Clinical characteristics, risk factors and outcomes of South-East Asian patients with acute pulmonary embolism

Clinical characteristics and anticoagulation patterns of patients with acute pulmonary thromboembolism and hemoptysis

Hemoptysis is a frequently encountered manifestation in cases of acute pulmonary thromboembolism (PTE), significantly impacting clinical decision-making. Despite its clinical relevance, studies focusing on patients with acute PTE and hemoptysis are notably scarce. In this retrospective study, we examined data from hospitalized patients with acute PTE at Peking Union Medical College Hospital (PUMCH) between January 2012 and October 2020. Among the 896 patients analyzed, 105 (11.7%) presented with hemoptysis. Patients with hemoptysis were younger, had higher RRs, and frequently reported chest pain, predominantly showing a negative sPESI score. A significant association with autoimmune diseases was observed (39.0% vs. 16.1%; p < 0.001), along with higher occurrences of pulmonary infections (29.5%), lung cancer (21.0%), and chronic heart failure (16.2%). Hemoptysis in PTE is multifactorial; 51.4% of cases were PTE-related, with 85.2% experiencing mild hemoptysis. Among patients with disease-related hemoptysis (13.3%), 90.9% with massive hemoptysis had underlying diseases, predominantly lung cancer. In 35.2% of cases, the cause of hemoptysis remained undetermined, with vasculitis accounting for 29.7%. Anticoagulation strategies varied with the severity of hemoptysis; 82.9% with mild and only 27.3% with massive hemoptysis received therapeutic-dose anticoagulation. Multivariate analysis identified massive hemoptysis as the most significant determinant of anticoagulation decisions. Patients with massive hemoptysis had the poorest outcomes, with an in-hospital mortality rate of 36.4% and 72.7% receiving reduced or no anticoagulation.

Fibrinolysis and clinical outcomes in acute pulmonary embolism. Madras medical college pulmonary embolism (M-PER) registry from India

BACKGROUND

Acute pulmonary embolism (APE) is the third most common cause of vascular death. Data on APE from India and other low-and middle-income countries is sparse.

OBJECTIVES

Study the clinical characteristics, prognostic factors, in-hospital mortality (IMH) and 12 months mortality of patients with APE in India.

METHODS

We prospectively enrolled 186 consecutive patients diagnosed with APE between November 2016 and November 2021 in Madras Medical College Pulmonary Embolism Registry (M-PER). All patients had electrocardiography and echocardiography. High risk patients and selected intermediate risk patients underwent fibrinolysis.

RESULTS

75 % of our patients were below 50 years of age. 35 % were women. The mean time to presentation from symptom onset was 6.04 ± 10.01 days. 92 % had CT pulmonary angiography. Intermediate risk category (61.3 %) was the more common presentation followed by high risk (26.9 %). Electrocardiography showed S1Q3T3 pattern in 56 %. 76 % had right ventricular dysfunction and 12.4 % had right heart thrombi(RHT) by echocardiography. 50.5 % received fibrinolysis. Patients with RHT received fibrinolysis more frequently (78.3 % vs 46.6 %; p = 0.007). In-hospital mortality (IHM) was 15.6 %. Systemic arterial desaturation and need for mechanical ventilation independently predicted IHM. Ten patients (5.3 %) were lost to follow up. One year mortality was 26.7 % (47/176). One year mortality of patients discharged alive was similar among high, intermediate and low risk groups(14.8 % vs 1.9 % vs 10.5 %; p = 0.891).

CONCLUSIONS

Patients with PE are often young and present late in India. The in-hospital and 12 months mortality were high. Low and intermediate risk groups had a high post discharge mortality similar to high risk patients.

Epidemiology of Cancer-Associated Thrombosis in Asia: A Systematic Review

The epidemiology of cancer associated thrombosis (CAT) in Asia is less well-studied and differs from that in the western countries. Here, we systematically examine population based and hospital-based studies reported between 1995 and 2020 to understand the epidemiology of CAT in Asia. From population-based studies, the estimated incidence of VTE in cancer patients was 1.85–9.88 per 1,000 person-years. The incidence of CAT in Asia is significantly higher than non-cancer associated VTE in the general population and cancer is perhaps the most important risk factor for VTE. Hospital-based studies were heterogeneous in study designs and reveal a wide range of prevalence of VTE among cancer patients at 0.5–44.6% while the cancer prevalence rates among VTE patients ranged from 6.1 to 65.5%. The cancer sites most associated with VTE and risk factors were similar between Asian and Western studies. CAT has a major impact on the survival of patients with cancer in Asia, but thromboprophylaxis is not commonly practiced and validated risk assessment tools are lacking. This study highlights the urgent need for large multinational epidemiological studies in Asia to establish the true burden of CAT and to guide appropriate prevention strategies.

Clinical characteristics and aetiological analysis of 133 patients for pulmonary embolism combined with haemoptysis

BACKGROUND

In the patients with pulmonary embolism (PE), PE itself can cause haemoptysis and other reasons can also cause haemoptysis. Therefore, the clinical characteristics and the causes of haemoptysis are lacking.

METHODS

A retrospective analysis was performed that involved screening 583 PE patients and determining that haemoptysis occurred in 141 cases. Of these, eight cases were omitted due to anticoagulation-related haemoptysis or unavailable data, leaving 133 cases that were enrolled in final analysis (127 acute and 6 chronic case of PE). We classified the acute PE patients who combined with diseases which can cause haemoptysis to non-simple group (n = 61) and those without these diseases to simple group (n = 66).

RESULTS

The incidence of haemoptysis in PE patients was 23.75%. In the simple group, the amount of haemoptysis ≤ 5 mL was 80.30% (53/66) and ≤ 20 mL was 90.91% (60/66). In the non-simple group who combined with lung cancer, the amount of haemoptysis ≤ 5 mL was 68.4% (26/38) and ≤ 20 mL was 86.8% (33/38). Further analyses revealed that the amount of haemoptysis in the non-simple group was larger than that in the simple group (median 5 [5-125] vs. 5 [5-5], p < 0.001; volume ≥ 100 mL: 29.5% vs. 6.1%, p< 0.001). Among all the PE patients, chronic thromboembolic pulmonary hypertension (CTEPH), PE combined with tuberculosis (TB) and PE combined with bronchiectasis were independent risk factors for the amount of haemoptysis ≥ 100 mL (OR = 15.00, (95% CI: 2.235-100.652); 12.00, (3.101-46.437); 60.00, (6.552-549.441), respectively).

CONCLUSIONS

The haemoptysis caused by acute PE or PE combined with lung cancer was mild and was characterised by blood in sputum. PE combined with TB, bronchiectasis and CTEPH are associated with moderate to massive haemoptysis, with a greater risk of haemoptysis ≥ 100 mL.

Diagnostic management of inpatients with a positive D-dimer test: developing a new clinical decision-making rule for pulmonary embolism

Background

A positive D-dimer test has high sensitivity but relatively poor specificity for the diagnosis of pulmonary embolism, causing difficulty for clinicians unskilled in pulmonary embolism diagnosis in determining whether a patient with a positive D-dimer test needs to undergo computed tomographic pulmonary angiography.

Objectives

We sought to develop a new clinical decision-making rule based on a positive D-dimer result to predict the probability of pulmonary embolism and to guide clinicians in making decisions regarding the need for computed tomographic pulmonary angiography.

Methods

We conducted a prospective, multicenter study in three hospitals in China. A total of 3014 inpatients with positive D-dimer results were included. In the derivation group, we built a multivariate logistic regression model and deduced a regression equation from which our score was derived. Finally, we validated the score in an independent cohort.

Results

Our score included nine variables (points): chest pain (1.4), chest tightness (2.3), shortness of breath (3.6), hemoptysis (3.4), heart rate ≥100 beats/min (3.6), blood gas analysis (2.9), electrocardiogram presenting a typical S1Q3T3 pattern (4.1), electrocardiogram findings (2.4), and ultrasonic cardiogram findings (3.7). The sensitivities and specificities were 100% and 86.94%, respectively, in the derivation group and 100% and 90.82%, respectively, in the validation group. Additionally, the observed and predicted proportions of patients who underwent computed tomographic pulmonary angiography were 16.82% and 10.76%, respectively, in the derivation group and 18.72% and 11.40%, respectively, in the validation group.

Conclusions

The new score can categorize inpatients with a positive D-dimer test as pulmonary embolism-likely or pulmonary embolism-unlikely, thus reducing unnecessary computed tomographic pulmonary angiography examinations.