Citation Information :
Mathiyalagan P, Rajangam T, Bhargavi K, Gnanaraj R, Sundaram S. Clinical Profile, Immediate- and Short-term Outcome of Patients with Intermediate-risk Acute Pulmonary Thromboembolism. Indian J Crit Care Med 2022; 26 (11):1192-1197.
Background: Long-term outcomes of acute pulmonary thromboembolism (PTE) have been reported. However, the immediate- and short-term outcomes have not been reported adequately.
Objectives: Primary objective was to determine the patient characteristics, and immediate- and short-term outcomes of intermediate-risk PTE, and the secondary objective was to evaluate the benefit of thrombolysis in normotensive PTE patients.
Material and methods: This study included patients diagnosed with acute intermediate PTE. Patient's electrocardiography (ECG) parameters along with echocardiography (echo), etc., conducted at the time of admission, during their stay in hospital, at the time of discharge, and during follow-up were recorded. The patients were treated using thrombolysis or anticoagulants depending on hemodynamic decompensation. During follow-up, they were reassessed for echo parameters–right ventricular (RV) function and pulmonary arterial hypertension (PAH).
Results: Among 55 patients, 29 (52.73%) were diagnosed with intermediate high-risk PTE and 26 (47.27%) with intermediate low-risk PTE. They were normotensive and most of them had a simplified pulmonary embolism severity index (sPESI) score <2. Typical ECG pattern S1Q3T3 along with echo patterns and elevated cardiac troponin levels were observed in most of the patients. Patients treated with thrombolytic agents showed a reduction in hemodynamic decompensation as opposed to patients treated with anticoagulants who had clinical signs of right heart failure (RHF) on follow-up after 3 months.
Conclusion: This study contributes to the existing literature on outcomes of intermediate-risk PTE and the effect of thrombolysis on patients with hemodynamic stability. Thrombolysis reduced the incidence and progression of RHF in patients with hemodynamic instability.
Turetz M, Sideris AT, Friedman OA, Triphathi N, Horowitz JM. Epidemiology, pathophysiology, and natural history of pulmonary embolism. Semin Intervent Radiol 2018;35(2):92–98. DOI: 10.1055/s-0038-1642036.
Lee AD, Stephen E, Agarwal S, Premkumar P. Venous thrombo-embolism in India. Eur J Vasc Endovasc Surg 2009;37(4):482–485. DOI: 10.1016/j.ejvs.2008.11.031.
Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, et al. ESC guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2020;41(4):543–603. DOI: 10.1093/eurheartj/ehz405.
Khosla R. Diagnosing pulmonary embolism. Indian J Crit Care Med 2006;10(2):105–111. DOI: 10.4103/0972-5229.25923.
Pruszczyk P, Skowrońska M, Ciurzyński M, Kurnicka K, Lankei M, Konstantinides S. Assessment of pulmonary embolism severity and the risk of early death. Pol Arch Intern Med 2021;131(12):16134. DOI: 10.20452/pamw.16134.
Maturana MA, Seitz MP, Pour-Ghaz I, Ibebuogu UN, Khouzam RN. Invasive strategies for the treatment of pulmonary embolism. Where are we in 2020? Curr Probl Cardiol 2021;46(3):100650. DOI: 10.1016/j.cpcardiol.2020.100650.
Giordano NJ, Jansson PS, Young MN, Hagan KA, Kabrhel C. Epidemiology, pathophysiology, stratification, and natural history of pulmonary embolism. Tech Vasc Interv Radiol 2017;20(3):135–140. DOI: 10.1053/j.tvir.2017.07.002.
Howard L. Acute pulmonary embolism. Clin Med (Lond) 2019; 19(3):243–247. DOI: 10.7861/clinmedicine.19-3-247.
Shah P, Arora S, Kumar V, Sharma S, Shah H, Tripathi B, et al. Short-term outcomes of pulmonary embolism: A national perspective. Clin Cardiol 2018;41(9):1214–1224. DOI: 10.1002/clc.23048.
Casazza F, Pacchetti I, Rulli E, Roncon L, Zonzin P, Zuin M, et al. Prognostic significance of electrocardiogram at presentation in patients with pulmonary embolism of different severity. Thromb Res 2018;163:123–127. DOI: 10.1016/j.thromres.2018.01.025.
Kukla P, Długopolski R, Krupa E, Furtak R, Szełemej R, Mirek- Bryniarska E, et al. Electrocardiography and prognosis of patients with acute pulmonary embolism. Cardiol J 2011;18(6):648–653. DOI: 10.5603/CJ.2011.0028.
Novicic N, Dzudovic B, Subotic B, Shalinger-Martinovic S, Obradovic S. Electrocardiography changes and their significance during treatment of patients with intermediate-high and high-risk pulmonary embolism. Eur Heart J Acute Cardiovasc Care 2020;9(4):271–278. DOI: 10.1177/2048872618823441.
Falsetti L, Marra AM, Zaccone V, Sampaolesi M, Riccomi F, Giovenali L, et al. Echocardiographic predictors of mortality in intermediate-risk pulmonary embolism. Intern Emerg Med 2022;17(5):1287–1299. DOI: 10.1007/s11739-021-02910-w.
Khemasuwan D, Yingchoncharoen T, Tunsupon P, Kusunose K, Moghekar A, Klein A, et al. Right ventricular echocardiographic parameters are associated with mortality after acute pulmonary embolism. J Am Soc Echocardiogr 2015;28(3):355–362. DOI: 10.1016/j.echo.2014.11.012.
Aujesky D, Hughes R, Jiménez D. Short-term prognosis of pulmonary embolism. J Thromb Haemost 2009;7(Suppl 1):318–321. DOI: 10.1111/j.1538-7836.2009.03408.x.
Piazza G. Advanced management of intermediate- and high-risk pulmonary embolism: JACC focus seminar. J Am Coll Cardiol 2020; 76(18):2117–2127. DOI: 10.1016/j.jacc.2020.05.028.
Xu Q, Huang K, Zhai Z, Yang Y, Wang J, Wang C. Initial thrombolysis treatment compared with anticoagulation for acute intermediate-risk pulmonary embolism: A meta-analysis. J Thorac Dis 2015;7(5): 810–821. DOI: 10.3978/j.issn.2072-1439.2015.04.51.
Meyer G, Vicaut E, Danays T, Agnelli G, Becattini C, Beyer- Westendorf J, et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med 2014;370(15):1402–1411. DOI: 10.1056/NEJMoa1302097.
Al-Hakim R, Li N, Nonas S, Zakhary B, Maughan B, Schenning R, et al. Evaluation and management of intermediate and high-risk pulmonary embolism. AJR Am J Roentgenol 2020;214(3):671–678. DOI: 10.2214/AJR.19.21861.
Paul G, Birinder P, Parshotam G. Catheter-based therapy for acute pulmonary embolism: Lifesaving in a clinical dilemma! Indian J Crit Care Med 2015;19(6):370–371. DOI: 10.4103/0972-5229.158297.
Chatterjee S, Chakraborty A, Weinberg I, Kadakia M, Wilensky RL, Sardar P, et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: A meta-analysis. JAMA 2014;311(23):2414–2421. DOI: 10.1001/jama. 2014.5990.