Clinical presentation and diagnostic work up of suspected pulmonary embolism in a district hospital emergency centre serving a high HIV/TB burden population

• Main Author: Bulajic, Bojana
• Other Authors: Welzel, Tyson
• Format: Dissertation
• Language: English
• Published: University of Cape Town 2019
• Subjects: Emergency Medicine
• Online Access: http://hdl.handle.net/11427/29664

Introduction: The diagnosis of Pulmonary Embolism (PE) is challenging to make and is often missed in the Emergency Centre. The true incidence of PE in South Africa is unknown. The diagnostic work-up of PE has been improved by the use of Clinical decision rules (CDRs) and CT Pulmonary Angiography (CTPA) in high-income countries. Currently used CDRs have not been validated in the South African environment, where HIV and TB are highly prevalent. Both conditions are known to induce a hyper-coagulable state. Methods: This study was a retrospective chart review of patients with suspected PE that had CTPAs performed from October 2013 to October 2015 at Mitchell’s Plain Hospital in South Africa. Data was collected on demographics, presenting symptoms and signs, vitals, bedside investigations, HIV and TB status, use of CDRs and CTPA result. A Revised Geneva Score was calculated retrospectively and compared to the CTPA result. Results: The median age of patients with confirmed PE was 45 years and 68% were female. The CTPA yield for PE in our study population was 32%. The most common presenting complaint was dyspnoea (83%), followed by cough and chest pain. 29% of patients also had clinical features of DVT. No sign or symptom was seen to be markedly different in those with confirmed PE compared to those without. Among patients with confirmed PE, 37% were HIV positive and 52% had current TB. The retrospective revised Geneva Scores compared poorly with the CTPA results. Discussion: PE remains a diagnostic challenge. Worldwide, the use of CDRs has shown to improve the utilization of CTPA. In our study, the retrospectively calculated CDR was not predictive of PE in a population with a high prevalence of HIV and TB. Emergency physicians should be cautious when making a clinical probability assessment of PE in this setting. However, further studies are needed to determine whether HIV and TB could be independent risk factors for PE.