|Year : 2021 | Volume
| Issue : 2 | Page : 130-134
Epidemiological study of acute pulmonary embolism in a tertiary care center
Sri Ramulu Kadiyala1, Abdul Razak1, Krishnananda Nayak2, Padmakumar Ramachandran1, Jyothi Samanth2, M Umesh Pai2
1 Department of Cardiology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India
2 Department of Cardiovascular Technology, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, India
|Date of Submission||04-Jan-2021|
|Date of Decision||09-Apr-2021|
|Date of Acceptance||18-Apr-2021|
|Date of Web Publication||25-Aug-2021|
Dr. Abdul Razak
Department of Cardiology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Acute pulmonary embolism remains a significant cause of morbidity and mortality. This study aimed to determine the clinical profile, management, and outcomes of patients with acute pulmonary embolism.
Methods: This was a retrospective, single-center, and observational study. All consecutive patients with proven diagnosis of pulmonary embolism and treated at a tertiary care center were included in the study based on inclusion and exclusion criteria.
Results: From January 2012 to May 2018, a total of 304 patients diagnosed with pulmonary embolism were included in the study. Majority of the patients (n = 195; 64.14%) were male. Among included patients, 92 (30.66%) were smokers, and 81 (26.6%) were obese. Dyspnea (98.03%) was the most commonly observed symptom. Of patients who underwent bilateral lower limb venous Doppler, deep vein thrombosis was noted in 172 (56.57%). Electrocardiography confirmed the presence of sinus tachycardia and classical S1Q3T3 pattern in 284 (93.42%) and 79 (25.99%) patients, respectively. Chest X-ray showed dilated main and right pulmonary arteries in 170 (55.92%) patients. Right ventricular dysfunction as detected by echocardiography was observed in 241 (79.28%) patients. Thrombolytic therapy was administered in 158 (51.97%) patients (n = 86 (28.29%) were treated with tenecteplase; n = 72 (23.68%) were treated with streptokinase).
Conclusions: This study gives an insight into the clinical profile of patients hospitalized with a confirmed diagnosis of acute pulmonary embolism along with treatment and diagnostic approaches adopted by the physician in the Indian scenario.
Keywords: Cardiovascular diseases, electrocardiography, pulmonary embolism
|How to cite this article:|
Kadiyala SR, Razak A, Nayak K, Ramachandran P, Samanth J, Pai M U. Epidemiological study of acute pulmonary embolism in a tertiary care center. Heart India 2021;9:130-4
|How to cite this URL:|
Kadiyala SR, Razak A, Nayak K, Ramachandran P, Samanth J, Pai M U. Epidemiological study of acute pulmonary embolism in a tertiary care center. Heart India [serial online] 2021 [cited 2021 Dec 4];9:130-4. Available from: https://www.heartindia.net/text.asp?2021/9/2/130/324607
| Introduction|| |
Acute pulmonary embolism, a potentially lethal form of deep vein thrombosis (DVT), is a relatively common cause of cardiovascular disease. It is one of the most common causes of death in Western countries. The disease is characterized by numerous usually nonspecific clinical manifestations as it involves a complex interplay between different organs. It is classified as massive (systemic hypotension or cardiogenic shock), submassive (right ventricular [RV] dysfunction without hypotension), and nonmassive pulmonary embolism. In-hospital mortality associated with massive pulmonary embolism is as high as 50%, whereas in-hospital mortality is 3% to 15% among patients with submassive pulmonary embolism. Nonmassive pulmonary embolism is associated with a mortality rate of 5% or less. Hence, the disease presents a diagnostic challenge to treating physicians. Moreover, as most of the deaths from acute pulmonary embolism occur within the first hour of presentation, delaying diagnosis leads to significant morbidity and mortality. A risk assessment tool to identify patients who are at risk of pulmonary embolism is of utmost importance. The Pulmonary Embolism Severity Index (PESI), a risk assessment tool based on clinical and hemodynamic parameters, stratifies the patients into five categories ranging from very low risk, with a 30-day mortality of <2%, to very high risk, with 10.0%–24.5% mortality. Subsequently, a simplified PESI (sPESI) risk assessment tool was developed. Extensive research to identify risk factors and outcomes of pulmonary embolism has been performed. However, a scarcity of literature is observed pertaining to the epidemiological study of the disease in India. Hence, this study was designed to determine the clinical profile, risk factors, management, and outcomes of patients admitted to a tertiary care center with a confirmed diagnosis of acute pulmonary embolism.
| Methods|| |
This retrospective, observational study included patients with pulmonary embolism at a tertiary care center between January 2012 and May 2018 were included in the study, depending upon inclusion and exclusion criteria. All consecutive patients who were diagnosed with pulmonary embolism by computed tomography (CT) pulmonary angiography were included in the study. However, clinically suspected cases of pulmonary embolism without any confirmed diagnosis were excluded from the study. The study was conducted in accordance with the Declaration of Helsinki and was approved by the institutional ethical committee.
Patients medical records were evaluated for data collection. Data including demographic details, findings of the different diagnostic modalities, treatment, and outcomes of patients included in the study were collected using a pre-defined case-record form. All the patients underwent chest X-ray, electrocardiography, and echocardiography. Management of patients with anticoagulation, thrombolysis, inferior vena cava filter implantation was based on the operator's discretion.
Descriptive analysis was performed. Continuous variables were presented as mean±standard deviation and categorical variables were shown as frequency (percentages). Statistical analysis was carried out using SPSS software (version 20) Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL). P < 0.05 was considered statistically significant.
| Results|| |
A total of 304 patients were included in the study. [Table 1] shows the baseline clinical and demographic characteristics of the study population. The majority of the patients were male (n = 195; 64%). The average age of patients was 38.0 ± 26.8 years. Of the included patients, 92 (30.66%) were smokers, and 81 (26.6%) were obese. The most common symptoms were 298 (98.03%) dyspnea. New York Heart Association (NYHA) class-III was noted in 152 (50.00%) patients. Of included patients, 128 (42.11%) patients had sPESI score ≥1.
|Table 1: Demographics and baseline clinical characteristics of the study population|
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Among patients who underwent bilateral lower limb venous Doppler, deep-vein thrombosis was observed in 172 patients (n = 22 (7.24%) patients with bilateral DVT; n = 84 (27.63%) with right limb DVT; n = 61 (20.07%) with left limb DVT). Pulmonary thromboembolism was provoked in 117 (38.49%) and unprovoked in the rest of two-third of the patients. A total of 295 (97.03%) patients had tachypnea, whereas tachycardia (PR-Pulse rate >110) was present in 123 (40.60%) patients [Table 2]. Electrocardiography showed sinus tachycardia in 284 (93.42%) patients, whereas classical S1Q3T3 sign was present in 79 (25.99%) patients. Chest X-ray confirmed the presence of the dilated main and right pulmonary arteries in 170 (55.92%) patients. RV dysfunction, as detected by echocardiography was observed in 241 (79.28%) patients. Moderate and severe pulmonary hypertension was noted in 148 (48.68%) and 95 (31.25%) patients, respectively. Involvement of thrombus burden in the proximal main left and right pulmonary arteries was seen in 170 (56.4%) patients, whereas 131 (43.6%) of the patients had thrombus burden in lobar and segmental pulmonary arteries. Low-molecular-weight heparin and unfractionated heparin were administered to 142 (46.71%) and 138 (45.39%) patients, respectively. Eight-six patients (28.29%) were treated with tenecteplase, while 72 (23.68%) were treated with streptokinase. In-hospital mortality was 39 (12.8%). At discharge, 45 (14.80%) patients had inferior vena cava filters. Among the patients discharged from the hospital, 154 (50.65%) used oral anticoagulation with warfarin, and 84 (27.63%) used new oral anticoagulants. Chronic thromboembolic pulmonary hypertension (CTEPH) was seen in 17 (5.59%) patients at 12-month follow-up and 11 patients of them underwent pulmonary endarterectomy. Treatment and clinical outcomes of the patients treated for acute pulmonary embolism are shown in [Table 3] and [Figure 1].
| Discussions|| |
This study gives an insight into the clinical profile of a cohort of 304 patients treated for a CT pulmonary angiogram-confirmed diagnosis of a pulmonary embolism at a tertiary care center. This study also provides a brief outline for different treatment modalities used among these patients along with treatment approach and clinical outcomes.
The average age of the patients diagnosed with pulmonary embolism patients was 38.0±26.8 years. In contrast, other studies demonstrated a higher occurrence of acute pulmonary embolism among those aged above 60 years., This could be explained by a higher prevalence of risk factors in patients with acute pulmonary embolism. The results of the study conducted by Dandan et al. demonstrated that patients with the disease were 42-years-old. In our study, obesity was seen in 27% of patients. It was suggested that the role of obesity in the thrombogenic effect by factor VIII-related activated protein C., Smoking, another important risk factor, was found in 31% of the patients. In the previous study, smoking (active or former) was a major risk factor found in approximately 61% of the patients. Dyspnea (98.03%) with NYHA Class III (50.00%) was the most common presentation among our patients which was in accordance with the published studies., However, tachypnea followed by tachycardia (PR >110) showed higher prevalence compared to our results. Similar to other studies, immobilization due to surgery or trauma and malignancy that provoked pulmonary embolism in 16.8% and 8.5% of the patients, respectively., Due to the activation of the coagulation system, cancer may increase the risk of thromboembolism. In our study, according to the sPESI score, 57.89% had zero scores which was in agreement with the findings noted in the study performed by Kilic et al. Electrocardiography found sinus tachycardia in 93.42% and S1Q3T3 pattern in 25.99% of the patients in our study. In the present study, 55.92% of patients had (chest X-ray) evidence of dilated main and right pulmonary arteries. The aforementioned findings are comparable with the results of the study performed by Ngahane et al. RV dysfunction as evident by echocardiograph was found in 79.28% of the patients. Among patients with pulmonary embolism, 48.68% and 31.25% had moderate and severe pulmonary hypertension, respectively. The study was done by Lolly et al., where 58.4% of the patients experienced RV dysfunction, and 84.9% had pulmonary arterial hypertension.
In our study, low-molecular-weight heparin and unfractionated heparin were used 46.71% and 45.39% of patients, respectively. Moreover, 28.29% received tenecteplase, while 23.68% received streptokinase. Nagamalesh et al. thrombolized 58% patients, of which 39% and 19% treated with tenecteplase and streptokinase. CTEPH has been estimated to occur in 0.1-0.5% of patients who survive a pulmonary embolism, but more recent prospective studies suggest that its incidence may be much higher. At one year follow-up, Rashidi et al. showed that the overall incidence of CTEPH was 9.9% at one-year follow-up, which agreed with our study results (5.59%). In our study, the mortality rate with pulmonary embolism is consistent with data reported by Ngahane et al.
We should acknowledge the limitation of the study. First, the patient study was nonrandomized and retrospective in nature which included a small number of patients. Second, the study reported clinical outcomes till discharge. Furthermore, the study was conducted tertiary care hospital study where patients received mainly from periphery center which could lead to the selection of more severe cases.
| Conclusions|| |
This study describes the clinical profile, risk factors, management, and outcomes of patients with acute pulmonary embolism. The outcomes of the patients underscore the importance of the early diagnosis and intervention in patients with acute pulmonary embolism. However, large randomized prospective studies are required for a detailed clinical profile and outcomes.
The first author prepared the draft of the manuscript, which was then reviewed and edited by the coauthors. All authors actively contributed and approved the final version of the manuscript.
The study was approved by the institutional ethical committee.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]