| Objectives:1)To conduct a retrospective single-center study for inpatients with pulmonary embolism in the emergency department of Renji hospital affiliated to Shanghai Jiaotong University school of medicine.and to provide reliable epidemiological and clinical data.2)To perform the risk stratification for the enrolled patients according to the guideline,and to analyze the risk factors associated with prognosis.3)To review 3 typical or special cases to for the purpose of clinical skill improvement.Case 1 report was about a young female who was diagnosed with pulmonary embolism after In Vitro Fertiliazation-Embryo Trans Plantation(IVF-ET),and case 2 and case 3 were about patients with acute massive PE who accepted successful thrombolytic treatment.Methods:1)Patients who were diagnosed with PE by computed tomographic pulmonary angiography(CTPA)and/or pulmonary ventilation-perfusion scintigraphy(V/Q scan)in Ren Ji hospital affiliated to Shanghai Jiaotong University school of medicine between 2011.7 and 2018.7 were reviewed and collected,the exclude criterias were as the follows:(1)the patients whose age were under 14 years old and(2)the patients who didn’t complete the treatment or(3)didn’t have the examination of CTPA or V/Q scan in Ren Ji hospital.The demographic features,length of hospital stay,expense,7 day mortality and thrombus distribution of vessel were collected and analyzed to provide the reliable epidemiological and clinical data.2)To evaluate the prognosis of enrolled patients above,all of the epidemiology data,radiographic features,risk factors,clinical symptoms and laboratory data of the cohort were reviewed and analyzed.All patients were divided into low-risk group,intermediate-low risk group,intermediate-high risk group and high risk group according to the 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism.All patients were also divided into survival group and death group.We compared two groups by the statistical method of single factor Logistic regression analysis and performed ROC analysis to find out the risk factor be able to predict the death of patients with pulmonary embolism.We selected 1 patient who was diagnosed pulmonary embolism after IVF-ET and 2 patients with massive pulmonary embolism who accepted thrombolytic therapy.We described their clinical courses including medical histories,therapeutic strategies and outcomes,and made summarizations of the case-based characteristics.Results:1)A total of 114 patients with acute pulmonary embolism were enrolled.The average age were 65.02±2.97 years,the median length of hospitalization were 12(8,16)days,the median hospital charge was 23624(17435,32654)RMB yuan,and the 7 days mortality was 3.51%(n=4).The average age in female patients was significantly older than that of male patients(69.22±3.54 vs 60.51±4.66 years,P=0.006).The most common site of embolism was lower right pulmonary artery(n=96,8 4.2%),followed by bilateral pulmonary embolism(n=77,67.5%),including multiple branch pulmonary arteries and/or bilateral main pulmonary arteries involvement.2)The average age of patients in both intermediate risk group were significantly higher than that of the patients in low risk group(P=0.002).The expense of patients in intermediate-low risk group and high risk group were higer than the patients in low risk group(P=0.018).The proportion of patients with chronic cardiac diseases in intermediate-high risk group and high risk group was higher than those of the patients in intermediate-low risk group(P=0.000).The levels of BNP(Brain Natriuretic Peptide)and SCr(Serum creatinine)of patients in intermediate-high risk group and high risk group were higher than patients in low risk group(p<0.05).The proportion of patients with thrombus in the sites of bilateral main pulmonary arteries in intermediate-low risk group and high risk group were higher than those in low risk group(P=0.001)Patients in death group had lower hospital stays(p=0.001)and lower expense(p=0.023),compared to patients in the survival group.The level of INR(International Normalized Ratio)(p=0.033)and the PESI(Pulmonary Embolism Sever Index)score(p=0.003)were higher in the death group.The relation between the level of D-dimer and risk stratification had no statistically significance.To predict high risk by ROC curve with the level of D-dimer,the area under the curve(AUC)was 0.364.The level of SCr are related to risk stratification.To predict high risk by ROC curve with the level of SCr,the area under the curve(AUC)was 0.667.3)Case 1 was a 27 years old female who occurred severe syncope 22 days after IVF-ET.She was diagnosed with massive pulmonary embolism by CTPA after agreement of giving up pregnancy and accepted the treatment of anticoagulation.Case 2 was a 64 years old female who had a“cardiac attack” out of hospital and diagnosed with acute pulmonary embolism by CTPA after cardio-pulmonary resuscitation,she accepted thrombolysis treatment cutting the edge of therapeutic indication during the invasive mechanical ventilator support,and survived quickly from the EICU.Case 3 was a 64 years old female who had fever,chest pain and recurrent syncope.She was initially diagnosed as pleuritis and pneumonia and was transferred to our hospital after 1 week ineffective antibiotic treatment.Timely diagnosis of acute massive pulmonary embolism by CTPA was made and immediate thrombolytic therapy improved the clinical symptoms significantly.All the clinical outcomes of three patients were well.Conclusions:1)The mid-aged and old patients occupied most proportion of PE patients.The thrombi were found in multiple sites of both pulmonary arteries in most patients with pulmonary embolism(n=77 in 114,67.5%),and there were thrombi in low right pulmonary artery in most patients(n=96in 114,84.2%).2)The results showed that the increased levels of BNP,INR,SCr,and the PESI score,the involvement of bilateral main pulmonary arteries and the history of chronic cardiac diseases may be related to the prognosis of pulmonary embolism.It seemed that the level of SCr was related to risk stratification.The risk of patients with pulmonary embolism was higher as the level of SCr increased,but the predictive value was low.3)Many studies showed that the morbidity of pulmonary embolism was higher in pregnant women who had IVF-ET,compared to natural conceptive individuals.Pregnancy after IVF-ET is an important risk factor of PE.It’s a challenge to diagnose and treat PE in pregnant women because of more ethic problems besides disease itself.We should take full consideration of the safety for the mother and the fetus when we conduct image examination and aggressive therapy.Thrombolysis treatment is the first choice for the high-risk patients with PE who don’t have the contraindications.For the patients with unstable hemodynamic condition be highly suspicious of PE,the evaluation of right ventricular structure and function combined with circulation situation is necessary as the evidence for guiding the thrombolysis treatment.For the intermediate-risk patients with pulmonary embolism,there still controversies for the thrombolytic therapy.Nevertheless,in the severe ones,the dynamic monitoring is obligatory,for implementation of thrombolytic treatment on patients getting worse and have no contraindications for fear of irreversible deterioration. |
