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A Multicentre study of anticoagulation in operable chronic thromboembolic pulmonary hypertension

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Bunclark, Katherine 
Newnham, Michael 
Chiu, Yi-Da 
Ruggiero, Alessandro 


Background: Chronic thromboembolic pulmonary hypertension (CTEPH) is an uncommon complication of acute pulmonary emboli necessitating lifelong anticoagulation. Despite this, little data exists on the safety and efficacy of Vitamin K Antagonists (VKAs) in CTEPH and none for Direct Oral Anticoagulants (DOACs).
Objectives: To evaluate outcomes and complication rates in CTEPH following Pulmonary Endarterectomy (PEA) for individuals receiving VKAs or DOACs. Methods: Consecutive CTEPH patients undergoing PEA between 2007 and 2018 were included in a retrospective analysis. Post-operative outcomes, recurrent venous thromboembolism (VTE) and bleeding events were obtained from patient medical records. Results: 794 individuals were treated with VKAs and 206 with DOACs following PEA. Mean observation period was 612 (SD 702) days. Significant improvements in haemodynamics and functional status were observed in both groups following PEA (p < 0.001). Major bleeding events were equivalent (p = 1) in those treated with VKAs (0.67%/person-year) and DOACs (0.68%/person-year). VTE recurrence was proportionately higher (p = 0.008) with DOACs (4.62%/person-year) than VKAs (0.76%/person-year), although survival did not differ.
Conclusions: Post-PEA functional and haemodynamic outcomes appear unaffected by anticoagulant choice. Bleeding events were similar, but recurrent VTE rates significantly higher in those receiving DOACs. Our study provides a strong rationale for prospective registry data and/or studies to evaluate the safety of DOACs in CTEPH.



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Journal of Thrombosis and Haemostasis

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Cambridge University Hospitals NHS Foundation Trust (CUH) (unknown)
Cambridge University Hospitals NHS Foundation Trust (CUH) (146281)
NIHR Biomedical Research Council