To evaluate the clinical characteristics, diagnosis, treatment and outcome of elderly patients with acute pulmonary embolism (APE), in order to strengthen the awareness of diagnosis of APE and reduce missed diagnosis and misdiagnosis.
A retrospective analysis of clinical data of 40 elderly patients (age ≥ 60 years old) diagnosed with APE admitted to TEDA International Cardiovascular Hospital from January 2008 to December 2018, including risk factors, clinical features, symptoms and signs, laboratory tests, risk of pulmonary embolism (Wells score), simplified pulmonary embolism severity index (sPESI), radiological tests, treatment, and outcome, etc. were conducted. Receiver operating characteristic (ROC) curve was drawn to analyze the diagnostic value of Wells score and spiral CT pulmonary angiography (CTPA) in APE.
A total of 40 elderly patients with APE were enrolled, male was 52.5%, and the age was (69.6±8.2) years old. The most common risk factor was deep vein thrombosis (DVT, 52.5%), followed by hypertension (37.5%) and heart failure (35.0%). The main clinical symptoms were exertional dyspnea (87.5%) and chest tightness (80.0%). Only 10.0% of patients had the triad of dyspnea, chest pain and hemoptysis at the same time. In addition, palpitation (65.0%) and lower limb swelling and pain (42.5%) were also common symptoms. The main clinical signs were shortness of breath (respiratory rate > 25 bpm, 80.0%), lung moist rales (52.5%), and tachycardia (heart rate > 100 bpm, 50.0%). The Wells score showed that 95% of the patients Wells ≥ 2, including moderate (Wells 2-6, 62.5%) and severe (Wells ≥ 7, 32.5%). Laboratory examination showed that 80.0% of patients had D-dimer > 0.5 mg/L, 72.5% had arterial partial pressure of oxygen (PaO) < 60 mmHg (1 mmHg = 0.133 kPa), and 75.0% had arterial partial pressure of carbon dioxide (PaCO) 500 ng/L or N-terminal pro-BNP (NT-proBNP) > 300 ng/L, and 47.5% had cardiac troponin I (cTnI) > 0.3 μg/L. The confirmed diagnosis rate of CTPA in APE was 88.6% (31/35); 5 cases were diagnosed by pulmonary ventilation/perfusion imaging in 6 cases; 4 cases were diagnosed by magnetic resonance pulmonary angiography (MRPA). The sPESI score showed that 36 patients were moderate-risk patients [26 patients with sPESI ≥ 1, and 10 patients with sPESI 0 but right ventricular dysfunction (RVD) and/or elevated cardiac biomarkers]. Thrombolytic therapy and anticoagulant therapy were performed on 17 of them: 8 were cured, 8 were improved, and 1 died; anticoagulant therapy was performed on 18 moderate-risk patients: 9 were cured, 7 were improved, 1 left the hospital without cure, and 1 died; the other 1 moderate-risk patient with PE caused by right atrial myxoma was treated by operation and ultimately died. Four low-risk patients were treated by anticoagulant therapy: 2 were cured and 2 improved. The area under the ROC curve (AUC) of Wells score combined with CTPA was 0.82 (95% confidence interval was 0.73-0.98, P < 0.01), the sensitivity was 74.2%, and the specificity was 90.0%.
DVT and chronic diseases are the most common risk factors for APE in the elderly patients, often accompanied by dyspnea, chest tightness, and lower limb swelling and pain. Early anticoagulation therapy in elderly APE can make a good prognosis. Wells score has an important predictive value for the diagnosis of APE, while blood D-dimer is an important exclusion parameter. CTPA test is the main diagnostic method for APE. The sPESI score can suggest risk stratification and prognosis, and further guided treatment.