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| ORIGINAL ARTICLE |
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| Year : 2023 | Volume
: 28
| Issue : 2 | Page : 173-181 |
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Clinical profile and short-term outcomes of patients admitted with acute pulmonary embolism in a tertiary care centre
Vinayak Pai1, Suyash Ambekar1, Milind Nadkar1, Alhad Mulkalwar1, Priyadarshi Prajjwal2
1 Department of Medicine, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra
2 Department of Medicine, Bharati Vidyapeeth University Medical College, Pune, Maharashtra, India
| Date of Submission | 02-Jan-2023 |
| Date of Decision | 17-Jan-2023 |
| Date of Acceptance | 03-Mar-2023 |
| Date of Web Publication | 21-Mar-2023 |
Correspondence Address:
Alhad Mulkalwar
Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Parel, Mumbai 400012, Maharashtra
Maharashtra
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijmh.IJMH_1_23
Background: Venous thromboembolism is a major contributor to the global disease burden, with an incidence of around 10 million cases per year and substantially associated morbidity and mortality. Objectives: The study aimed to assess the clinical, laboratory, and radiological profile along with electrocardiogram and echocardiogram changes and the treatment and outcomes in patients admitted with acute pulmonary embolism (PE) in a tertiary care centre. The etiologies and risk factors of the same were also evaluated. Materials and Methods: This was a hospital-based prospective observational study conducted among 31 patients over a period of 18 months. The study was conducted at a tertiary care centre in the Department of General Medicine. Patients of age more than 12 years, admitted with a confirmed diagnosis of acute PE based on computed tomography pulmonary angiography (CTPA), were included in the study. Results: Thrombolysis was done in 12.9% cases, while anticoagulants were given in 87.1% cases. Oxygen therapy was required in 74.2% cases on day 1 while in 9.7% on day 30. Secondary pulmonary hypertension was the commonest complication observed in the study, in 54.8% cases. Severe hypoxia was seen in 35.4% cases. No complications were seen in 6.4% cases. Mortality was recorded in 9.6% of the cases. Conclusion: Since PE is among the leading causes of death and disability, there should be a high degree of suspicion in all clinical settings. And since prolonged immobilisation is a strong risk factor for PE patients at risk, they should be offered prophylactic anticoagulation. Keywords: Anticoagulants, oxygen therapy, pulmonary hypertension, venous thromboembolism, comorbidity
How to cite this article:
Pai V, Ambekar S, Nadkar M, Mulkalwar A, Prajjwal P. Clinical profile and short-term outcomes of patients admitted with acute pulmonary embolism in a tertiary care centre. Int J Med Health Dev 2023;28:173-81 |
How to cite this URL:
Pai V, Ambekar S, Nadkar M, Mulkalwar A, Prajjwal P. Clinical profile and short-term outcomes of patients admitted with acute pulmonary embolism in a tertiary care centre. Int J Med Health Dev [serial online] 2023 [cited 2023 May 28];28:173-81. Available from: https://www.ijmhdev.com/text.asp?2023/28/2/173/372144 |
| Introduction | |  |
Pulmonary embolism (PE) is a common and potentially lethal condition. Most patients who succumb to PE do so within the first few hours of the event. Despite diagnostic advances for PE, delays in diagnosis of the condition are common and represent an important issue.[1] As a cause of sudden death, massive PE is second only to sudden cardiac death. There are roughly 10 million cases of PE per year. PEs are the primary cause of at least 10,000–12,000 deaths per year and a contributing cause of at least 30,000–40,000 deaths per year. The true incidence associated with PE is unknown because they often go undiagnosed or unnoticed until autopsy.[2] Less than 5%–10% of symptomatic PEs are fatal within the first hour of symptoms.[3] There are several markers used for risk stratification, and these are also independent predictors of adverse outcomes. These include hypotension, cardiogenic shock, syncope, evidence of right heart dysfunction, and elevated cardiac enzymes. Some electrocardiogram (ECG) changes, including S1Q3T3, also correlate with a worse short-term prognosis. There are other patient-related factors, such as chronic obstructive pulmonary disease and chronic heart failure, which have also been thought to play a role in disease prognosis.
PE is possibly as deadly an illness as acute myocardial infarction. Nevertheless, the lay public has not been well educated about PE. Consequently, early detection and prompt presentation for medical evaluation has lagged far behind the public awareness of acute coronary syndromes and stroke. While the etiology of PE is focused on acquired and inherited causes of hypercoagulability, there is also an association between atherosclerotic disease and spontaneous venous thrombosis.[4]
The most common reversible risk factor for PE is obesity, an imminent developing pandemic in our society. Other common reversible risk factors include cigarette smoking and hypertension. However, public fascination with PE has centered on long-haul air travel, a rare cause of venous thromboembolism.[5] PE also occurs in the context of illness attributable to surgery, trauma, immobilization, cancer,[6] oral contraceptives,[7] pregnancy, and postmenopausal hormone replacement therapy,[8] as well as medical conditions such as pneumonia and congestive heart failure. Genetic predisposition to venous thrombosis is being increasingly recognized,[9] and studies have demonstrated the important contribution of an inherent prothrombotic state.[10] Increased levels of clotting factors and activation peptides contribute to the risk of PE. Deficiencies of anticoagulant factors also increase thrombotic risk.[10]
Unfortunately, the diagnosis of PE is often missed because patients with PE present with non-specific signs and symptoms. If left untreated, approximately one-third of the patients who survive an initial PE die from a subsequent embolic episode. Despite treatment with anticoagulant therapy, a significant proportion of survivors of acute deep vein thrombosis (DVT) or PE are at risk of suffering from disabling sequelae such as post-thrombotic syndrome, recurrent venous thromboembolism (VTE), or chronic thromboembolic pulmonary hypertension.[5] Given the limitations of medical therapy, promising endovascular treatment modalities have evolved over the past two decades in an effort to mitigate acute and chronic disability from VTE.[11],[12],[13]
Akram et al.[14] in 2009 concluded that among a cohort of patients presenting with clinically suspected PE, clinical characteristics, comorbidities, and radiological features were similar when comparing groups with computed tomography pulmonary angiography (CTPA)-proven or CTPA-refuted PE. However, right ventricular (RV) dimensions, radiological consolidation on imaging, and D-dimer levels were significantly higher in the PE group. Patients with suspected PE have a poor prognosis, irrespective of whether PE is confirmed or not. This appears accentuated in patients without PE, a finding possibly under-recognized in clinical practice. A recent Indian study by Praveen Kumar et al.[15] observed PE index to be a strong independent predictor of right ventricular dysfunction in PE, correlating linearly with different variables associated with higher morbidity and mortality, enabling accurate risk stratification and selection of patients for more aggressive treatment. Planquette et al.[16] in 2021 suggested a prevalence of PE in coronavirus disease (COVID-19) patients close to 5% in the whole population and upto 20% in the clinically suspected population. PE seems to be associated with more extensive lung damage and requires more frequent invasive ventilation. Further, during the COVID-19 pandemic, Trimaille et al.[17] in 2021 found that acute PE patients with COVID-19 have a peculiar clinico-radiological and biological profile and a dismal prognosis.
The true incidence of PE is unknown, and comorbidities associated with PE are increasing (aging population and medical comorbidities), but the increased incidence in the face of decreased mortality likely reflects increased use of more sensitive CT angiography for diagnosis rather than a true change in prevalence.[18] PE disproportionately affects the older population and its incidence rates in those older than 70 years are three times higher than those aged 45–69 years, which again are three times higher than those aged 20–44 years. The reported incidence of VTE is inconsistent with regard to gender, though several studies suggest a higher incidence in males.[19] Considering the inconsistency in data and burden of the disease, in terms of morbidity and mortality, the authors undertook this study with an aim to assess the clinical, laboratory, and radiological profile along with ECG and echocardiogram (ECHO) changes along with the treatment and outcomes in patients admitted with acute PE in a tertiary care centre. The etiologies and risk factors of the same were also evaluated.
| Materials and Methods | | |
This was a hospital-based prospective observational study conducted among 31 patients over a period of 18 months. The study was conducted at a tertiary care centre in the Department of General Medicine of Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai. Patients of age more than 12 years, admitted with the confirmed diagnosis of acute PE based on CTPA, attending outpatient department/inpatient department of the hospital, were included in the study. It was conducted after obtaining due permission from the Institutional Ethics Committee and Review Board of Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai (Reference no: IEC/167/2017). and after taking written informed consent from the patients. Once the patients were enrolled for the study, a thorough medical history was taken, and physical examination was done as per the proforma. CTPAs were performed using a multi-slice CT scanner and 1 mm collimation with images viewed on a Vitrea Workstation. Confirmatory testing for PE consisted of positive CT pulmonary angiography for PE of the lower limb that was positive for proximal DVT in a patient presenting with chest symptoms. Demographic parameters of age, sex, symptoms, signs, mean pulse rate per minute, history of comorbidities, treatment history, examination signs on admission, mean systolic and diastolic blood pressure, jugular venous pressure (JVP), accessory muscles of respiration were noted down as per patient’s or caregiver’s history and physician’s notes. Lab investigations sent by the treating physician were recorded. Detailed history, including past, personal treatment history, cardiovascular system findings, and per abdomen findings, were noted down. Radiological findings of ECG, chest X-ray, ultrasonography Doppler, and two-dimensional (2D) ECHO were recorded. Patients were followed up till death, discharge, or 3 months, whichever was earlier. Quantitative data was presented with the help of mean and standard deviation. Comparison among the study groups was made with the help of unpaired t test as per the results of normality test. Qualitative data was presented with the help of frequency and percentage tables. Association among the study groups was assessed with the help of the Fisher test, Student t test, and Chi-square test. P value less than 0.05 is taken as significant. Statistical analysis was performed using SPSS version (Statistical Package for the Social Sciences) 26.0 software.
| Results | | |
General characteristics
Mean age of patients was 50.9 years with a minimum age of 18 and maximum age of 80 years. No significant correlation was found between the gender or age of the patients with the prevalence of PE. Mean pulse rate per minute on day 1 was 99.8, and mean respiratory rate per minute on day 1 was 26. Mean body temperature on day 1 was 37.3°C. Past medical history of any prothrombotic event - DVT/PE/cerebral venous thrombosis was present in 32.3% cases, while past history of risk factors (fracture, immobility, bedridden state, lower limb swelling) was present in 45.2% cases. Amongst the study participants, two patients were suffering from COVID-19, and one patient had a history of the same from which he had recovered. Diabetes was present in five cases, while hypertension was present in four cases. Post-tuberculosis (TB) sequelae were seen in two cases, active TB in one patient and nine cases had no comorbidities. Thus, diabetes was the commonest comorbidity. Five patients were chronic smokers, while seven patients were chronic alcoholics. Two cases were given analgesics, six cases with antibiotics, five cases were on antidiabetic medication, and one case was on home isolation for COVID-19.
Clinical characteristics
Breathlessness, being the commonest symptom in the study, was seen in 90.3% cases, while chest pain was seen in 45.1% cases. Leg swelling was seen in 32.2% cases. Almost all patients improved symptomatically by day 30. Presence of breathlessness reduced from 90.3% to 20% cases and that of chest pain reduced from 45.1% to 3.2% cases. 38.7% cases had no symptoms on day 30. General condition was moderate in 80.6% cases while poor in 19.4% cases. General condition was fair in 54.8% cases. Mean systolic blood pressure reduced to 110.5 mm of Hg, while diastolic increased to 81.2 mm of Hg on day 30. Mean JVP was 2.6 cm on day 1, which reduced to 1.58 cm on day 30. Thus, there was a slight fall in the JVP over a period of 30 days. On day 1, the use of accessory muscles was present in 22 cases, while it was reduced to three patients on day 30. Thus, there was a reduction in the respiratory distress seen over a period of 30 days. On day 1, air entry was decreased in eight cases, which was seen in five cases on day 30. On day 30, air entry was bilaterally equal in two cases [Table 1]. On day 1, heart sound S1 was normal and S2 was loud in eight cases, while on day 30, the same was seen in seven cases. S1 and S2 were normal in all the other patients on day 1 and day 30. Per abdomen findings were almost same on day 1 and day 30, with most cases showing no tenderness or rigidity [Table 2]. Mean hemoglobin was 10.8 g/dl on day 1, which increased to 11.32 g/dl on day 30. Thus, there was a slight increase in the hemoglobin level. Mean blood urea nitrogen was 17.9 mg/dl on day 1, which was 12.1 mg/dl on day 30. Mean creatinine level was 2.1 mg/dl on day 1, which was reduced to 1.6 mg/dl on day 30. Mean levels of serum glutamic-oxaloacetic transaminase/serum glutamic pyruvic transaminase were 31.43/17.4 U/l on day 1 and 27.6/26.1 U/l on day 30. Mean value of glycated haemoglobin was 5.43 g/dl in the participants of the study. Dyslipidemia was present in 29% cases of the study, while routine urine was abnormal in 22.6% cases. Sinus tachycardia was seen in 70.9% cases. S1Q3T3 pattern, which is the classical ECG finding in PE, was seen in 9.6% cases. Thus, sinus tachycardia was the commonest ECG finding in this study. Pleural effusion was seen in 3.2% cases, infiltrates in 51.6%, and cardiomegaly in 12.9% cases [Table 3]. Surprisingly, infiltrates were seen in more than half of the patients at the time of presentation, which could be explained by COVID-19, TB, pulmonary metastases, aspiration or post-infective sequelae. Dilated right atrium and RV were seen in 48.40% cases, while left ventricular failure was seen in 6.4% cases. Dilated right atrium and RV are usually seen in hemodynamically significant cases of PE. Left ventricular failure is usually not seen. 2D ECHO was normal in 45.1% cases. The thrombus is usually not visualized on 2D ECHO unless it is large and present in the main pulmonary trunk. Major vessel embolism was seen on CTPA in 51.6% cases. Major vessels include the main pulmonary trunk, the right and left main pulmonary branches, and the lobar branches. Minor vessel embolism was seen on CTPA in 48.3% cases (minor vessels include the segmental vessels and their branches). Presence of antinuclear antibodies was observed in only 3.2% cases, and antiphospholipid syndrome profile was positive in 6.4% cases. DVT was seen in 35.4% cases. No evidence of DVT was seen in 64.5% cases. Bilateral lower limb DVT was seen in 6.4% cases. Thus, DVT was seen in more than one-third of cases. Serum homocysteine was within normal limits in 70.9% cases. It was elevated in 25.8% cases. | Table 1: Distribution of patients according to findings of respiratory system
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Treatment and outcome
Thrombolysis was done in 12.9% cases, while anticoagulants were given in 87.1% cases. Thus, most cases were eligible for anticoagulation but not thrombolysis. Amongst the study participants, oxygen therapy was required in 74.19% cases on day 1 and in 9.6% on day 30. Thus, most patients were hypoxic at the time of presentation [Table 4]. Among the complications, secondary pulmonary hypertension was the commonest in our study, seen in 54.8% cases. Severe hypoxia was seen in 35.4% of cases. No complications were seen in 6.4% cases [Table 5]. Fatalities were reported in 9.7% (n = 3) cases.
| Discussion | | |
The current study revealed many significant findings. The mean age of patients was 50.94 years. This is similar to the studies of Planquette et al.,[16] Manuel et al.,[20] Praveen Kumar et al.,[15] and Planquette et al.[16] retrospective nested case–control study estimating the prevalence of symptomatic PE found the median age of the population was 63 years (53–79), and 59.8% were male. Manuel et al.[20] retrospective observational study assessing the clinical profile, management, and outcomes of patients with PE found 50 patients with the median age was 50.5 ± 17.8 years. The age groups 35–44 years and 55–64 years were the most affected; 72% of patients were over the age of 40 years, and 52% were male. The study by Praveen Kumar et al.[15] found the mean age of the patients was 47.1 (±12.4) years and ranged from 25 years to 75 years. Among the patients, 20 were males and 15 were females, and the mean duration of presentation after the onset of symptoms was 5.7 days (± SD 3.7 days).
In the present study, mean pulse rate per minute on day 1 was 99.81, and mean respiratory rate per minute on day 1 was 26. Mean temperature on day 1 was 37.39°C. Past history of prothrombotic state DVT, PE, cerebral venous thrombosis was present in 32.3% cases, while past history of risk factors (fracture, immobility, bedridden state, lower limb swelling) was present in 45.2% cases. Two cases had COVID-19 infection and one patient had a history of the same from which he had recovered; diabetes was present in five cases, while hypertension was present in four cases. Post-TB sequelae were seen in two cases. Active TB was seen in one patient. Nine cases had no comorbidities. This is comparable to the study of Manuel et al.,[20] wherein prevalent comorbidities included immobilization for more than 72 hours (48%), hospitalization or recent surgery (28%), and hypertension (36%). In three patients (6%), there were no identified risk factors or comorbidities. Volschan et al.[21] reported that absence of the effect of muscle pump which maintains venous return is the main promotional mechanism of blood stasis in immobilized patients. It was also observed in the present study that five cases (16.1%) were smokers, while seven cases (22.5%) were alcoholics.
In the present study, two cases were given analgesics, six cases with antibiotics, five cases were on antidiabetic medication, while one case was on home isolation for COVID-19 infection. Breathlessness was the commonest symptom amongst the patients, seen in 90.3% cases. Chest pain was present on admission in 45.1% cases. Leg swelling was seen in 32.2% cases. Manuel et al.,[20] Planquette et al.,[17] and Praveen Kumar et al.[15] noted similar observations in their studies. Manuel et al.[20] retrospective observational study observed respiratory symptoms, including dyspnea (68%), chest pain (40%), and cough (18%), to be the most frequent. Only 4% patients were asymptomatic, and one patient presented with cardiorespiratory arrest. In the present study, all the patients were tachypnoeic. 70.9% patients had tachycardia at the time of the presentation. Thus, tachypnea was the commonest clinical sign in this study. 29% patients were in shock at the time of presentation. Praveen Kumar et al.[15] reported tachypnea and tachycardia as the most common clinical signs. Hypotension and tachycardia as signs of cardiogenic shock were present in one-fourth of the patients and both signs correlated well with the severity of pulmonary vascular obstruction. In the present study, presence of leg swelling was reduced to 9.6% cases, while that of breathlessness was reduced to 32.2%. No symptoms were seen in 38.7% cases on day 30. General condition was moderate in 80.6% cases while poor in 19.4% cases. On day 30, fair condition was seen in 54.8% cases. Mean systolic blood pressure reduced to 110.5 mm of Hg while diastolic increased to 81.2 mm of Hg on day 30. Mean JVP was 2.6 cm on day 1, which reduced to 1.58 cm on day 30. On day 1, the use of accessory muscles was present in 22 cases, while it was reduced to 3 on day 30. Mortality was seen in 3 (9.6%) cases on day 30. This finding was similar to the study of Volschan et al.,[21] which showed in-hospital mortality of 19.5%. It was observed in the present study that on day 1, air entry was decreased in eight (25.8%) cases, which was seen in five (16.1%) cases on day 30. On day 1, heart sound S1 was normal and S2 was loud in eight cases, while on day 30, the same was seen in seven cases. S1 and S2 were normal in all the other patients on day 1 and day 30. Per abdomen, findings were almost the same on day 1 and day 30. This is in concordance with the studies of Planquette et al.[16] and Manuel et al.[20] Manuel et al.[20] also found that 67% of the complicating events occurred in the PCTA subgroup of massive PE; 30% of patients had a very high risk of 30-day mortality, according to the admission, and a third of the deaths occurred within the first 24 hours of hospitalization, It was observed in the present study that mean hemoglobin was 10.8 g/dl on day 1 which increased to 11.32 g/dl on day 30. Planquette et al.[16] found no difference among PE patients and the two control groups regarding hemoglobin level, platelet count, lymphocyte count, creatinine, ASAT, and ALAT levels. In the present study, mean blood urea nitrogen was 17.9 mg/dl on day 1, which was 12.1 mg/dl on day 30. Mean creatinine was 2.1 mg/dl on day 1, which was 1.6 mg/dl on day 30. Similar observations were noted in the studies of Trimaille et al.[17] and Planquette et al.[16] The study by Planquette et al.[16] showed that the risk of PE was significantly associated with CRP elevation compared to CT controls. In the present study, mean serum glutamic-oxaloacetic transaminase/serum glutamic pyruvic transaminase was 31.43/17.4 U/l on day 1, which was 27.6/26.1 U/l on day 30. Mean glycated haemoglobin was 5.43 g/dl. Despite the progress in diabetes treatments, diabetes is still associated with an unfavorable clinical patient profile and a higher risk for adverse events, including substantially increased in-hospital mortality in acute PE. Lipid profile was abnormal in 29% cases, while routine urine was abnormal in 22.6% cases in our study. A study by Aysegul Karalezli et al.[22] found that a low HDL-C level with hyperhomocysteinemia increases susceptibility to PE. It was observed in the present study that sinus tachycardia was seen in 70.9% cases, while arrhythmia was seen in 3.2% cases. The classical S1Q3T3 pattern was seen in only 9.6% cases. This is similar to the studies of Praveen Kumar et al.[15] and Manuel et al.[20] Praveen Kumar et al.[15] found the majority of patients with PE, 34 of 35 (97.1%), were in sinus rhythm, while atrial fibrillation occurred in one of 35 (2.8%). S1Q3T3 pattern was present in 18 patients (51.4%). Nonspecific abnormalities of the ST segment or T-wave were the most common ECG abnormalities, and one or both occurred in 15 of 35 (42.8%) patients with PE. P pulmonale, right ventricular hypertrophy, right axis deviation, and right bundle branch block occurred in 6% of patients. Manuel et al.[20] showed that electrocardiogram was normal in only 22% of patients, and the classic S1Q3T3 pattern was found in only 18%. It was observed in our study that infiltrates were seen in 51.6% cases, while cardiomegaly was in 12.9% cases. Normal chest X-ray was seen in 29% cases. Manuel et al.[20] in their retrospective observational study of 50 patients found that 26% patients had normal chest radiography. In our study, dilated right atrium and RV were seen in 48.3% cases, while left ventricular failure was seen in 6.4% cases. This finding was like the study of Praveen Kumar et al.[15] Normal ECHO was seen in 45.1% cases. Praveen Kumar et al.[15] study observed ECHO showed dilated right atrium in 25 patients (71.4%) and both right atrial and right ventricular dilatation (RV/LV > 1) in 20 patients (57.4%). Pulmonary artery hypertension of moderate-to-severe degree was evident in 20 patients (57.4%). Right ventricular dysfunction was observed in 11 patients (31.4%). Presence of thrombus in pulmonary artery, right atrium, and right ventricle was evident in six (17.1%), three (8.6%), and two patients (5.7%), respectively. Preexisting cardiac abnormalities were seen in a few patients. Severe left ventricular dysfunction was present in one patient. One patient had preexisting rheumatic heart disease in the form of moderate mitral stenosis. The ECHO was normal in two patients (5.7%). Rozkovec et al.[23] showed that patients with right ventricular dysfunction had at least a two-fold higher risk of dying in the short term, as compared with patients without right ventricular dysfunction. A study by Grifoni et al.[24] assessing the long-term clinical outcomes of patients with PE found TTE (transthoracic echocardiogram) to have a 100% negative predictive value for predicting PE-related death on the basis of RV dysfunction, but the positive predictive value was only 5%. In the present study, CTPA showed a major vessel embolism in 51.6% cases. This is comparable to the studies of Planquette et al.,[16] Rozkovec et al.,[23] Grifoni et al.,[24] and Praveen Kumar et al.[15] The high clinical suspicion associated with the immediate availability of pulmonary CT angiography and other diagnostic tests allow us to confirm PE cases and exclude other differential diagnoses with greater consistency to the results. Planquette et al.[16] retrospective nested case–control study observed locations of the emboli were proximal (pulmonary trunk or lobar artery) in 27 (45.7%) patients, segmental in 24 (40.6%) patients and subsegmental in eight (13.6%) patients. Praveen Kumar et al.[15] study reported CT pulmonary angiography showed thrombus in main or branch PA in 21 (60.0%) patients. Among these 14 (40.0%) had massive burden of thrombus. Remaining 14 (40.0%) patients had thrombus in segmental branches. In the present study, minor vessel embolism was seen in 48.4% cases. Planquette et al.,[16] Trimaille et al.,[17] and Manuel et al.[20] noted similar observations in their studies. Trimaille et al.[17] retrospective study evaluating the determinants and prognosis of acute PEs found a proportion of subsegmental (10.2% vs. 11.1%) and segmental PEs (35.6% vs. 24.7%) among PEs in COVID-19 affected and non-affected patients. Thrombus was present in all the 27 cases, localized in areas with COVID-19-related lung injuries. Presence of antinuclear antibodies and antiphospholipid antibodies was observed in 3.2% cases and 6.4% cases respectively. However, these tests could not be performed in 32.2% patients. In a study by Ginsberg et al.[25] there was found to be a strong association between LA and VTE. There was no association between the presence of ACLA (Anti-CardioLipin Antibodies) and VTE because of the high frequency of positive ACLA assays in patients without VTE. It was observed in our study that evidence of DVT was seen in 34.5% cases. Bilateral lower limb DVT was seen in 6.45% cases. No evidence of DVT was seen in 64.5% cases. Manuel et al.[20] retrospective observational study reported the presence of deep-vein thrombosis by doppler ultrasound in 20% patients. Serum homocysteine was elevated in 25.8% cases in our study. Mean homocysteine levels were significantly higher in PE group than in the control group in a study conducted by Aysegul Karalezli et al.[23] Thrombolysis was done in 12.9% cases, while anticoagulants were given in 87.1% cases. This is concordant with the studies of Manuel et al.,[20] Planquette et al.,[16] Trimaille et al.,[18] Praveen Kumar et al.,[15] Volschan et al.,[21] and Becattini et al.[26] Thrombolysis allows early pulmonary reperfusion, and despite increasing the risk of major bleeding, is indicated in unstable patients. Manuel et al.[20] retrospective observational study showed heparins were the most common form of in-hospital anticoagulation. Unfractionated heparin was used in 32% of patients for 5.4 ± 2.1 days. Low-molecular-weight heparins were used in 44% of patients for 6.2 ± 3.7 days. Among these patients, 70% used oral anticoagulation with warfarin, and 6% used new oral anticoagulants. Thrombolytic therapy was used in 18% of the patients. In 12 patients, it was not possible to determine the type of anticoagulant used or whether they used thrombolytic therapy. Planquette et al.[16] retrospective nested case–control study observed at PE diagnosis, 32 (54.2%) patients had received anticoagulant at prophylactic dose (at least one dose) and four (6.9%) patients at therapeutic dose. Among these 59 PE patients, 25 (42.4%) were treated by intermittent mandatory ventilation in ICU, corresponding to a PE prevalence in ICU of 8.0%. Therapeutic anticoagulation and hydroxychloroquine treatment were not associated with a decreased risk of PE. Trimaille et al.[17] retrospective study reported that more patients with COVID-19 infection were under standard or intermediate dose of thromboprophylaxis before acute PE in comparison with patients not affected with COVID-19 infection. In the study by Praveen Kumar et al.[15] a total of nine patients (25.7%) were thrombolyzed. Among these four patients (11.4%) required mechanical ventilation. Two patients recovered with mechanical ventilator support, and the other two patients couldn’t. Volschan et al.[21] reported that 20% of the patients were hypotensive, but thrombolytic therapy was used in only 15% of them. In the present study, oxygen therapy was required in 74.2% cases on day 1 and 9.7% on day 30. Similar observations were noted in the studies of Planquette et al.[16] and Trimaille et al.[17] Planquette et al.[16] also observed PE patients more often required invasive ventilation compared to CTPA controls and CT controls. PE patients exhibited more extensive parenchymal lesions (>50%) than CT controls. D-dimer levels were 5.1 times higher in PE patients than CTPA controls. 312 (24.7%) required ICU. Trimaille et al.[17] retrospective study observed transfer to the ICU occurred more frequently in PE patients with COVID-19 (45.8% vs. 6.2%), as did mechanical ventilation (40.7% vs. 6.2%). There was a trend for a higher in-hospital death rate. Amongst the complications, secondary pulmonary hypertension was the commonest in our study, seen in 54.8% cases. Severe hypoxia was seen in 35.4% cases. No complications were seen in 6.4% cases. 9.6% cases succumbed. Praveen Kumar et al.[15] reported total mortality, including in-hospital and 1-month follow-up to be 11.4% (4 patients). Among these, three patients who had PE index >60% and right ventricular dysfunction died in hospital during the initial admission. Two patients who died during the initial admission had pre-existing congestive heart failure due to cardiomyopathy, and the third patient had lung malignancy. One patient who had ovarian malignancy died after one month due to a bleeding complication. Manuel et al.[20] in their retrospective observational study of 50 patients reported complications in 38% of the patients; 30% had respiratory failure requiring mechanical ventilation, and 14% were in cardiogenic shock. The 24-hour and in-hospital mortality rates were 2.5% and 20%, respectively. Planquette et al.[16] reported that BMI, history of venous or arterial thrombosis, were not associated with the occurrence of PE, and active smoking was uncommon in COVID-19 affected population and was not associated with the occurrence of PE. Therapeutic anticoagulation and hydroxychloroquine treatment were not associated with a decreased risk of PE. Intermittent mandatory ventilation was associated with an increased risk of PE.
| Conclusion | | |
PE is a disease with high morbidity and mortality. Hence, there should be a high degree of suspicion in the appropriate clinical setting.
Recommendation
As prolonged immobilization is a strong risk factor for pulmonary embolism, patients at risk should be offered prophylactic anticoagulation.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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