3.62 to 0.52) and pulmonary embolism (-1.23; 95% CI, -3.16 to 0.69) were associated with reduced T-scores, albeit not reaching statistical significance. In a cluster of older female patients with DVT, anxiety tended to increase over time., Conclusion: While most patients with VTE reported reduced anxiety over time, some patients experienced worsening. Female sex, older age, more anxiety at baseline, no VTE history, and DVT were associated with increased anxiety 3 months after VTE., Competing Interests: Declaration of competing interests C.A. reports honoraria for lectures from Bayer, Daiichi Sankyo, BMS/Pfizer, and Sanofi and participation in advisory boards for Bayer, Daiichi Sankyo, BMS/Pfizer, and Sanofi outside the current work. D.S., S.N., T.H., I.P., and B.W. have no conflicts of interest to declare with regard to the present study., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: The Pulmonary Embolism Quality of Life (PEmb-QoL) questionnaire is the only existing disease-specific instrument for measuring quality of life after pulmonary embolism (PE). It includes six dimensions: frequency of complaints, limitations in activities of daily living, work-related problems, social limitations, intensity of complaints and emotional complaints. The present study aimed to determine the psychometric properties including responsiveness and structural validity of the German version., Methods: The analysis used data from participants of the LEA cohort study at University Hospital Augsburg. The PEmb-QoL was administered via postal surveys 3, 6 and 12 months post-PE. Internal consistency and test-retest reliability were evaluated by calculating Cronbach's alpha and intra-class correlation coefficients (ICC). Standardized response means (SRM) were calculated for investigating responsiveness. For evaluating the fit of the factor structure, confirmatory factor analysis (CFA) was conducted., Results: Overall, we used data from 299 patients 3 months after PE. Cronbach's alpha (0.87-0.97) and ICC (0.53-0.90) were in an acceptable to good range. SRM scores showed good responsiveness of all dimensions. CFA revealed the four-factor model including one general factor to have a good model fit., Conclusion: Despite existing floor effect, most standard criteria of reliability and validity were met and indications for appropriateness of the PEmb-QoL summary score could be found. Apart from some restrictions concerning the factor structure and the dimension of social limitations, our results support the use of the PEmb-QoL questionnaire for evaluating PE-specific quality of life. Future studies should seek replication in different samples to ensure generalizability of the findings., (© 2022. The Author(s).)

Venous thromboembolism (VTE) occurs frequently and represents a serious threat to patient health. However, its effects on mental health have not been studied sufficiently. The objective of this study was to investigate whether VTE alters the patients' mental state. We gathered questionnaire data on 100 patients (59 men, 41 women; age ranging from 24 to 85 years) concerning psychological symptoms and body image. Our results show that after a VTE, patients develop psychological symptoms, some of which persist for more than 2 years. Examples of those symptoms include depression, intrusion, and increased scrutiny of the body. Intrusion (flashbacks, nightmares, and other traumatic sensations of reliving the thrombotic event) affected 69% of patients and may lead to social isolation, occasionally including loss of employment. Depression affected more than 50% of patients. Productivity typically decreases, and body functionality and feeling of health changed in 34-76% of patients. However, anxiety, disordered impulse control, and maladjustment were less frequent (40% or less), and patients' emotional attitude to their bodies (liking their bodies or being angry with their bodies, feelings of shame and attractiveness) tended not to change over time. Nevertheless, we feel it may be advisable to identify patients with relevant psychological changes after VTE by means of a short evidence-based questionnaire and to offer them psychological treatment in order to improve management and quality of life of these patients. The goal is, therefore, to develop diagnostic and therapeutic recommendations., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Few data are available on the long-term course and predictors of quality of life (QoL) following acute pulmonary embolism (PE)., Research Question: What are the kinetics and determinants of disease-specific and generic health-related QoL 3 and 12 months following an acute PE?, Study Design and Methods: The Follow-up after Acute Pulmonary Embolism (FOCUS) study prospectively followed up consecutive adult patients with objectively diagnosed PE. Patients were considered for study who completed the Pulmonary Embolism Quality of Life (PEmb-QoL) questionnaire at predefined visits 3 and 12 months following PE. The course of disease-specific QoL as assessed using the PEmb-QoL and the impact of baseline characteristics using multivariable mixed effects linear regression were studied; also assessed was the course of generic QoL as evaluated by using the EuroQoL Group 5-Dimension 5-Level utility index and the EuroQoL Visual Analog Scale., Results: In 620 patients (44% women; median age, 62 years), overall disease-specific QoL improved from 3 to 12 months, with a decrease in the median PEmb-QoL score from 19.4% to 13.0% and a mean individual change of -4.3% (95% CI, -3.2 to -5.5). Female sex, cardiopulmonary disease, and higher BMI were associated with worse QoL at both 3 and 12 months. Over time, the association with BMI became weaker, whereas older age and previous VTE were associated with worsening QoL. Generic QoL also improved: the mean ± SD EuroQoL Group 5-Dimension 5-Level utility index increased from 0.85 ± 0.22 to 0.87 ± 0.20 and the visual analog scale from 72.9 ± 18.8 to 74.4 ± 19.1., Interpretation: In a large cohort of survivors of acute PE, the change of QoL was quantified between months 3 and 12 following diagnosis, and factors independently associated with lower QoL and slower recovery of QoL were identified. This information may facilitate the planning and interpretation of clinical trials assessing QoL and help guide patient management., Clinical Trial Registration: German Clinical Trials Registry (Deutsches Register Klinischer Studien: www.drks.de); No.: DRKS00005939., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: To assess the dynamic of various health-related quality of life (HRQoL) parameters 3 years after pulmonary thromboendarterectomy (PTE), and to identify factors affecting HRQoL parameters in patients with chronic thromboembolic pulmonary hypertension (CTEPH) in the long-term follow-up after surgery., Methods: This prospective cohort study included 128 patients with CTEPH before and after the PTE (3 year follow-up). The HRQoL was examined using the Short-Form 36 Health Survey Questionnaire (SF-36)., Results: In patients with CTEPH 3 years after PTE, a significant improvement in all the HRQoL parameters. The summary indicators of the physical and mental components of health remained at the same level as 1 year after the PTE and did not exceed 50 points. The residual pulmonary hypertension was a leading factor limiting parameters of physical and mental health 3 years after a PTE. In addition, the parameters of physical activity were adversely affected by age and the age-adjusted Charlson Comorbidity Index., Conclusions: In the study group of patients with CTEPH, PTE contributes to a significant improvement in all HRQoL parameters, which observed both 1 year and 3 years after surgery. The leading factor adversely affecting the physical and emotional components of health in the long-term period after PTE was residual pulmonary hypertension recorded in the early postoperative period. In addition, some physical HRQoL parameters are affected by age and age-adjusted Charlson Comorbidity Index.

Background: Pulmonary embolism (PE) is the third most common cause of cardiovascular death. However, comprehensive knowledge on the lived experience of patients with PE is lacking so far. The objective of this study was to fill this gap using a qualitative research approach., Methods: A qualitative study using focus group methodology was conducted. Sampling of patients followed the maximum variation strategy. Sample size was determined by saturation. The patients were presented eight questions, which asked for their experiences in terms of prodromal and acute symptoms, changes of physical and mental well-being, daily life and social life, and experiences with PE medication and treatment. The focus group discussions were digitally recorded and transcribed verbatim. The constant comparative method was used for data analysis., Results: Five focus groups with n = 18 participants (50% female, median age 56 years) in total were performed. Major identified themes were: (1) progressing dyspnea and pain as major prodromal and acute symptoms, (2) persisting dyspnea and loss of physical fitness, (3) depression, fears and threat monitoring, (4) exhaustion which improves over time, (5) social contacts ranging between ignorance and overprotection, (6) anticoagulants as lifesavers and threat, (7) quick versus delayed diagnosis, (8) left alone by health care providers, and (9) unsupportive health care system., Conclusion: PE may be associated with considerable mental health problems and the existing health care system is experienced as not supportive by a number of patients. Further results from larger, quantitative studies are needed to estimate the extent of the identified problems., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background and Objective: Despite the established importance of thromboprophylaxis in patients with Venous Thromboembolism (VTE), a limited number of studies have assessed the awareness of VTE and thromboprophylaxis therapy among the affected patients. The aim of the current study was to assess awareness and to explore variables associated with awareness about VTE and its thromboprophylaxis., Methods: A cross-sectional study was conducted on hospitalized patients who received thromboprophylaxis (5000 units of heparin subcutaneously (SC) q8-12h, or 30-40 mg of enoxaparin SC once daily). In addition to the sociodemographic variables, awareness and perception of VTE and its thromboprophylaxis were assessed using a validated questionnaire. Multiple logistic regressions were conducted to build a model of variables significantly associated with VTE awareness., Results: A total of 225 patients participated in the study, with only 38.2% and 22.2% of the participants being aware of Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) respectively. Logistic regression showed that the participants with low educational level had 3.046 value, with the odds being not aware of DVT or PE compared with participants with high educational level. Participants without a personal history of VTE had 7.374 value, with the odds being not aware of DVT or PE compared with those who had a personal history of VTE. Participants who had a negative perception of VTE had 2.582 value, with the odds being not aware of DVT or PE compared with participants who had a positive perception and those who did not have any information about DVT or PE had 13.727 value, with the odds being not aware of DVT or PE., Conclusion: The findings reveal that there is a lack of awareness about VTE and its thromboprophylaxis among the study participants. Patients with lower educational level and those with no history of previous VTE need awareness improvement about VTE and its thromboprophylaxis. Clinical Pharmacists need to focus on providing information about VTE and improving patients' perception about VTE and its thromboprophylaxis with the aim of improving the awareness about VTE, and hence the better health outcome., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Following back surgery a man developed extensive pulmonary emboli that proved fatal., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: While the importance of patients' quality of life (QoL) in chronic cardiac or pulmonary disease is uncontroversial, the burden of an acute pulmonary embolism (PE) on QoL has received little attention thus far., Objectives: We aimed to validate the German PEmb-QoL questionnaire, identify associations between QoL and clinical/functional parameters, and investigate the prognostic relevance of QoL for long-term survival in survivors of an acute PE episode., Patients/methods: Patients were invited for a clinical follow-up visit including assessment of QoL using the German PEmb-QoL questionnaire 6 months after an objectively confirmed PE at a single center. Internal consistency reliability, construct-related validity, and regressions between PEmb-QoL and clinical patient-characteristics were assessed using standard scale construction techniques., Results: Overall, 101 patients [median age, 69 ([interquartile range] IQR 57-75) years; women, 48.5%] were examined 208 (IQR 185-242) days after PE. Internal consistency reliability and construct-related validity of the PEmb-QoL questionnaire were acceptable. As many as 47.0% of patients reported dyspnea, 27.5% had right ventricular (RV) dysfunction on transthoracic echocardiography (TTE), and 25.3% were diagnosed with post-PE impairment (PPEI) at 6-month follow-up. Furthermore, 15.9% of patients were diagnosed with depression 6 months after an acute PE. The QoL was affected by dyspnea, preexisting pulmonary disease, and PPEI, and a reduced QoL was associated with an increased risk for long-term mortality after an observation period of 3.6 years., Conclusions: The German PEmb-QoL questionnaire is a reliable instrument for assessing QoL 6 months after PE. The QoL was affected by dyspnea, preexisting pulmonary disease, and PPEI and was associated with long-term mortality., (© 2019 The Authors. Journal of Thrombosis and Haemostasis published by Wiley Periodicals, Inc. on behalf of International Society on Thrombosis and Haemostasis.)

Introduction: There is an increasing awareness that patients with acute pulmonary embolism (APE) suffer long-term consequences like fatigue, anxiety, and reduced physical capacity. However, we lack knowledge on how patients manage everyday life and physical activity following an APE. The study aimed to explore how patients experience and cope with daily life and physical activity in the first year following an APE., Materials and Methods: Semi-structured individual interviews were performed with 16 patients, 6-12 months after a first-time APE event. The methodological framework for the analysis was interpretive description., Results: Most participants had managed to return to their daily routines at the time of the interview, although some struggled more than others. They experienced their daily life and well-being to be negatively affected by fatigue, anxious thoughts and bodily hypervigilance, and were concerned about themselves, their family, friends and life situation. In many cases, they lacked advice from health professionals. Participants used various strategies for re-engaging in everyday life and physical activities, reflecting their physical and mental resources, contextual support, and different life situation. One central theme was the challenge of coming to terms with a more vulnerable identity, and adjusting this identity to established family and work roles., Conclusions: Most participants had managed to resume their everyday life 6-12 months after the APE event, but were still limited in their daily activities and found it difficult to sustain a sufficient level of physical activity. They described different barriers and facilitators, which should be addressed in future rehabilitation interventions., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Purpose: Little is known about the quality of life following pulmonary embolism (PE). The aim of the study was to assess the 12-month illness burden in terms of health-related quality of life (HrQoL) and mortality, in relation to differences in patient characteristics., Methods: The PREFER in VTE registry, a prospective, observational study conducted in seven European countries, was used. Within 2 weeks following an acute symptomatic PE, patients were recruited and followed up for 12 months. Associations between patient characteristics and HrQoL (EQ-5D-5L) and mortality were examined using a regression approach., Results: Among 1399 PE patients, the EQ-5D-5L index score at baseline was 0.712 (SD 0.265), which among survivors gradually improved to 0.835 (0.212) at 12 months. For those patients with and without active cancer, the average index score at baseline was 0.658 (0.275) and 0.717 (0.264), respectively. Age and previous stroke were significant factors for predicting index scores in those with/without active cancer. Bleeding events but not recurrences had a noticeable impact on the HrQoL of patients without active cancer. The 12-month mortality rate post-acute period was 8.1%, ranging from 1.4% in Germany, Switzerland, and Austria to 16.8% in Italy. Mortality differed between patients with active cancer and those without (42.7% vs. 4.7%)., Conclusion: PE is associated with a substantial decrease in HrQoL at baseline which normalizes following treatment. PE is associated with a high mortality rate especially in patients with cancer, with significant country variation. Bleeding events, in particular, impact the burden of PE.

Objective: To conduct a cross-cultural adaptation of the Cambridge Pulmonary Hypertension Outcome Review (CAMPHOR) as an instrument to evaluate the perception of symptoms, functional limitation, and health-related quality of life (HRQoL) in subjects diagnosed with pulmonary arterial hypertension (PAH) or chronic thromboembolic pulmonary hypertension (CTEPH) in Colombia., Methods: The adaptation process involved 3 phases: translation, cognitive debriefing interviews, and a validation survey. To evaluate the psychometric properties, we recruited individuals ≥ 18 years of age who had been diagnosed with PAH or CTEPH to take part in the latter two stages of the adaptation process. All individuals were being followed on an outpatient basis by the pulmonary hypertension programs at Hospital Universitario San Ignacio, Fundación Clínica Shaio,and Clínicos IPS, all located in the city of Bogotá, Colombia., Results: A Spanish-language version of the CAMPHOR was developed for use in Colombia. The internal consistency was excellent for the symptoms, functioning, and quality of life scales (Cronbach's alpha coefficients of 0.92, 0.87, and 0.93, respectively). Test-retest reliability was above 0.70. The evaluation of the convergent validity and known group validity of the CAMPHOR scales confirmed that there were moderate and strong correlations with the related constructs of the Medical Outcomes Study 36-item Short-Form Health Survey, version 2, as well as showing their capacity to discriminate disease severity., Conclusions: The Spanish-language version of the CAMPHOR developed for use in Colombia was the result of a translation and cultural adaptation process that allows us to consider it equivalent to the original version, having shown good psychometric properties in the study sample. Therefore, its use to assess the impact of interventions on the HRQoL of patients with PAH or CTEPH is recommended, in research and clinical practice.

For patients living with chronic conditions, the daily life will change due to symptoms, drug treatment, and psychosocial factors caused by the disease. Our studies show that Swedish patients with PAH or CTEPH are satisfied with the information they have received, but still have a wish for more. Therefore, it is important to repeat the information on a regular basis and to make sure that patients have understood and remember the messages. In order to increase the knowledge about their disease, improve compliance with treatment and quality of life, patients and next of kin should continuously be informed by the multidisciplinary team at the PAH/CTEPH-specialist care centers.

This is a case of a 68-year-old man with Parkinson's disease who was admitted in the psychiatry floor for new-onset aggressive behaviour and hallucinations. On the third day of hospitalisation, he suddenly developed dyspnoea followed by an ECG showing atrial fibrillation with rapid ventricular response. A few seconds later, he went into cardiac arrest; he was resuscitated after multiple rounds of Advanced Cardiovascular Life Support. A transthoracic echo showed hypokinetic and enlarged right ventricle. A CT Chest showed a saddle embolus. Patient was provided with systemic thrombolysis, which led to an improvement in his haemodynamic status. Interestingly, his psychotic symptoms also improved. In this paper, we present and review how pulmonary embolism can be associated with acute psychosis., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Venous thromboembolism (VTE) is a serious, potentially traumatic, life-threatening condition and a major cause of mortality and morbidity. The aim of this study was to obtain detailed understandings of the impact of VTE and examine individual's experiences over the first year since a first-time VTE., Design: A longitudinal qualitative interview study using inductive thematic analysis. This study presents follow-up data for 11 participants, first interviewed 6 months following a first-time VTE., Setting: Outpatients recruited from a community haematology clinic in a UK District General Hospital., Participants: Eleven participants (seven females and four males) recruited from a community haematology clinic. Participants had experienced a first-time VTE and participated in qualitative interviews 3 months previously., Intervention: Audio-recorded semistructured interviews with a sample of 11 participants who experienced a first-time deep vein thrombosis or pulmonary embolism within the previous year. Interviews were transcribed and analysed using inductive thematic analysis., Results: Four overarching themes were identified: life changing and forever changed, the trauma of care, 'thrombo-neuroses' and through adversity comes growth. Theme content varied according to age and developmental stage, presence of VTE symptoms and the experience of diagnosis., Conclusions: The data demonstrate the psychosocial impact of VTE and its diagnosis as physically and psychologically challenging, and individuals reported being forever changed by the experience. Participants' reported continued high levels of trauma and anxiety symptoms, triggered by physical (eg, symptoms) and psychological (eg, health anxiety, negative emotions) reminders of VTE. Wider primary care service issues including misdiagnosis maintained negative emotions and health anxiety with implications for relationships with professionals. Targeted clinical interventions to better identify and support individuals at risk of distress and enhance psychological well-being and reduce distress are discussed., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Essentials The minimal clinically important difference (MCID) for PEmbQoL has not yet been determined. We estimated the MCID for PEmbQoL and its subscales via anchor- and distribution-based approaches. Our results indicate that MCID for PEmbQoL appears to be 15 points. Our work enables interpretation of changes or differences in PEmbQoL. SUMMARY: Background Pulmonary embolism (PE) reduces quality of life (QOL). The PEmbQoL questionnaire, a PE-related QOL measure, was recently developed and validated and has been used to quantify disease-specific QOL in clinical studies of patients with PE. However, to date, interpretation of PEmbQoL scores has been limited by a lack of information on the minimal clinically important difference (MCID) of this measure. Objective To determine the MCID for PEmbQoL and its subscales using anchor-based and distribution-based approaches. Methods We analyzed data from the ELOPE Study, a prospective, multicenter cohort study of long-term outcomes after a first episode of acute PE. At baseline and 1, 3, 6 and 12 months after PE, we measured generic QOL (SF-36), PE-specific QOL (PEmbQoL) and dyspnea severity (UCSD Shortness of Breath Questionnaire). We used time-varying repeated-measures mixed-effect models to estimate anchor-based MCID and effect sizes to estimate distribution-based MCID. Results Eighty-two patients participated in this sub-study. Their mean age was 49.4 years, 60% were male and 84% had PE diagnosed in an outpatient setting. Using both anchor- and distribution-based approaches, the MCID for PEmbQoL appears to be 15 points. Based on this MCID, 42%, 59%, 66% and 75% of patients experienced at least one MCID unit of improvement in PEmbQoL from baseline to 1, 3, 6 and 12 months, respectively. Conclusion Our results provide new information on the MCID of PEmbQoL, a PE-specific QOL questionnaire that can be used by researchers and clinicians to measure and interpret changes in PE-specific QOL over time, or as an outcome in clinical trials., (© 2018 International Society on Thrombosis and Haemostasis.)

Background: Pulmonary thromboendarterectomy (PTE) is a recognized treatment for patients with chronic thromboembolic pulmonary hypertension (CTEPH), with good long-term hemodynamic results. The aim of this study was to test the hypothesis that the dynamics of health-related quality of life (QoL), 1 year after PTE, depend both on the clinical determinants associated with the underlying disease and the adverse events occurring in the early postoperative period., Methods: This prospective cohort study included 136 patients with CTEPH. All patients before and after PTE (1-year follow-up) were examined in terms of QoL, by using the Short Form 36 Health Survey Questionnaire., Results: One year after PTE, a significant improvement in the QoL of patients was observed in all subscales of the Short Form 36 Health Survey Questionnaire, except in the general health scale. Multivariate analysis showed that the predictors adversely affecting the dynamics of QoL after PTE were the presence of comorbidities (such as chronic obstructive pulmonary disease [COPD] and coronary artery disease) and early postoperative complications (specific ones for this category of patients are residual pulmonary hypertension and neurological complications, and nonspecific ones are atrial fibrillation and heart failure)., Conclusions: The determinants that affect the dynamics of QoL 1 year after PTE in patients with CTEPH were the presence of comorbidities (COPD and coronary artery disease) and adverse events in the early postoperative period (residual pulmonary hypertension, neurological complications, atrial fibrillation, and heart failure)., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: The purpose of the study was to test the psychometrical properties of the Chinese version of the Pulmonary Embolism Quality of Life (PEmb-QoL) questionnaire., Methods: We translated the English version of the PEmb-QoL into Chinese. Patients at various periods after pulmonary embolism diagnosed at Peking Union Medical College Hospital between May 2016 and Dec 2017 were invited to complete the questionnaire. Standard psychometrical tests and criteria were used to evaluate the acceptability, reliability and validity of the Chinese version of the PEmb-QoL., Results: A total of 108 participants completed the questionnaire and were included for further analysis. The Chinese version of the PEmb-QoL showed good internal consistency (Crohnbach's alpha ranging from 0.643 to 0.930), inter-item correlations (0.369-0.599), and item-total correlations (0.341-0.893). Test-retest reliability was also good (0.759-0.896). Moderate correlations between PEmb-QoL and SF-36 dimensions, and low correlations between PEmb-QoL and clinical characteristics supported convergent and discriminant validity. Exploratory factor analysis suggested four underlying dimensions: work-related problems, daily activity limitations, emotional complaints and frequency and intensity of complaints., Conclusions: The Chinese version of the PEmb-QoL questionnaire is both valid and reliable for measuring quality of life in patients at various periods after pulmonary embolism, proving the universality of this disease-specific questionnaire., (Copyright © 2018. Published by Elsevier Ltd.)

Background: The present comparative study with healthy volunteers was conducted to investigate the depressive status and temperament in patients with chronic thromboembolic pulmonary hypertension (CTEPH)., Methods and results: The results of the temperament and personality scale test, and the Quick Inventory of Depressive Symptomatology-Self Report revealed that CTEPH patients have a significantly higher depressive status than healthy volunteers., Conclusions: It may be that CTEPH patients are more likely to have a depressive temperament in origin. It is expected that the relationship between the biological traits of CTEPH (e.g., genetics) and patients' depressive temperament will be elucidated in the future.

Background: The existing evidence base in pulmonary embolism (PE) is primarily focused on diagnostic methods, medical treatment, and prognosis. Only a few studies have investigated how everyday life is affected by PE, although many patients are negatively affected both physically and emotionally after hospital discharge. Currently, no documented rehabilitation options are available for these patients. We aim to examine whether an 8-week home-based exercise intervention can influence physical capacity, quality of life, sick leave, and use of psychotropic drugs in patients medically treated for PE., Methods: One hundred forty patients with incident first-time PE will be recruited in five hospitals. After inclusion, patients will be randomly allocated to either the control group, receiving usual care, or the intervention group, who will be exposed to an 8-week home-based exercise program in addition to usual care. The intervention includes an initial individual exercise planning session with a physiotherapist, leading to a recommended exercise program of a minimum of three weekly training sessions of 30-60 minutes' duration. The patients have regular telephone contact with the physiotherapist during the 8-week program. At the time of inclusion, after 2 months, and after 6 months, the patients' physical capacity is measured using the Incremental Shuttle Walk test. Furthermore the patients' quality of life, sick leave, and use of psychotropic drugs is measured using self-reported questionnaires. In both randomization arms, all follow-up measurements and visits will take place at the hospital from which the patient was discharged. Levels of eligibility, consent, adherence, and retention will be used as indicators of study feasibility., Discussion: We expect that the home-based exercise program will improve the physical capacity and quality of life for the patients in the intervention group. The study will furthermore contribute significantly to the limited knowledge about the optimal rehabilitation of PE patients, and may thereby form the basis of future recommendations in this field., Trial Registration: ClinicalTrials.gov, NCT02684721 . Registered on 20 January 2016.

Background and Objective: Dyspnoea in pulmonary embolism (PE) remains poorly characterized. Little is known about how to measure intensity or about the underlying mechanisms that may be related to ventilatory abnormalities, alveolar dead space ventilation or modulating factors such as psychological modulate. We hypothesized that dyspnoea would mainly be associated with pulmonary vascular obstruction and its pathophysiological consequences, while the sensory-affective domain of dyspnoea would be influenced by other factors., Methods: We undertook a prospective study of 90 consecutive non-obese patients (mean ± SD age: 49 ± 16 years, 41 women) without cardiorespiratory disease. All patients were hospitalized with symptoms for <15 days and a confirmed PE (multi-detector computed tomography (MDCT) scan, n = 87 and high-probability ventilation/perfusion scan, n = 3). Patients underwent assessment of dyspnoea using the Borg score, modified Medical Research Council (mMRC) scale, assessment of psychological trait, state of anxiety and depression and chest pain via the Visual Analogical Scale at the time of maximum dyspnoea. Functional evaluations such as the quantitative ventilation-perfusion lung scan, echocardiography, alveolar dead space fraction and tidal ventilation measurements were completed within 48 h of admission., Results: Multivariate analyses demonstrated that dyspnoea was mainly linked to pulmonary vascular obstruction and/or its consequences such as raised pulmonary arterial pressure and chest pain. The sensory-affective domain of dyspnoea showed additional determinants such as age, depression and breathing variability., Conclusion: Dyspnoea is mainly related to vascular consequences of PE such as increased pulmonary arterial pressure or chest pain. The sensory-affective domain of dyspnoea also correlates with age, depression and breathing variability., (© 2016 Asian Pacific Society of Respirology.)

Objectives: Venous thromboembolism (VTE, including deep vein thrombosis [DVT] and pulmonary embolism [PE]) is a serious, potentially traumatic, life-threatening condition and a major cause of mortality and morbidity. The aim of this study was to explore the patients' experiences of VTE and its psychosocial impact., Methods: Audio-recorded semistructured interviews with a purposive sample of 12 participants who had experienced a first-time DVT or PE within the previous 6 months. Interviews were transcribed and thematically analysed., Results: Four key themes with 10 subthemes were identified. The major themes were as follows: VTE as life-changing and traumatic, living with uncertainty and fear of reoccurrence, feeling let down by health services, and positive changes and outcomes. The content of themes varied according to age at the time of VTE and participants' experiences of diagnosis and treatment., Conclusions: The data demonstrate the psychosocial impact of VTE as life-changing, encompassing a dynamic duality of trauma and growth. The findings highlight a potential role for health care professionals in identifying and supporting individuals at risk of post-traumatic stress, and targeted interventions to enhance psychological well-being and recovery and reduce distress. Statement of contribution What is already known on this subject? Venous thromboembolism (VTE) is often characterized by sudden onset and may carry a significant threat to life, particularly in the form of pulmonary embolism. Early studies suggest that health-related quality of life is negatively affected by VTE and there is likely to be a high prevalence of trauma. What does this study add? This study explores for the first time the experience of, and reactions to, VTE in the 6 months following its occurrence. It explores the role that psychological well-being can play in recovery after VTE. This study highlights that improvements are needed to support VTE patients to cope with the emotional impact of VTE. A dual process of trauma and post-traumatic growth after VTE is reported for the first time., (© 2016 The British Psychological Society.)

Long-term right ventricular (RV) function, functional capacity, exercise capacity, and quality of life following pulmonary embolism (PE), and the impact of thrombolysis, are unclear. A systematic review of studies that evaluated these outcomes with ⩾ 3-month mean follow-up after PE diagnosis was performed. For each outcome, random effects meta-analyses were performed. Twenty-six studies (3671 patients) with 18-month median follow-up were included. The pooled prevalence of RV dysfunction was 18.1%. Patients treated with thrombolysis had a lower, but not statistically significant, risk of RV dysfunction versus those treated with anticoagulation (odds ratio: 0.51, 95% CI: 0.24 to 1.13, p=0.10). Pooled prevalence of at least mild functional impairment (NYHA II-IV) was 33.2%, and at least moderate functional impairment (NYHA III-IV) was 11.3%. Patients treated with thrombolysis had a lower, but not statistically significant, risk of at least moderate functional impairment versus those treated with anticoagulation (odds ratio: 0.48, 95% CI: 0.15 to 1.49, p=0.20). Pooled 6-minute walk distance was 415 m (95% CI: 372 to 458 m), SF-36 Physical Component Score was 44.8 (95% CI: 43 to 46), and Pulmonary Embolism Quality of Life (QoL) Questionnaire total score was 9.1. Main limitations included heterogeneity among studies for many outcomes, variation in the completeness of data reported, and inclusion of data from non-randomized, non-controlled, and retrospective studies. Persistent RV dysfunction, impaired functional status, diminished exercise capacity, and reduced QoL are common in PE survivors. The effect of thrombolysis on RV function and functional status remains unclear.

Patients with chronic thromboembolic pulmonary hypertension (CTEPH) experience debilitating symptoms that have a negative impact on their quality of life (QoL) in terms of physical capability, psychological wellbeing and social relationships. The use of QoL measurement tools is important in the assessment of treatment efficacy and in guiding treatment decisions. However, despite the importance of QoL, particularly to the patient, it remains under-reported in clinical studies of CTEPH therapy. CTEPH is unique in pulmonary hypertension in that it is potentially curable by surgery; however, a proportion of patients either have residual PH following surgery or are not operable. Although some patients with CTEPH have been treated off-label with pulmonary arterial hypertension-specific therapies, there have been few randomised controlled trials of these therapies in patients with CTEPH. Moreover, in these trials QoL outcomes are variably assessed, and there is little consistency in the tools used. Here we review the assessment of QoL in patients with CTEPH and the tools that have been used. We also discuss the effect of surgical intervention and medical therapies on QoL. We conclude that further studies of QoL in patients with CTEPH are needed to further validate the optimal QoL tools., (Copyright ©ERS 2016.)

Pulmonary embolism (PE) is a rare paediatric diagnosis, but its presence is likely to be underestimated due to the subtle and non-specific nature of its symptoms. Common clinical features of PE include shortness of breath, pleuritic chest pain and acute cardiovascular collapse. Less common symptoms can include persistent unexplained tachycardia, fever or deep vein thrombosis. Rarely do patients present with abdominal pain and self-resolving shortness of breath; symptoms our patient experienced. However, in contrast to popular belief, having normal vital signs does not necessarily lower the probability of PE. D-dimer, a specific fibrin degradation product, has a good negative predictive value for venous thromboembolism diagnosis but its use in children is less clear, with up to 40% of children with PE having a normal D-dimer level. CT pulmonary angiography remains the gold standard in diagnosis., (2015 BMJ Publishing Group Ltd.)

Background: The Pulmonary Embolism Quality of Life questionnaire (PEmb-QoL) is a 40-item questionnaire to measure health-related quality of life in patients with pulmonary embolism. It covers six 6 dimensions: frequency of complaints, limitations in activities of daily living, work-related problems, social limitations, intensity of complaints, and emotional complaints. Originally developed in Dutch and English, we prospectively validated a German version of the PEmb-QoL., Methods: A forward-backward translation of the English version of the PEmb-QoL into German was performed. German-speaking consecutive adult patients aged ≥18 years with an acute, objectively confirmed pulmonary embolism discharged from a Swiss university hospital (01/2011-06/2013) were recruited telephonically. Established psychometric tests and criteria were used to evaluate the acceptability, reliability, and validity of the German PEmb-QoL questionnaire. To assess the underlying dimensions, an exploratory factor analysis was performed., Results: Overall, 102 patients were enrolled in the study. The German version of the PEmb-QoL showed a good internal consistency (Cronbach's alpha ranging from 0.72 to 0.96), item-total (0.53-0.95) and inter-item correlations (>0.4), and test-retest reliability (intra-class correlation coefficients 0.59-0.89) for the dimension scores. A moderate correlation of the PEmb-QoL with SF-36 dimension and summary scores (0.21-0.83) indicated convergent validity, while low correlations of PEmb-QoL dimensions with clinical characteristics (-0.16-0.37) supported discriminant validity. The exploratory factor analysis suggested four underlying dimensions: limitations in daily activities, symptoms, work-related problems, and emotional complaints., Conclusion: The German version of the PEmb-QoL questionnaire is a valid and reliable disease-specific measure for quality of life in patients with pulmonary embolism., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Purpose: The aim of the current study was to translate and test the psychometrical properties of the disease-specific pulmonary embolism quality-of-life questionnaire (PEmb-QoL)., Methods: Patients with a prior history of pulmonary embolism (PE) were identified from the thrombosis registry at Østfold Hospital Trust, Fredrikstad, Norway. All eligible patients were asked to complete the generic EuroQol 5-dimension (EQ-5D) QoL questionnaire as well as the disease-specific PEmb-QoL at baseline and after 2 weeks. Construct validity was tested using principal component factor analysis. Criterion validity was tested using Spearman's correlation coefficients (rho) between EQ-5D and PEmb-QoL. Internal consistency reliability was calculated using Cronbach's alpha coefficient, while test-retest reliability was calculated using the intra-class correlation coefficients (ICC)., Results: A total of 213 participants had complete datasets and were included in further analyses. Factor analysis with varimax rotation yielded six factors explaining 71% of the cumulative variance. Cronbach's alpha coefficient was found to be 0.94, indicating a very good intercorrelation of items. Of the 213 participants, 145 (68%) completed the questionnaire a second time. The ICC ranged from 0.75 to 0.86, indicating good test-retest reliability. All factors were found significant with p values <0.001. The criterion validity of the PEmb-QoL was confirmed through good correlation with other similar health-related quality-of-life constructs in the EQ-5D., Conclusions: Findings of the current study indicate that Norwegian version of the PEmb-QoL is both valid and reliable, thus representing an important supplement in subjective outcomes measurement among patients sustaining PE.

Background: The PEmb-QoL is a validated 40-item questionnaire to quantify health-related quality of life in patients having experienced pulmonary embolism (PE). It covers six health dimensions: frequency of complaints, activities of daily living limitations, work-related problems, social limitations, intensity of complaints, and emotional complaints. Originally developed in Dutch and English, we sought to prospectively validate the psychometric properties of a French version of the PEmb-QoL., Methods: We performed a forward and backward translation of the English version of the PEmb-QoL into French. French-speaking consecutive adult patients with an acute, objectively confirmed PE admitted to the emergency department of a Swiss university hospital between 08/2009 and 09/2011 were recruited telephonically. We used standard psychometric tests and criteria to evaluate the acceptability, reliability, and validity of the French version of the PEmb-QoL. We also performed an exploratory factor analysis., Results: Overall, 102 patients were enrolled in the study. The French version of the PEmb-QoL showed good reliability (internal consistency, item-total and inter-item correlations), reproducibility (test-retest reliability), and validity (convergent, discriminant) in French-speaking patients with PE. The exploratory factor analysis suggested three underlying dimensions: limitations in daily activity (items 4b-m, 5a-d), symptoms (items 1a-h and 7), and emotional complaints (items 9a-f and j)., Conclusion: We successfully validated the French version of the PEmb-QoL questionnaire in patients with PE. Our results show that the PEmb-QoL is a valuable tool for assessing health-related quality of life after PE in French-speaking patients.

Objective: To explore the psychological consequences of experiencing symptomatic pulmonary embolism (PE)., Design: Qualitative interview-based study using interpretative phenomenological analysis., Setting: Outpatients who attended an anticoagulation clinic in a district general hospital., Participants: Patients attending an anticoagulation clinic following hospital admission for symptomatic PE were approached to participate. A total of 9 (4 women, 5 men) of 11 patients approached agreed to be interviewed. Participants were aged between 26 and 72 years and had previously experienced a PE between 9 and 60 months (median=26 months, mean=24 months)., Intervention: Audiotaped semistructured qualitative interviews were undertaken to explore participants experiences of having a PE and how it had affected their lives since. Data were transcribed and analysed using interpretative phenomenological analysis to identify emergent themes., Results: Three major themes with associated subthemes were identified. Participants described having a PE as a life-changing experience comprising initial shock, followed by feeling of loss of self, life-changing decisions and behaviour modification. Features of post-traumatic stress disorder (PTSD) were described with flashbacks, hypervigilance and intrusive thoughts being most prevalent. Participants identified several areas of support needed for such patients including easier access to support through information giving and emotional support., Conclusions: Long-term consequences of venous thromboembolism go beyond the physical alone. Patients describe experiencing symptomatic PE to be a life-changing distressing event leading to behaviour modification and in some PTSD. It is likely that earlier psychological intervention may reduce such long-term sequelae.

Background: The objective of this prospective study was to assess the prevalence of anxiety and depression disorders and their association with quality of life (QoL), clinical parameters and survival in patients with pulmonary hypertension (PH)., Methods: We prospectively assessed 158 patients invasively diagnosed with pulmonary arterial hypertension (n = 138) and inoperable chronic thromboembolic PH (n = 20) by clinical measures including quality of life (QoL, SF-36 questionnaire), cardiopulmonary exercise testing and six minute walking distance and by questionnaires for depression (PHQ-9) and anxiety (GAD-7). According to the results of the clinical examination and the questionnaires for mental disorders (MD) patients were classified into two groups, 1) with moderate to severe MD (n = 36, 22,8%), and 2) with mild or no MD (n = 122). Patients were followed for a median of 2.7 years. Investigators of QoL, SF-36 were blinded to the clinical data., Results: At baseline the 2 groups did not differ in their severity of PH or exercise capacity. Patients with moderate to severe MD (group 1) had a significantly lower QoL shown in all subscales of SF-36 (p < 0.002). QoL impairment significantly correlated with the severity of depression (p < 0.001) and anxiety (p < 0.05). During follow-up period 32 patients died and 3 were lost to follow-up. There was no significant difference between groups regarding survival. Only 8% of the patients with MD received psychopharmacological treatment., Conclusion: Anxiety and depression were frequently diagnosed in our patients and significantly correlated with quality of life, but not with long term survival. Further prospective studies are needed to confirm the results.

Pulmonary embolism (PE) in pregnancy carries a significant mortality. Pregnant patients often present via the acute medical take with symptoms of possible PE and require timely assessment and investigation. The symptoms of PE are sometimes very difficult to differentiate from those of normal pregnancy and the vast majority of patients will require imaging. The radiation risks to mother and foetus from imaging may cause considerable anxiety (to both patients and healthcare providers) and need to be explained to patients in the context of a potentially life-threatening condition so they can be actively involved in decision-making on how best to proceed. When PE is diagnosed in pregnancy, there are obstetric considerations around the time of delivery and women should receive specialist follow-up.

Background: Psychological distress has been widely studied in many cardiovascular and pulmonary diseases, but the condition in acute pulmonary embolism (APE) is unknown. The purpose of this study was to investigate levels of depression and anxiety and their influencing factors in APE patients., Methods: Sixty consecutive patients with APE were subjected to investigation of depression and anxiety by the Beck Depression Inventory and State-Trait Anxiety Inventory, and 60 community-based subjects were enrolled as controls. APE patients were stratified as high-risk, intermediate-risk and low-risk according to the disease severity. Scores of depression and anxiety were compared by statistical analysis using paired t tests between APE patients and controls, and by analysis of variance within the APE patients with the three risk stratification. Factors influencing depression and anxiety were evaluated., Results: The mean age of the patients (38 males and 22 females) was (52 ± 12) years. APE patients displayed higher scores of depression (P = 0.04) and anxiety (P = 0.001) compared with controls. Patients in the high-risk group displayed higher scores of depression (P = 0.004) and anxiety (P = 0.001) compared with those in the intermediate- and low-risk groups. Depression scores were highly correlated with anxiety scores (r = 0.60, P < 0.001). Both depression and anxiety inversely related to risk stratification (P < 0.01), age (P < 0.05), and arterial blood oxygen pressure (PaO2) (P < 0.05). Linear regression analysis showed that PaO2 was independently inversely related to both depression (P < 0.01) and anxiety (P < 0.05); risk stratification and age were independently inversely related to anxiety (P < 0.05)., Conclusions: Patients of APE suffered high levels of depression and anxiety, which were negatively influenced by PaO2, risk stratification and age.

Background: To our knowledge, studies evaluating the quality of life (QoL) in patients with a history of acute pulmonary embolism (PE) are not available, even though QoL is a key outcome component of medical care and a predictor of disease-specific prognosis., Methods: As part of a large follow-up study, the Short Form 36 (SF-36) was presented to consecutive patients who had survived one or more episodes of acute PE. The results of all nine subscales of the SF-36 were compared with sex- and age-adjusted Dutch population norms. Single and multivariate analyses were performed to identify independent determinants of the QoL in our study population., Results: The SF-36 was completed by 392 patients. Except for the health change subscale, patients had substantially lower QoL than population norms on all eight remaining subscales. After multivariate analysis, the time interval between the last thromboembolic episode and study inclusion was inversely related to QoL, and significant determinants of poor QoL were prior PE, age, obesity, active malignancy, and cardiopulmonary comorbid conditions. Regression models that included all identified significant determinants proved to be quite modest predictors for QoL in the individual patient. Awareness of illness, coping mechanisms, and self-management behavior might be additional important indicators of QoL in our study population but require further investigation., Conclusion: We identified several PE- and non-PE-related determinants of QoL in patients with a history of acute PE, which is impaired compared with sex- and age-adjusted population norms. QoL after acute PE should be studied more extensively and added as a standard measure to outcome studies.

Introduction: Depression is known to have a bidirectional relationship with cardiovascular disease. Severe major depression associated with psychomotor retardation and immobility can be a risk factor for pulmonary embolism; the reverse pathway has not been reported., Case Report: We report a case of a 61-year-old man diagnosed with multiple pulmonary thromboembolism finally attributed to a right pulmonary artery intraluminal sarcoma. One month after the onset of presenting symptoms, the patient suddenly developed an episode of severe, melancholic depression, which remitted in six weeks under treatment with venlafaxine 225 mg/day., Discussion: Pathophysiological mechanisms implicated in the development of depression in our patient might resemble those postulated for post-myocardial infarction depression; in line with the "vascular depression" hypothesis, cerebral damage in the limbic circuitry caused by transient hypoxia, an inflammatory response or both may have contributed., Conclusion: Multiple pulmonary thromboembolism seems to have a bidirectional relationship with major depression, in a similar way as myocardial infarction does., (Copyright © 2010 Elsevier Inc. All rights reserved.)

In this case study we report on a patient with advanced myxofibrosarcoma and lung metastases, suffering from severe dyspnoea. Symptoms were not manageable by means of standard palliative care, which made palliative sedation therapy necessary in order to alleviate dyspnoea. On the basis of this case study, indications, drugs, therapy monitoring and ethical aspects of palliative sedation therapy are discussed.

Background: Even though quality of life (QoL) has become a key component of medical care, there is no instrument available that specifically measures QoL after pulmonary embolism (PE). Recently, the Pulmonary Embolism Quality of Life (PEmb-QoL) Questionnaire has been developed to address this gap., Objective: To evaluate the validity of the PEmb-QoL questionnaire., Methods: We distributed the PEmb-QoL questionnaire and the Short Form-36 (SF-36) questionnaire twice among consecutive subjects with a history of objectively confirmed acute PE. Internal consistency reliability, test-retest reliability, convergent validity and criterion validity, and correlations between the PEmb-QoL and clinical patient characteristics were assessed using standard-scale construction techniques., Results: Ninety participants completed the questionnaires twice. Internal consistency was adequate (Cronbach's alpha 0.62-0.94), as well as test-retest reliability (intra-class correlation coefficients: 0.78-0.94). Furthermore, correlation between the PEmb-QoL questionnaire and the SF-36 questionnaire supported convergent validity. Age, obesity, cardiopulmonary comorbidity, centrally located PE and a family history of venous thromboembolism were shown to be independent determinants of disease-specific QoL., Conclusion: The PEmb-QoL questionnaire is a reliable instrument to specifically assess QoL following PE, which is helpful in the identification of patients with decreased QoL following acute PE.

Health-related quality of life (QoL) has been associated with several social and medical conditions in patients with deep vein thrombosis (DVT) and pulmonary embolism (PE). To the best of our knowledge, there is no study investigating the relationship of QoL with psychological variables in this patient population. We assumed as a hypothesis an association between heightened levels of fatigue and psychological distress, as well as decreased QoL in patients with an objectively diagnosed venous thromboembolic event. Study participants were 205 consecutively enrolled out-patients (47.4 years, 54.6% men) with DVT and/or PE. Approximately 10 days before blood collection for thrombophilia work-up, QoL, fatigue, and psychological distress were assessed using the Short Form Health Survey (SF-12), the Multidimensional Fatigue Symptom Inventory Short Form (MFSI-SF) as well as the Hospitality Anxiety and Depression scale (HADS). After controlling for demographic and medical factors, fatigue (p < 0.01) but not psychological distress (p>0.05) was negatively associated with physical QoL, explaining 11.0% of the variance. Fatigue (p < 0.001) and psychological distress (p < 0.001) were significant predictors of mental QoL, explaining an additional 36.2% and 3.6% of the variance. Further analyses revealed that all subscales of the HADS (e.g. anxiety and depression) and of the MFSI-SF (e.g. general fatigue, physical fatigue, emotional fatigue, mental fatigue and vigor) were significant predictors of mental QoL. MFSI-SF subscales also predicted physical QoL. The findings suggest that fatigue and psychological distress substantially predict QoL in patients with a previous venous thromboembolic event above and beyond demographic factors.

Background: The link between psychosocial factors and coronary heart disease is well established, but although effects on coagulation and fibrinolysis variables may be implicated, no population-based study has sought to determine whether venous thromboembolism is similarly related to psychosocial factors., Objective: To determine whether venous thromboembolism (deep vein thrombosis or pulmonary embolism) is related to psychosocial factors., Patients/methods: A stress questionnaire was filled in by 6958 men at baseline from 1970 to 1973, participants in a cardiovascular intervention trial. Their occupation was used to determine socio-economic status., Results: After a maximum follow-up of 28.8 years, 358 cases of deep vein thrombosis and/or pulmonary embolism were identified through the Swedish hospital discharge and cause-specific death registries. In comparison with men who, at baseline, had no or moderate stress, men with persistent stress had increased risk of pulmonary embolism [hazard ratio (HR)=1.80, 95% CI: 1.21-2.67]. After multivariable adjustment, the HR decreased slightly to 1.66 (95% CI: 1.12-2.48). When compared with manual workers, men with white-collar jobs at intermediate or high level and professionals showed an inverse relationship between occupational class and pulmonary embolism (multiple-adjusted HR=0.57, 95% CI: 0.39-0.83). Deep vein thrombosis was not significantly related to either stress or occupational class., Conclusion: Both persistent stress and low occupational class were independently related to future pulmonary embolism. The mechanisms are unknown, but effects on coagulation and fibrinolytic factors are likely.

Objectives: The authors hypothesized that emergency department (ED) patients with a delayed diagnosis of pulmonary embolism (PE) will have a higher frequency of altered mental status, older age, comorbidity, and worsened outcomes compared with patients who have PE diagnosed by tests ordered in the ED., Methods: For 144 weeks, all patients with PE diagnosed by computed tomographic angiography were prospectively screened to identify ED diagnosis (testing ordered from the ED) versus delayed diagnosis (less than 48 hours postadmission). Serum troponin I level, right ventricular hypokinesis on echocardiography, and percentage pulmonary vascular occlusion were measured at diagnosis; patients were prospectively followed up for adverse events (death, intubation, or circulatory shock)., Results: Among 161 patients with PE, 141 (88%) were ED diagnosed and 20 (12%) had a delayed diagnosis. Patients with a delayed diagnosis were older than ED-diagnosed patients (61 [+/-15] vs. 51 [+/-17] years; p < 0.001), had a longer median time to heparin administration (33 vs. 8 hours; p < 0.001), and had a higher frequency of altered mental status (30% vs. 8%; p = 0.01) but did not have a higher frequency of prior cardiopulmonary disease (25% vs. 23%). Patients with a delayed diagnosis had equal or worse measures of PE severity (right ventricular hypokinesis on echocardiography, 60% vs. 58%; abnormal troponin I level, 55% vs. 24%); on computed tomographic angiography, ten of 20 patients with a delayed diagnosis had PE in lobar or larger arteries and >50% vascular obstruction. Patients with a delayed diagnosis had a higher rate of in-hospital adverse events (9% vs. 30%; p = 0.01)., Conclusions: In this single-center study, the diagnosis of PE was frequently delayed and outcomes of patients with delayed diagnosis were worse than those of patients with PE diagnosed in the ED.

Over the last decade we have witnessed an avalanche of newly identified risk factors for venous thrombosis. This has advanced our knowledge of its etiology, because more determinants have been described and because the underlying concepts have received a new and broader understanding. Venous thrombosis is a common multicausal disease occurring as the result of interacting genetic, environmental and behavioral risk factors. Some of these have been known since medieval times, such as the increased risk of thrombosis during immobilization in pregnancy and after childbirth (although retained milk of the breast-feeding mother was seen as the primary cause for the latter). Pregnancy and puerperium still cause thrombosis, as do exogenous hormones in oral contraceptives and hormonal replacement therapy. Furthermore, the immobilization in the puerperium of the old days translates directly to situations of immobilization in current times, such as prolonged travel in airplanes or excessive electronic gaming. While pedigrees with abundant thrombosis were observed in the early 1900s, the first cause of heritable thrombophilia (antithrombin deficiency) was discovered in 1965, with the subsequent identification of deficiencies of protein C and protein S in the early 1980s. These were uncommon and strong risk factors, whereas the more recently discovered genetic variants are common and weak, and cause disease only in the presence of other factors.