Admission electrocardiographic markers of atrial cardiomyopathy predict persistent pulmonary hypertension and chronic thromboembolic pulmonary hypertension after acute pulmonary embolism: a retrospective cohort study.

Persistent pulmonary hypertension (PH) and chronic thromboembolic pulmonary hypertension(CTEPH) are important complications after acute pulmonary embolism(PE), yet early risk stratification remains limited. We evaluated whether admission electrocardiographic markers of atrial cardiomyopathy are associated with 3-month persistent PH and confirmed CTEPH. This single-center retrospective cohort included 1,579 consecutive adults with computed tomography pulmonary angiography-confirmed acute PE between August 2018 and August 2025. All underwent admission electrocardiography and structured 3-month echocardiographic reassessment.The primary outcome was persistent PH, defined as intermediate/high echocardiographic PH probability at 3 months; the secondary outcome was confirmed CTEPH.The sinus rhythm subset was defined a priori for evaluating P-wave-based markers, including P-wave indices, P-terminal force in lead V1 (PTFV1), and interatrial block. Persistent PH occurred in 292 patients (18.5%), and confirmed CTEPH in 44 (2.8%). Because CTEPH work-up was mainly triggered by intermediate/high echocardiographic PH probability, confirmed CTEPH was ascertained within the persistent PH group. In the sinus rhythm subset, persistent PH was associated with longer P-wave duration, greater dispersion, higher PTFV1, and more frequent interatrial block (all p < 0.001). After adjustment, PTFV1 (OR 1.21 per 10 mm·ms, 95% CI 1.14-1.29; p < 0.001) and interatrial block (OR 1.78, 95% CI 1.28-2.49; p = 0.001) remained independently associated with persistent PH and confirmed CTEPH. Among acute PE survivors in sinus rhythm, P-wave-based ECG markers of atrial cardiomyopathy, particularly PTFV1 and interatrial block, were independently associated with persistent PH and confirmed CTEPH. These exploratory risk-enrichment markers are not applicable to non-sinus rhythms and require external validation.