Original Contributions
Risk Factors Associated with Delayed Diagnosis of Acute Pulmonary Embolism

https://doi.org/10.1016/j.jemermed.2011.06.004Get rights and content

Abstract

Background

Prompt diagnosis and treatment of acute pulmonary embolism (PE) is essential to reduce mortality. Risk factors for PE are well known, but factors associated with delayed diagnosis are less clear.

Objective

Our objective was to identify clinical factors associated with delayed diagnosis of patients with acute PE presenting to a tertiary-care emergency department (ED).

Methods

We studied 400 consecutive adults who presented to our ED with acute, symptomatic PE. All patients were diagnosed by computed tomography (CT) angiography. Early diagnosis was defined as CT diagnosis < 12 h from ED arrival, and delayed diagnosis as CT diagnosis > 12 h. Univariate and multiple logistic regression models were used to identify factors associated with delayed diagnosis. Odds ratios with 95% confidence intervals are reported.

Results

The median time from arrival to diagnosis was 2.4 h (interquartile range 1.4–7.6), and 73 (18.3%) patients had delayed diagnosis. Patients aged > 65 years and those with coronary artery disease or congestive heart failure had longer times from ED arrival to CT diagnosis, whereas patients with recent immobility had shorter times. Patients diagnosed > 12 h were older and had higher rates of morbid obesity and coronary artery disease, whereas patients diagnosed < 12 h had higher rates of tachycardia. In multiple regression modeling, tachycardia and recent immobility remained associated with early diagnosis, whereas morbid obesity remained associated with delayed diagnosis.

Conclusions

Older patients with cardiovascular comorbidities had longer times from ED arrival to CT diagnosis. Our data suggest that these patients represent more of a diagnostic challenge than those presenting with traditional risk factors for PE, such as tachycardia and recent immobilization. Physicians should consider these factors to diagnosis acute PE promptly in the ED.

Introduction

Acute pulmonary embolism (PE) is a common and potentially fatal disorder if not promptly diagnosed and treated 1, 2, 3, 4, 5. Even with anticoagulation, the 14- and 90-day mortality rates are approximately 10% and 20%, respectively 6, 7, 8, 9. Studies have previously shown potential for significant outpatient delays from initial symptom onset to the diagnosis of PE in the emergency department (ED) 1, 2, 3. Kline et al. reported that patients diagnosed within 48 h of ED arrival had improved outcomes, and we recently reported that anticoagulation within 24 h of ED arrival is associated with reduced mortality (4,5). Indeed, prompt diagnosis and treatment with anticoagulation are essential to improve outcomes and reduce mortality for patients with acute PE.

Current guidelines suggest the initiation of anticoagulation therapy even before confirmatory diagnosis if clinicians feel that the probability of PE is high, especially in hemodynamically unstable patients 1, 3, 10. However, many patients present without hemodynamic instability, and so emergency physicians must risk-stratify patients to make a prompt diagnosis. Traditional risk factors for PE have been well established, but factors associated with the timing of diagnosis have not been as well studied. We therefore conducted a retrospective review of patients with acute PE to identify clinical factors associated with delayed diagnosis.

Section snippets

Methods

We conducted a retrospective review of consecutive adult patients who presented to a single, tertiary-care ED with acute, symptomatic PE between June 17, 2002 and September 6, 2005 (4). Patients were identified based upon review of International Classification of Diseases, 9th Revision codes 415.1–415.19. We included only patients with symptoms compatible with acute PE (i.e., chest pain, dyspnea, hypoxia, pre-syncope, or syncope), and patients were excluded if an asymptomatic PE was

Results

We identified 400 consecutive adult patients with a median age of 68.0 years (IQR 54.0–76.0); 195 patients (48.8%) were male (Table 1). The median time from ED arrival to CT diagnosis was 2.4 h (IQR 1.4–7.6) (Table 1). Seventy-three (18.3%) patients had delayed diagnosis (Table 2, Table 3).

Patients with age > 65 years, CAD, and CHF had significantly longer times from arrival to diagnosis (Table 1), although only age > 65 years and CAD were univariate predictors of delayed diagnosis (Table 2, Table 3

Discussion

Early diagnosis is essential to reduce the high morbidity and mortality associated with acute PE. It is therefore essential for clinicians to recognize not only risk factors for PE but also the clinical factors that may delay management. In our study we identified several such factors that were associated with delayed diagnosis.

Previous studies have examined the demographics and comorbidities associated with the timing of the diagnosis of acute PE. Kline et al. studied 161 patients with acute

Conclusions

This study was designed to identify clinical factors associated with delayed diagnosis of acute PE. Patients with age > 65 years, cardiovascular disease, and those with morbid obesity had delayed diagnosis, whereas those with recent immobility and tachycardia were diagnosed more expediently. Therefore, clinicians should be aware of these factors to provide expedient management of acute PE and to reduce the morbidity and mortality associated with such delays.

Article Summary

1. Why is this topic important?

  1. Pulmonary embolism can be a rapidly

Cited by (37)

  • Venous thromboembolism in pregnant obese Individuals

    2024, Best Practice and Research: Clinical Obstetrics and Gynaecology
  • Risk Factors for Postoperative Complications After Surgical Treatment of Type B and C Injuries of the Thoracolumbar Spine

    2023, World Neurosurgery
    Citation Excerpt :

    Such factors can be strongly associated with major and minor medical or surgical complications.20 Better management of identified and modifiable risk factors can reduce morbidity when surgery cannot be postponed; therefore an active search for modifiable risk factors should always be performed, including trying to achieve an accurate diagnosis as early as possible, so a decision for proper treatment can be made promptly, and all the necessary personnel and structural resources identified, gathered, and prepared for use when needed.21 In our study, the most frequentlyreported surgical complication was surgical site infection.

View all citing articles on Scopus

The authors have no personal disclosures. The authors received support from the Center for Translation Science Activities (CTSA). The CTSA is funded through the National Institutes of Health (NIH) (Grant Number 1 UL1 RR024150-01). The contents are solely the responsibility of the authors and do not necessarily represent the official view of the NIH. Information is available at http://www.ncrr.nih.gov/.

View full text