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ORIGINAL ARTICLE
Year : 2017  |  Volume : 6  |  Issue : 1  |  Page : 15-18

Clinical profile of patients presenting with acute pulmonary thromboembolism in a tertiary care hospital in India: A retrospective study


Department of Pulmonary Medicine, KLE University's Jawaharlal Nehru Medical College, Belgaum, Karnataka, India

Date of Web Publication20-Mar-2017

Correspondence Address:
Bhagyashri B Patil
Department of Pulmonary Medicine, KLE University's Jawaharlal Nehru Medical College, Belgaum, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JDRNTRUHS.JDRNTRUHS_9_17

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  Abstract 

Objective: To study the clinical profile in patients with acute pulmonary embolism.
Methods: Retrospective study of clinical profile and management of patients presenting with acute pulmonary embolism from January 2015 to January 2016.
Results: 53 patients who were newly diagnosed to have acute pulmonary thromboembolism with a mean age of 47.2 years with 91% being males were included in the study. It was found that majority of the patients had atleast 1 risk factor for embolisation(58.5%) with smoking being the most important risk factor. Dyspnea (71.7%) and syncope (17.0%) were the predominant symptoms. 39.6% patients had tachycardia and 22.6% had hypotension. Echocardiography was done in all patients. 45 patients (84.9%) had pulmonary arterial hypertension, 31 patients (58.4%) had evidence of RA/RV dysfunction and 3 patients (5.7%) had evidence of thrombus in heart. CT pulmonary angiogram was done in all patients. 32(60.3%) patients underwent anticoagulataion with unfractionated heparin, 10(18.7%) patients were thrombolysed and 6(11.3%) patients underwent embolectomy. 5 patients underwent both thrombolysis and anticoagulation. However independent of the mode of treatment, most patients had good treatment outcomes with the mortality rate being only 7.5%.
Conclusion: Pulmonary embolism can have multiple presentations in terms of clinical symptoms, signs and investigations. Early diagnosis and aggressive management is the key to successful outcome.

Keywords: Anticoagulation, CTPA, ECHO, pulmonary embolism, thrombolysis


How to cite this article:
Lolly M, Patil BB, Eti A, Sujay J, Khan S, Bansal A. Clinical profile of patients presenting with acute pulmonary thromboembolism in a tertiary care hospital in India: A retrospective study. J NTR Univ Health Sci 2017;6:15-8

How to cite this URL:
Lolly M, Patil BB, Eti A, Sujay J, Khan S, Bansal A. Clinical profile of patients presenting with acute pulmonary thromboembolism in a tertiary care hospital in India: A retrospective study. J NTR Univ Health Sci [serial online] 2017 [cited 2017 Aug 21];6:15-8. Available from: http://www.jdrntruhs.org/text.asp?2017/6/1/15/202586




  Introduction Top


Acute pulmonary thromboembolism (PE) is a condition which is unrecognized and under diagnosed clinically despite its high mortality. It has an average annual incidence of about one case per 1000 population in the western world, and is responsible for approximately 5–10% of all in-hospital deaths.[1],[2] This is mainly due to the fact that the clinical symptoms, signs, and investigations requiring the support of its diagnosis are relatively nonspecific. However, despite various advances in the diagnosis and treatment of this condition, there are various discrepancies in its rates and clinical outcomes worldwide.

The PIOPED I and II (Prospective Investigation of Pulmonary Embolism Diagnosis) were landmark trials that studied the clinical characteristics of patients with mild-to-massive pulmonary embolism.[3] They gave various clinical syndromes of pulmonary embolism, thereby allowing an astute clinician to recognize and appropriately investigate for the diagnosis of acute PE which holds well till today.

Most of the available data of acute PE are of western origin with very few studies from the Asian countries, especially India. Hence, the current retrospective study was undertaken to know the clinical profile in this group of hospitalized patients in a tertiary care hospital in India.


  Materials and Methods Top


Data source and collection

This retrospective study included all patients who were admitted and diagnosed with acute PE during January 2015 to January 2016 at a tertiary hospital in India. Initially, hospital admission records of all patients admitted during the above specified period were assessed via the hospital database to find patients who had a primary diagnosis of acute PE. The patient registration numbers were used to obtain the corresponding files from the medical records department. Only patients with a confirmed diagnosis of acute PE based on a computed tomography (CT) pulmonary angiogram were included in the study. There were no exclusion criteria.

Data collected from the patient files included age, sex, assessment for risk factors, symptoms, signs, chest roentogram and transthorasic echocardiographic (ECHO) findings, treatment obtained, and outcome. All the findings recorded were present within the first 24–48 h of admission. Chest X-ray findings are based on the reports given by the radiologist. Similarly, echocardiographic findings are those based on the reports given by the cardiologist.


  Results Top


A total of 53 patients were admitted during the study period with a clinical diagnosis of acute PE as confirmed by CT pulmonary angiography. The mean age of the cohort was 47.2 ± 13 years with 91% being males [Table 1]. It was found that majority of the patients had at least 1 risk factor for embolization (58.5%) with smoking being the most important risk factor [Table 2].
TABLE 1: BASELINE CHARACTERISTICS

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TABLE 2: RISK FACTORS

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Dyspnea was the predominant symptom (71.7%) followed by syncope (17.0%), cough (15.1%), chest pain (7.6%), and hemoptysis (3.8%). A total of 39.6% patients presented with tachycardia and 22.6% with hypotension, making them valuable signs in the assessment of patients with PE. Lower limb swelling was also a predominant sign in approximately 22.7% of the patients [Table 3]; [Figure 1]. Moreover, lower limb deep vein thrombosis (DVT) was confirmed in 32 (60.3%) of the patients.
TABLE 3: SYMPTOMS AND SIGNS

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Figure 1: Symptoms in patients with acute PE

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All except 10 patients had a normal chest roentogenogram at the time of diagnosis, with consolidation being the most common abnormal X-ray finding. ECHO was used as a screening tool in all patients. A total of 84.9% of the patients had an abnormal ECHO with pulmonary arterial hypertension being the most important finding [Table 4].
TABLE 4: CHEST X-RAY AND ECHO RESULTS

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In relation to treatment, 32 (60.3%) patients underwent anticoagulation with unfractionated heparin, 10 (18.7%) patients were thrombolyzed, and 6 (11.3%) patients underwent embolectomy. Five patients underwent both thrombolysis and anticoagulation. However, independent of the mode of treatment, most patients had good treatment outcomes with the mortality rate being only 7.5%.


  Discussion Top


This retrospective study gives an insight on the clinical profile of a cohort of 53 hospitalized patients in India with a confirmed diagnosis of acute PE based on CT pulmonary angiography.

The mean age of our cohort was 47.2 ± 13 years with 91% being males. This is in contrast to a majority of the studies which claim a higher incidence of acute PE among those aged above 60 years. In a study done by Goldhaber et al.,[4] the authors found that majority of patients with PE were in the age group of 70–79 years. In another study done by Miniati et al.,[5] the authors found significantly higher incidence of acute PE cases in patients with age >65 years (P < 0.001). However, in a similar study done in India, mean age was similar to the cohort in our study (39 ± 12.1 years).[6]

Second, it was found that more than half of the patients (58.5%) had at least one risk factor for PE indicating the importance to look for a risk factor in each and every patient with acute PE. It was found that each and every study had a different risk factor for acute PE.[3],[7],[8] In our study smoking was the major risk factor for acute PE and was found in 22 (41.5%) of the patients. In the landmark study of PIOPED,[3] it was found that in the absence of cardiopulmonary disease, smoking was one of the major risk factor found in approximately 43% of the patients, which is similar to our study findings. In a study done by Klok et al.,[9] 61% of the study cohort patients confirmed a smoking history (active or former) at the time of diagnosis of PE. In another meta-analysis done by Cheng et al.,[10] it was found that ever smokers had 17% more likely risk of developing PE. This could be due to the fact that smoking increases the risk of DVT, which is also confirmed in our study, where approximately 60.3% of the patients were diagnosed with a lower limb DVT as the primary cause of PE.

Similar to other studies,[3],[5],[6] dyspnea was a predominant symptom (71.7%) in the study cohort. Moreover, it was found that dyspnea was the sole symptom in 54.7% of the patients. This confirms an important fact that the finding of solitary dyspnea in a patient provides a strong suspicion for PE.

A total of 81.1% of the patients had a normal chest X-ray in the current study. It could suggest that a patient with a predominant respiratory symptoms but a normal chest X-ray could provide a differential of acute PE. There are numerous chest X-ray findings that could indicate a pulmonary embolism, however, these findings are neither sensitive nor specific. Hence, the primary aim to do an X-ray in a PE suspect would be to rule out other causes that could lead to particular symptoms in a patient. Therefore, the presence of a normal X-ray does not rule out the presence of acute PE but in fact makes the diagnosis more likely. In other studies,[6],[11],[12] it has been found that the incidence of a normal X-ray in patients with a confirmed PE ranges from 24% to up to 80%. Other common findings in these patients included consolidation and pleural effusion.

Transthorasic echocardiography was done in all the patients in our study mostly prior to a CT angiography. An abnormal ECHO was found in 84.9% of the patients. This implies its use as an important screening tool in a suspect of acute PE, especially if there is no prior cardiopulmonary disease. The abnormality was mainly in the form of a raised pulmonary artery pressure. Similar findings were found in a study done by Agarwal et al.,[6] where 83% of the patients with a confirmed diagnosis of acute PE had an abnormal ECHO.

Lastly it was found that, despite the mode of treatment given, the clinical outcome was good with only 3 in hospital deaths among the 53 patients. This could be due to the prompt diagnosis and treatment given to this group of patients or due to the younger age of the cohort.

The main strength of this study is that only confirmed cases based on pulmonary angiography were taken as the study group. The limitations include its retrospective study design and that it is a single centre study.


  Conclusion Top


In conclusion, PE can have multiple presentations in terms of clinical symptoms, signs, and investigations. The key to diagnosis of acute PE is the ability to clinically suspect the condition followed by appropriate investigations. We found that dyspnea is “the most important” symptom and presence of isolated dyspnea in a patient with no prior cardiopulmonary disease strongly points to its diagnosis. These patients have at least one risk factor that predisposes to PE. Smoking is found to be an important risk factor in our study. Transthorasic echocardiography can be used as an important tool to aid in the diagnosis of the PE. Moreover, prompt diagnosis and treatment may lead to improved clinical outcomes. However, all these findings need further prospective studies to prove the same.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wells PS, Rodger M. Diagnosis of Pulmonary Embolism: When is imaging needed?. Clin Chest Med 2003;24:13-28.  Back to cited text no. 1
    
2.
Kearon C. Natural history of venous thrombolism. Circulation 2003;107:22-30.  Back to cited text no. 2
    
3.
Stein PD, Beemath A, Matta F, Weg JG, Yusen RD, Hales CA, et al. Clinical Characteristics of Patients with Acute Pulmonary Embolism: Data from PIOPED II. Am J Med 2007;120:871-9.  Back to cited text no. 3
    
4.
Acute pulmonary embolism: Clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER) Samuel Z Goldhaber, Luigi Visani, Marisa De Rosa, for ICOPER*.  Back to cited text no. 4
    
5.
Miniati M, Cenci C, Monti S, Poli D. Clinical Presentation of Acute Pulmonary Embolism: Survey of 800 Cases. PLoS One 2012;7:e30891.  Back to cited text no. 5
    
6.
Agarwal R, Gulati1 M, Mittal BR, Jindal SK. Clinical Profile, Diagnosis and Management of Patients Presenting with Symptomatic Pulmonary Embolism. Ind J Chest Dis Allied Sci 2006;48:110-4.  Back to cited text no. 6
    
7.
Pinjala R. Venous thromboembolism risk & prophylaxis in the acute hospital care setting (ENDORSE), a multinational cross-sectional study: Results from the Indian subset data. Indian J Med Res 2012; 36:60-7.  Back to cited text no. 7
    
8.
Lee AD, Stephen E, Agarwal S, Premkumar P. Venous Thrombo-embolism in India. Eur J Vasc Endovasc Surg 2009;37:482-85.  Back to cited text no. 8
    
9.
Klok FA, Mos ICM, Tamsma JT, van Kralingen KW, Huisman MV. Smoking patterns in patients following a pulmonary embolism. Eur Resp J 2009;33:942-3.  Back to cited text no. 9
    
10.
Cheng YJ, Liu ZH, Yao FJ, Zeng WT, Zheng DD, Dong YG, et al. Current and Former Smoking and Risk for Venous Thromboembolism: A Systematic Review and Meta-Analysis. PloS Med 2013;10:1-14.  Back to cited text no. 10
    
11.
Elliott CG, Goldhaber SZ, Visani L, DeRosa M. Chest radiographs in acute pulmonary embolism. Results from the International Cooperative Pulmonary Embolism Registry. Chest 2000;118:33-8.  Back to cited text no. 11
    
12.
Stein PD, Willis PW de Mets DL. Chest Roentgenogram in Patients with Acute Pulmonary Embolism and no Pre-existing Cardiac or Pulmonary Disease. Am J Noninvasive Cardiol 1987;1:171-6.  Back to cited text no. 12
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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