Acute pulmonary embolism: in hospital outcome from a prospective observational registry (M-PER) from a low-and middle-income country
Authors: Gnanaraj J P , Vivek J , Rajesh S , Nilavan A , Rajasekar Ramesh D , Elangovan C , Elavarasi E , Ravindran R , Nageswaran P M , Tamilselvan S , Pratap Kumar G , Venkatesan S , Manohar G , Swaminathan N , Ravishankar G 
Published: October 2022

Abstract

Background
Acute Pulmonary embolism the third most common cause of cardiovascular death in the world. Despite the large burden of acute pulmonary embolism, there is a paucity of prospective data from low-and middle-income countries.

Purpose
To study the clinical characteristics, treatment strategies employed, in-hospital outcome, one-year follow up results, and the prognostic factors in patients with acute pulmonary embolism from a low-and middle-income country.

Methods
All consecutive patients diagnosed with and treated for acute pulmonary embolism at our institution from November 2016 to November 2021 were included in the registry. Pulmonary embolism was diagnosed using clinical features (Wells' criteria of ≥3) supported by either CT angiogram or echocardiogram. Detailed history, clinical examination, preliminary basic blood investigations, cardiac troponins along with coagulation workup, ECG and ECHO were done for all patients. Patients were classified as having massive or high risk, submassive or intermediate risk and low risk pulmonary embolism based hemodynamic status, sPESI score, echocardiogram and cardiac troponins. Treatment was at the discretion of treating physician. In general, all patients with massive pulmonary embolism were considered for thrombolysis. All patients received anticoagulation with unfractionated heparin. Outcomes included hospital lengths of stay, all-cause in-hospital mortality and one year mortality

Results
186 patients with acute pulmonary embolism were prospectively enrolled during period. 62% were male. Mean age was 42.38±13.4 years. The risk factors noticed include prior history of venous thromboembolism, active malignancy, recent surgery, trauma, immobilisation, diabetes, hypertension, and chronic obstructive pulmonary disease in 18%, 5%, 10%, 8%, 14%, 17%, 10% and 3% of our patients respectively. Shortness of breath (98%), chest pain (37%), leg swelling (37%), cough (33%), shock (27%), syncope (15%) and haemoptysis (12%) were the reasons for presentation. Sinus tachycardia was the commonest finding (80%).
Right ventricular (RV) strain pattern was present in 68%, S1Q3T3 pattern in 56% and RBBB in 32%. RV dilatation was present in 93% and RV dysfunction in 75%. Thrombus was visualised in the pulmonary artery in 37% and right heart chambers in 12% (714). 26% were classified as high risk, 60% as intermediate risk and 13.4% as low risk acute pulmonary embolism. Overall 50% (92% of high-risk and 41% of intermediate risk) patients received fibrinolytic therapy.
In hospital mortality was 16% (29 patients) of which 72% were from high-risk group. In the high-risk group those who were fibrinolysed had a lower mortality compared to those not lysed. (75% vs 40%). This difference was not observed in the intermediate risk group.

Conclusion
Acute pulmonary embolism is a disease with high in-hospital mortality. Fibrinolytic therapy with streptokinase has a lifesaving potential in high risk patients.

Funding Acknowledgement
Type of funding sources: None.