Presyncope Is Associated with Intensive Care Unit Admission in Emergency Department Patients with Acute Pulmonary Embolism

Abstract

Introduction: Syncope is common among emergency department (ED) patients with acute pulmonary embolism (PE) and indicates a higher acuity and worse prognosis than in patients without syncope. Whether presyncope carries the same prognostic implications has not been established. We compared incidence of intensive care unit (ICU) admission in three groups of ED PE patients: those with presyncope; syncope; and neither. Methods: This retrospective cohort study included all adults with acute, objectively confirmed PE in 21 community EDs from January 2013-April 2015. We combined electronic health record extraction with manual chart abstraction. We used chi-square test for univariate comparisons and performed multivariate analysis to evaluate associations between presyncope or syncope and ICU admission from the ED, reported as adjusted odds ratios (aOR) with 95% confidence intervals (CI). Results: Among 2996 PE patients, 82 (2.7%) had presyncope and 109 (3.6%) had syncope. ICU admission was similar between groups (presyncope 18.3% vs syncope 25.7%) and different than their non-syncope counterparts (either 22.5% vs neither 4.7%; p<0.0001). On multivariate analysis, both presyncope and syncope were independently associated with ICU admission, controlling for demographics, higher-risk PE Severity Index (PESI) class, ventilatory support, proximal clot location, and submassive and massive PE classification: presyncope, aOR 2.79 (95% CI, 1.40, 5.56); syncope, aOR 4.44 (95% CI 2.52, 7.80). These associations were only minimally affected when excluding massive PE from the model. There was no significant interaction between either syncope or presyncope and PESI, submassive or massive classification in predicting ICU admission. Conclusion: Presyncope appears to carry similar strength of association with ICU admission as syncope in ED patients with acute PE. If this is confirmed, clinicians evaluating patients with acute PE may benefit from including presyncope in their calculus of risk assessment and site-of-care decision-making. [

Development and validation of a prognostic tool: Pulmonary embolism short-term clinical outcomes risk estimation (PE-SCORE)

“…We included symptoms, signs, and findings likely to represent higher PE severity. As an example, we chose syncope instead of shortness of breath or chest pain based on clinical experience and evidence in the literature [31][32][33][34]. We added a variable that factored in initial heart rate < 50 or > 100 bpm [35].…”

Disposition of emergency department patients with acute pulmonary embolism after ambulance arrival

“…5,22,[33][34][35] At first glance, it is unsurprising that patients who arrived via EMS were sicker and had higher rates of 30-day all-cause mortality. How-ever, after adjusting for PE Severity Index class, Charlson Comorbidity score, troponin, BNP, and syncope or presyncope, 36 patients with acute PE who arrived by EMS were still less likely to be discharged within 24 h and more likely to die within 30 days. We found that EMS was an independent predictor of our 2 primary outcomes.…”

Prevalence of and Eligibility for Surveillance Without Anticoagulation Among Adults With Lower-Risk Acute Subsegmental Pulmonary Embolism

“…We translated those recommendations into explicit surveillance eligibility criteria, as described in eTable 1 in Supplement 1. We assumed that patients without a documented recent provocation for VTE (eg, major surgery or oral estrogen) had none—a reasonable assumption in our setting, given our medical record review experience that clinicians nearly always inquire about and document recent VTE provocations for patients with acute PE . We deemed the absence of VTE provocation as a contraindication to withholding anticoagulation because of increased risk for VTE recurrence .…”