Post-pulmonary embolism syndrome (PPES) encompasses a diverse spectrum of long-term complications that are associated with persistent dyspnea, exercise intolerance, and a decrease in quality of life. The PPES constellation ranges from life-threatening conditions such as chronic thromboembolic pulmonary hypertension (CTEPH) to nonlife-threatening but still debilitating conditions such as chronic thromboembolic pulmonary disease (CTED) or post-PE deconditioning. The safety and efficacy of exercise and cardiopulmonary rehabilitation programs to prevent and manage these symptoms in PPES has not been well established. Herein, we review contributors to PPES and synthesize the evidence for exercise training after PE to treat and prevent PPES.
Porres-AguilarMRivera-LebronBKimNH, et al. Post-pulmonary embolism syndrome, CTEPD, and CTEPH. Vasc Med2024; 29: 457–461.
3.
YuriditskyEHorowitzJMLauJF.Chronic thromboembolic pulmonary hypertension and the post-pulmonary embolism (PE) syndrome. Vasc Med2023; 28: 348–360.
4.
KlokFAvan der HulleTden ExterPL, et al. The post-PE syndrome: A new concept for chronic complications of pulmonary embolism. Blood Rev2014; 28: 221–226.
5.
ShahKPLeeCMcBaneRD, et al. Post-pulmonary embolism syndrome—A diagnostic dilemma and challenging management. Mayo Clin Proc2024; 99: 1965–1982.
6.
LuijtenDde JongCMMNinaberMK, et al. Post-pulmonary embolism syndrome and functional outcomes after acute pulmonary embolism. Semin Thromb Hemost2023; 49: 848–860.
7.
DelcroixMde PerrotMJaïsX, et al. Chronic thromboembolic pulmonary hypertension: realising the potential of multimodal management. Lancet Respir Med2023; 11: 836–850.
8.
FountainJHPeckTJFurfaroD.Sequelae of acute pulmonary embolism: From post-pulmonary embolism functional impairment to chronic thromboembolic disease. J Clin Med2024; 13: 6510.
9.
GkenaNKirgouPGourgoulianisKIMalliF.Mental health and quality of life in pulmonary embolism: A literature review. Adv Respir Med2023; 91: 174–184.
10.
ValerioLMavromanoliACBarcoS, et al. Chronic thromboembolic pulmonary hypertension and impairment after pulmonary embolism: The FOCUS study. Eur Heart J2022; 43: 3387–3398.
11.
BonnefoyPBMargelidon-CozzolinoVCatella-ChatronJ, et al. What’s next after the clot? Residual pulmonary vascular obstruction after pulmonary embolism: From imaging finding to clinical consequences. Thromb Res2019; 184: 67–76.
12.
GurumurthyGReynoldsLde WitK, et al. Is pulmonary embolism a chronic disease?Clin Med (Lond)2025; 25: 100325.
13.
KlokFAAgenoWAyC, et al. Optimal follow-up after acute pulmonary embolism: A position paper of the European Society of Cardiology Working Group on Pulmonary Circulation and Right Ventricular Function, in collaboration with the European Society of Cardiology Working Group on Atherosclerosis and Vascular Biology, endorsed by the European Respiratory Society. Eur Heart J2022; 43: 183–189.
14.
LuijtenDMeijerFMMBoonGJAM, et al. Diagnostic efficacy of ECG-derived ventricular gradient for the detection of chronic thromboembolic pulmonary hypertension in patients with acute pulmonary embolism. J Electrocardiol2022; 74: 94–100.
15.
HumbertMKovacsGHoeperMM, et al. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J2023; 61: 2200879.
16.
JaisXTapsonVFernandesTM, et al. Diagnosis of chronic thromboembolic pulmonary hypertension. J Heart Lung Transplant2025; 44(7S): S1–S7.
17.
KabadiAKerrKFernandesTM.Updates in the diagnosis and management of chronic thromboembolic disease. Curr Opin Pulm Med2023; 29: 340–347.
18.
DharmavaramNEsmaeeliAJacobsonK, et al. Cardiopulmonary exercise testing, rehabilitation, and exercise training in postpulmonary embolism. Interv Cardiol Clin2023; 12: 349–365.
19.
EwertRObstAMühleA, et al. Value of cardiopulmonary exercise testing in the prognosis assessment of chronic obstructive pulmonary disease patients: A retrospective, multicentre cohort study. Respiration2022; 101: 353–366.
20.
Chacin-SuarezAMedina-InojosaJTaylor JennaL, et al. The association between changes in peak oxygen uptake following phase II outpatient cardiac rehabilitation and major adverse cardiovascular events: A community cohort. JACC2021; 77(18_Suppl_1): 1454.
21.
van KanCvan der PlasMNReesinkHJ, et al. Hemodynamic and ventilatory responses during exercise in chronic thromboembolic disease. J Thorac Cardiovasc Surg2016; 152: 763–771.
22.
Dzikowska-DiduchOKostrubiecMKurnickaK, et al. The post-pulmonary syndrome – Results of echocardiographic driven follow up after acute pulmonary embolism. Thromb Res2020; 186: 30–35.
23.
MorrisTAFernandesTMChannickRN.Evaluation of dyspnea and exercise intolerance after acute pulmonary embolism. Chest2023; 163: 933–941.
24.
DanielsbackaJSRostbergLOlsénMFMannerkorpiK."Whole life changed" – Experiences of how symptoms derived from acute pulmonary embolism affects life. A qualitative interview study. Thromb Res2021; 205: 56–62.
25.
FischerSMeisingerCLinseisenJ, et al. Depression and anxiety up to two years after acute pulmonary embolism: Prevalence and predictors. Thromb Res2023; 222: 68–74.
26.
MaKAKahnSRAkaberiA, et al. Serial imaging after pulmonary embolism and correlation with functional limitation at 12 months: Results of the ELOPE Study. Res Pract Thromb Haemost2018; 2: 670–677.
27.
MagyarUStalderOBaumgartnerC, et al. Association between severity of pulmonary embolism and health-related quality of life. J Thromb Haemost2024; 22: 516–525.
28.
SteinerDNoppSHeinzeG, et al. Functional limitations 3 and 12 months after venous thromboembolism: A cohort study. Res Pract Thromb Haemost2024; 8: 102464.
29.
HunterRNobleSLewisSBennettP.Long-term psychosocial impact of venous thromboembolism: A qualitative study in the community. BMJ Open2019; 9: e024805.
30.
GwozdzAMde JongCMMFialhoLS, et al. Development of an international standard set of outcome measures for patients with venous thromboembolism: An International Consortium for Health Outcomes Measurement consensus recommendation. Lancet Haematol2022; 9: e698–e706.
31.
de JongCMMde WitKBlackSA, et al. Use of patient-reported outcome measures in patients with venous thromboembolism: Communication from the ISTH SSC Subcommittee on Predictive and Diagnostic Variables in Thrombotic Disease. J Thromb Haemost2023; 21: 2953–2962.
32.
SpruitMASinghSJGarveyC, et al. An official American Thoracic Society/European Respiratory Society statement: Key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med2013; 188: e13–64.
33.
EnrightPL.The six-minute walk test. Respir Care2003; 48: 783–785.
34.
KonstantinidesSVMeyerGBecattiniC, et al. 2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J2020; 41: 543–603.
35.
KennyCLennonOKlokFA, et al. Effectiveness of rehabilitation programmes targeting quality of life, psychological wellbeing, and functional capacity in pulmonary embolism survivors; A systematic review and best evidence synthesis. Thromb Res2025; 246: 109242.
36.
XiangWLeiYJXiangH, et al. Exercise and pulmonary embolism: A systematic review of exercise safety, feasibility and effectiveness. Eur Respir Rev2025; 34: 240241.
37.
BoonGJanssenSMJBarcoS, et al. Efficacy and safety of a 12-week outpatient pulmonary rehabilitation program in Post-PE Syndrome. Thromb Res2021; 206: 66–75.
38.
GleditschJJervanØHaukeland-ParkerS, et al. Effects of pulmonary rehabilitation on cardiac magnetic resonance parameters in patients with persistent dyspnea following pulmonary embolism. Int J Cardiol Heart Vasc2022; 40: 100995.
39.
JervanØHaukeland-ParkerSGleditschJ, et al. The effects of exercise training in patients with persistent dyspnea following pulmonary embolism: A randomized controlled trial. Chest2023; 164: 981–991.
40.
NoppSKlokFAMoikF, et al. Outpatient pulmonary rehabilitation in patients with persisting symptoms after pulmonary embolism. J Clin Med2020; 9: 1811.
41.
Cires-DrouetRSMayorga-CarlinMToursavadkohiS, et al. Safety of exercise therapy after acute pulmonary embolism. Phlebology2020; 35: 824–832.
42.
GhramAJenabYSooriR, et al. High-intensity interval training in patients with pulmonary embolism: A randomized controlled trial. Med Sci Sports Exerc2021; 53: 2037–2044.
43.
YueTWangYLiuH, et al. Effects of high-intensity interval vs. moderate-intensity continuous training on cardiac rehabilitation in patients with cardiovascular disease: A systematic review and meta-analysis. Front Cardiovasc Med2022; 9: 845225.
44.
HannanALHingWSimasV, et al. High-intensity interval training versus moderate-intensity continuous training within cardiac rehabilitation: A systematic review and meta-analysis. Open Access J Sports Med2018; 9: 1–17.
45.
RolvingNBrockiBCBloch-NielsenJR, et al. Effect of a physiotherapist-guided home-based exercise intervention on physical capacity and patient-reported outcomes among patients with acute pulmonary embolism: A randomized clinical trial. JAMA Netw Open2020; 3: e200064.
46.
LakoskiSGSavagePDBerkmanAM, et al. The safety and efficacy of early-initiation exercise training after acute venous thromboembolism: A randomized clinical trial. J Thromb Haemost2015; 13: 1238–1244.
47.
LuijtenDEsJAbbinkJ, et al. Cardiopulmonary exercise testing in dyspnoeic persons with a recent acute pulmonary embolism. CHEST Pulm2025; 3: 100164.
48.
Haukeland-ParkerSJervanØJohannessenHH, et al. Pulmonary rehabilitation to improve physical capacity, dyspnea, and quality of life following pulmonary embolism (the PeRehab study): Study protocol for a two-center randomized controlled trial. Trials2021; 22: 22.
49.
MeyerGVicautEDanaysT, et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med2014; 370: 1402–1411.
50.
KlokFAPiazzaGSharpASP, et al. Ultrasound-facilitated, catheter-directed thrombolysis vs anticoagulation alone for acute intermediate-high-risk pulmonary embolism: Rationale and design of the HI-PEITHO study. Am Heart J2022; 251: 43–53.
51.
GiriJMahfoudFGebauerB, et al. PEERLESS II: A randomized controlled trial of large-bore thrombectomy versus anticoagulation in intermediate-risk pulmonary embolism. J Soc Cardiovasc Angiogr Interv2024; 3: 101982.
52.
SistaAKTroxelABTarpeyT, et al. Rationale and design of the PE-TRACT trial: A multicenter randomized trial to evaluate catheter-directed therapy for the treatment of intermediate-risk pulmonary embolism. Am Heart J2025; 281: 112–122.
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