Prospective Study of the Clinical Features and Outcomes of Emergency Department Patients with Delayed Diagnosis of Pulmonary Embolism

Abstract

Objectives: The authors hypothesized that emergency department (ED) patients with a delayed diagnosis of pulmonary embolism (PE) will have a higher frequency of altered mental status, older age, comorbidity, and worsened outcomes compared with patients who have PE diagnosed by tests ordered in the ED.Methods: For 144 weeks, all patients with PE diagnosed by computed tomographic angiography were prospectively screened to identify ED diagnosis (testing ordered from the ED) versus delayed diagnosis (less than 48 hours postadmission). Serum troponin I level, right ventricular hypokinesis on echocardiography, and percentage pulmonary vascular occlusion were measured at diagnosis; patients were prospectively followed up for adverse events (death, intubation, or circulatory shock).Results: Among 161 patients with PE, 141 (88%) were ED diagnosed and 20 (12%) had a delayed diagnosis. Patients with a delayed diagnosis were older than ED-diagnosed patients (61 [AE15] vs. 51 [AE17] years; p < 0.001), had a longer median time to heparin administration (33 vs. 8 hours; p < 0.001), and had a higher frequency of altered mental status (30% vs. 8%; p = 0.01) but did not have a higher frequency of prior cardiopulmonary disease (25% vs. 23%). Patients with a delayed diagnosis had equal or worse measures of PE severity (right ventricular hypokinesis on echocardiography, 60% vs. 58%; abnormal troponin I level, 55% vs. 24%); on computed tomographic angiography, ten of 20 patients with a delayed diagnosis had PE in lobar or larger arteries and >50% vascular obstruction. Patients with a delayed diagnosis had a higher rate of in-hospital adverse events (9% vs. 30%; p = 0.01).

Predicting anticoagulant-related bleeding in patients with venous thromboembolism: a clinically oriented review

“…Nevertheless, even with the new generation of anticoagulant agents, the most relevant and frequent complication of anticoagulant treatment is major haemorrhage, which is notoriously associated with significant morbidity, mortality and considerable costs [11][12][13]. Since the need for anticoagulation therapy after an acute VTE episode is undisputable [1,2,[14][15][16][17], assessment of the individual bleeding risk is most relevant when choosing the appropriate anticoagulant drug and treatment duration.…”

Delays in Diagnosis of Acute Pulmonary Thromboembolism: Clinical Outcomes and Risk Factors

“…This study documents probable reasons of delay in the diagnosis of acute PTE and relationship between these factors and prognosis. There are only a few studies about delays in diagnosis of PTE (5,6,(12)(13)(14)(15)(16). Delayed diagnosis has not been clearly related to mortality rates in these previous investigations.…”

Accuracy of Very Low Pretest Probability Estimates for Pulmonary Embolism Using the Method of Attribute Matching Compared with the Wells Score

“…The majority of patients were female (6,914) and white race (6,199). Most patients had either dyspnea (6,103) or pleuritic chest pain (5,275) or both symptoms (2,964). Table 3 provides descriptive data including means for continuous variables and proportions for ordinal data for the ten predictor variables used to assess pretest probability.…”

“…Experts continue to suggest that physicians too often fail to diagnose PE and thus are subject to medicolegal allegations of negligence. 1,2 Physicians in the United States are increasingly concerned about medical malpractice secondary to missed PE. 3,4 These influences, together with the widened availability and acceptance of D-dimer and computerized tomography pulmonary angiography (CTPA), may have led to increased testing for PE among very-low-risk outpatients.…”