Baseline characteristics:
A total of 109 patients with a primary diagnosis of pulmonary embolism were included in the study. The mean age of the patients was 59 ± 19 years, and 51.4% (N = 56) were male. Upon admission, the mean arterial blood pressure was 110/70 mmHg, and the mean heart rate was 100 beats per minute. The most common clinical symptom observed was shortness of breath, affecting 86% of patients (N = 94), followed by chest pain in 53% of patients (N = 58).
Regarding the diagnostic methods, pulmonary CT angiography was used to diagnose 73.4% of patients (N = 80), while clinical evaluation and ventilation-perfusion scans were used in 23.9% (N = 26) and 2.8% (N = 3) of patients, respectively. Sub-massive pulmonary embolism was found to be the most common type, accounting for 51.4% of cases (N = 56). Among the patients, 61.5% had a provoked embolism (N = 67), while 38.5% had an unprovoked pulmonary thromboembolism (N = 42). Abnormal electrocardiogram (ECG) readings were observed in 85.3% of patients (N = 93), with the S1Q3T3 pattern observed in only 16% of patients (N = 18). Sinus tachycardia was found in 44% of patients (N = 48), and the most common ECG finding was the presence of the pathologic Q wave in lead III, observed in 55% of patients (N = 60). Pathologic Q waves were defined as Q waves with a width greater than 1 mm or depth greater than 2 mm or exceeding 25% of the depth of the QRS complex.
Laboratory results showed a mean D-dimer level of 6648 ± 2476 ng/mL in 90 patients and a mean troponin level of 8431 ± 1512 ng/L in 74 patients. The majority of patients (82.6%) had a normal ejection fraction on echocardiography (N = 89). The mean systolic pulmonary artery pressure was 41 mmHg, with a maximum value of 95 mmHg. Out of the total patients, 18.3% received r-PA therapy (N = 20), and 82.6% did not experience any specific complications during hospitalization (N = 90). Hematoma was the most common complication observed, affecting 4.6% of patients (Table 1).
Table 1
Characteristics and Clinical profile of Patients with Pulmonary Embolism
Variables | Number or Mean ± SD N = 109 |
Age (yr) | 59.2 ± 19.7 |
Sex -Male -Female | 56 (51.4%) 53 (48.6%) |
Risk factors -Malignancy -pregnancy -CHF - CKD - Prior VTE -recent surgery - OCP consumption - Bed rest - lower Limb Immobility - Recent infection | 5 (10.2%) 2 (4.1%) 4 (8.2%) 2 (4.1%) 8 (16.3%) 10 (20.4%) 4 (8.2%) 10 (2.4%) 15 (30.6%) 1 (2%) |
PE severity - Small - Sub-massive - Massive | 13 (12%) 56 (51%) 40 (37%) |
Treatment strategy - Anticoagulant therapy - Thrombolytic therapy | 80 (73%) 29 (27%) |
Symptoms/presentation - Cardiac arrest (Out of hospital) - Dyspnea - Chest pain - Syncope - Lightheadedness - Palpitation - Hemoptysis | 3 (2.7%) 94 (86.2%) 58 (53.2%) 25 (23%) 12 (11%) 10 (9%) 5 (4.5%) |
Diagnosis -Pulmonary CTA -Clinical -Perfusion scan | 80 (73%) 26 (23.9%) 3 (2.8%) |
ECG changes - Sinus tachycardia - Q in lead III - S in lead I - Inverted T wave in lead III - Inverted T wave in precordial leads - RBBB - S in lead V5, V6 | 48 (44%) 60 (55%) 32 (29%) 56 (51%) 37 (34%) 21 (17%) 14 (13%) |
PE category - Provoked - Unprovoked | 67 (61%) 42 (39%) |
Lab tests - Troponin - D dimer | 8431 ± 1512 6649 ± 2477 |
Echo findings - LVEF >= 50% < 50% - PASP <40 40–60 >60 | 90 (82.6%) 19 (17.4%) 28 (42%) 27 (18%) 12 (18%) |
Abbreviations: |
CHF (congestive heart failure), CKD (chronic kidney disease), |
VTE (venous thromboembolism), PE (pulmonary embolism), |
CTA (computed tomography angiogram), ECG (electrocardiogram), |
RBBB (right bundle branch block), OCP (oral contraceptive pill), |
LVEF (left ventricular ejection fraction), and PASP (pulmonary arterial systolic pressure). |
SD stands for standard deviation. |
Mortality:
Among the 109 hospitalized patients diagnosed with pulmonary embolism, 11 died despite diagnosis and treatment, resulting in a hospital mortality rate of 10%.
In this study, we examined the factors associated with in-hospital and mid-term mortality in patients with pulmonary embolism. The following variables were analyzed: age, sex, presence of provoked pulmonary embolism, severity of pulmonary embolism, thrombolytic therapy, left ventricular ejection fraction (LVEF), and systolic pulmonary artery pressure (Table 2).
Table 2
Risk Factors of in-hospital and Follow-up Mortality in Patients with pulmonary embolism.
Variable | In hospital death = 11 N(%) | P | Mid term death = 18 N(%) | P |
Age > 65 yr Yes No | 6(55) 5(45) | 0.492 | 14(78) 4(22) | 0.002 |
Sex Male Female | 2(18) 9(82) | 0.029 | 8(44) 10(56) | 0.28 |
Provoked Yes No | 11(100) 0(0) | 0.006 | 13(72) 5(28) | 0.21 |
Massive PE Yes No | 9(82) 2(18) | 0.014 | 6(33) 13(67) | 0.86 |
Thrombolytic therapy Yes No | 8(73) 3(27) | 0.001 | 12(67) 6(33) | 0.65 |
LVEF > = 50% Yes No | 3(27) 8(73) | 0.001 | 14(82) 3(18) | 0.37 |
PASP < 40 Yes No | 3(29) 8(71) | 0.77 | 12(67%) 6(33%) | 0.33 |
Abbreviations: |
PE (pulmonary embolism), LVEF (left ventricular ejection fraction), |
PASP (pulmonary arterial systolic pressure). "N" refers to the number of patients in each group, |
while "%" represents the percentage of patients in each group. |
"P" stands for p-value. The table also uses the following abbreviations: "yr" for the year, and |
"Yes" and "No" indicate the presence or absence of a particular characteristic or risk factor. |
In-hospital mortality:
Of the patients who died in the hospital, the majority were aged 65 or older (55%). However, the difference in mortality based on age was not statistically significant (p = 0.492). In terms of sex, a higher percentage of female patients died in the hospital (82%) compared to male patients (18%), and this difference in mortality based on sex was marginally significant (p = 0.029).
All patients who died in the hospital had a provoked pulmonary embolism, indicating the presence of a known trigger or risk factor for their condition. The presence of provoked pulmonary embolism was significantly associated with in-hospital mortality (p = 0.006). Among the patients who died in the hospital, the majority had a massive pulmonary embolism (82%) compared to a non-massive pulmonary embolism (18%). The difference in mortality based on the severity of pulmonary embolism was statistically significant (p = 0.014).
Furthermore, a large proportion of patients who died in the hospital did not receive thrombolytic therapy (73%), while a smaller percentage did receive thrombolytic therapy (27%). The absence of thrombolytic therapy was significantly associated with in-hospital mortality (p = 0.001). Additionally, among the patients who died in the hospital, a higher percentage had an LVEF below 50% (73%) compared to an LVEF of 50% or higher (27%). The presence of an LVEF of 50% or higher was significantly associated with lower in-hospital mortality (p = 0.001). However, the difference in mortality based on systolic pulmonary artery pressure (PASP) was not statistically significant (p = 0.77).
Midterm mortality:
Follow-up was conducted on the patients, with a mean time of 27 months between hospitalization and follow-up and a minimum interval of 8 months. During this period, 18 patients died, resulting in an overall mortality rate of 22.8%, with seven of them dying within the first year after pulmonary embolism. Among the patients who died during the follow-up period, a higher proportion were aged 65 or older (78%) compared to those younger than 65 (22%), and this difference in mortality based on age was statistically significant (p = 0.002). However, there was no statistically significant difference in mortality based on sex (p = 0.28).
In terms of the presence of provoked pulmonary embolism, a large percentage of patients who died during the follow-up period had a provoked pulmonary embolism (72%), while a smaller percentage had an unprovoked pulmonary embolism (28%). However, the difference in mortality based on the presence of provoked pulmonary embolism was not statistically significant (p = 0.21). Similarly, the severity of pulmonary embolism, as indicated by the presence of a massive or non-massive pulmonary embolism, did not show a statistically significant difference in mortality (p = 0.86).
Thrombolytic therapy did not demonstrate a statistically significant difference in mortality during the follow-up period (p = 0.65). Additionally, there was no statistically significant difference in mortality based on LVEF (p = 0.37) or PASP (p = 0.33) among the patients who died during the follow-up period.
Bleeding:
During hospitalization, 10 out of 109 patients (9.1%) experienced bleeding as a complication. In the follow-up period, only 1 out of 79 patients (1.3%) had bleeding. Therefore, a total of 11 patients (10.4%) experienced bleeding as a complication throughout the entire study( Table 3). The bleeding complications included gastrointestinal bleeding, hematoma at the IV-line site, vaginal bleeding, and intracerebral hemorrhage, but none of them were fatal.
Table 3
Complications during hospitalization and follow-up for patients with Pulmonary embolism.
Complication | In hospital(n = 109) N(%) | follow up(n = 79) N(%) | Total |
Bleeding | 10 (9.1) | 1(1.3) | 11(10.4) |
Recurrence of PE | - | 0 | 0 |
CTEPH | - | 2(2.5) | 2 |
Death | 11(10) | 18(22.8) | 29(33.8) |
CTEPH: chronic thromboembolic pulmonary hypertension |
Other findings:
During the follow-up period, 52 patients were discharged with warfarin (47.7%), 41 patients with NOAC (37.8%), and 2 patients with enoxaparin (1.8%). The mean duration of anticoagulant therapy was 8.7 months, with a minimum duration of 2 months. During the follow-up, echocardiography was performed on 34 patients, revealing a mean ejection fraction of 56 ± 52% and an enlarged right ventricle in 55.8% of patients. Additionally, 49% of cases had impaired right ventricular function. The mean systolic pulmonary artery pressure was 29.8 ± 22 mmHg, with a maximum systolic pulmonary artery pressure of 38 mmHg. Two patients were diagnosed with chronic thromboembolic pulmonary hypertension(CTEF). Four patients with heart failure were discharged from the hospital.