Asymptomatic pulmonary embolism in psychiatric patients

Introduction: Pulmonary embolism (PE) and deep vein thrombosis (DVT) are integral elements of venous thromboembolism (VTE), which ranks as the third most prevalent cardiovascular condition in the general population [1]. PE represents the most critical clinical manifestation of VTE [2]. The annual incidence of acute PE varies between 0.039% and 0.115% [3], and this condition is notably prevalent within psychiatric populations [4]. The connection between psychiatric disorders and PE is intricate and not fully elucidated. If left unrecognized and untreated, it poses a significant risk to life. Therefore, alongside well-known risk factors, it is essential to consider risk factors that are particularly relevant to individuals with psychiatric conditions. Recognizing these risk factors along with diagnostic indicators can facilitate early detection and effective management of the disorder.

Aim: The objective of this study is to ascertain the incidence rate of PE among the psychiatric population under examination, as well as to identify specific risk factors, which encompass medication types, treatment interventions, and various clinical and non-clinical attributes.

Methods: We conducted a descriptive, retrospective analysis by examining electronic medical records at the Psychiatric Hospital Sarajevo (PHS) to detect asymptomatic pulmonary thromboembolism (PTE) in patients admitted over a one-year timeframe from January 2025 to January 2026. The diagnosis of PTE was validated through elevated plasma D-dimer levels alongside positive imaging results from contrast-enhanced CT scans. We gathered data regarding patient demographics, clinical profiles, psychotropic medications administered, instances requiring coercive measures, as well as laboratory test outcomes and imaging findings. Furthermore, we documented details about anticoagulant therapy received by these patients along with their clinical outcomes.

Results: Among the 454 patients hospitalized during the specified year-long period, 8 individuals (1.76%) developed pulmonary thromboembolism; comprising 6 women (75%) and 2 men (25%). Six patients were diagnosed with psychotic disorders, one was treated for bipolar affective disorder, while another had unipolar depression. None exhibited catatonia. All patients were on multiple psychotropic medications (polypharmacy), including clozapine at an average dosage of 200 mg/day. All subjects were chronic patients who had been repeatedly hospitalized in psychiatric facilities. During the current admission when PTE was diagnosed, 7 patients (87.5%) were occasionally subjected to physical restraint according to their clinical presentation. Additionally, six of these individuals had comorbid psychiatric diagnoses alongside their primary conditions. The mean D-dimer level recorded was 1.73 but normalized following anticoagulant therapy. Remarkably, all patients achieved complete recovery without any fatal outcomes.

Conclusion: The findings from this study indicate a markedly higher incidence of PE in hospitalized psychiatric patients compared to that observed in the general populace. Factors such as chronicity in psychiatric conditions, treatment with clozapine antipsychotics, and previous experiences of restraint are significant predictors for PE among psychiatric inpatients; thus warranting careful consideration for identifying high-risk individuals within this demographic.

References

1. Sapota-Zaręba K, Nasierowski T. The risk of pulmonary embolism in the context of various clinical situations and management in psychiatric patients. Psychiatr Pol. 2023 Oct 31;57(5):955-965. English, Polish. doi: 10.12740/PP/152585. Epub 2023 Oct 31. PMID: 38345121. 2. Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2020; 41: 543-603. 3. Wendelboe AM, Raskob GE. Global Burden of Thrombosis: Epidemiologic Aspects. Circ Res. 2016 Apr 29;118(9):1340-7. 4. Takeshima M, Ishikawa H, Shimizu K, Kanbayashi T, Shimizu T. Incidence of venous thromboembolism in psychiatric inpatients: a chart review. Neuropsychiatr Dis Treat 2018; 14: 1363-1370.