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Case study 2

A case of “failure to recover” from pulmonary embolism (PE)

Jack is a 56-year-old orthodontist with a history of deep vein thrombosis (DVT) 12 years ago.


  • He was treated with anticoagulation for 3 months

  • 8 years ago, Jack developed an acute pulmonary embolism (PE) after a long flight

  • Jack was started on anticoagulation subsequent to the PE, and he has been on it ever since


Jack’s HCP notes that Jack never completely “recovered” from the PE.


  • He has persistent exercise intolerance

  • Occasional palpitations and chest pressure—but no syncope

  • His father had DVT; otherwise, no meaningful family history


Jack’s past medical history includes systemic hypertension and mild arthritis.


  • He’s on an ACE inhibitor, warfarin, and a beta blocker

  • 16 years ago, he had a knee arthroscopy but has had no other surgeries


On physical exam, Jack appeared generally well.


  • His lungs were clear, though a murmur was heard over the left posterior lung field

  • His heart showed a II/VI holosystolic murmur along the left lower sternal border and a somewhat loud P2

  • He had no edema or clubbing


On referral, initial evaluation of Jack revealed the following:


  • Chest x-ray showed mild cardiomegaly and clear lungs

  • Chest CT showed mosaic perfusion and potential irregularities of the right descending pulmonary artery; no luminal filling defects were evident

  • Echocardiogram showed moderate right ventricular (RV) enlargement and dysfunction

  • RV systolic pressure was estimated to be 64 + right atrial pressure


Segmental map

segmental map image


There are evident defects on Jack’s ventilation/perfusion (V/Q) scan

V/Q scan image


Key learnings

Failure to symptomatically return to baseline after an acute PE should raise suspicion for CTEPH1

V/Q scanning is highly reliable and should be ordered promptly2

Bilateral large defects are typical in surgically accessible CTEPH

Referral to a CTEPH center (several throughout the US and Europe) is recommended when CTEPH is suspected2


1. McLaughlin VV, Archer SL, Badesch DB, et al. ACCF/AHA 2009 expert consensus document on pulmonary hypertension. Circulation. 2009;119(116):2250-2294. 2. Kim NH, Delcroix M, Jenkins DP, et al. Chronic thromboembolic pulmonary hypertension. J Am Coll Cardiol. 2013;62(suppl D):D92-D99.