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Diagnosing Pulmonary Embolism: Guidelines Matter

Using inappropriate clinical criteria to exclude PE places patients at increased risk.

Evidence-based guidelines for diagnosis of pulmonary embolism exist, but does adherence to the guidelines affect outcome? To answer this question, researchers conducted a prospective, observational study of 1529 consecutive patients who presented with suspected PE to 117 emergency departments in France and Belgium.

Treating physicians completed a standardized data form on demographics, medical history, signs and symptoms, and diagnostic testing. Based on international guidelines, the authors predefined appropriate diagnostic criteria for confirming or excluding PE. Two investigators independently analyzed each case and classified the diagnostic criteria used by the treating physicians as appropriate or inappropriate.

PE was clinically diagnosed in 28% of patients and ruled out in 72%. The diagnostic criteria used by treating physicians were deemed appropriate and inappropriate, respectively, in 92% and 8% of patients in whom PE was confirmed and in 43% and 57% of those in whom PE was ruled out.

Among patients in whom PE was excluded at presentation, thromboembolic events occurred in 7.7% of those whose workup was inappropriate and in 1.2% of those whose workup was appropriate, yielding a relative risk of 6.4 and an absolute difference in risk of 6.5%. Increased risk for an inappropriate workup occurred in patients with these characteristics: pregnancy (odds ratio, 5.92), current anticoagulant use (OR, 4.57), age older than 75 (OR, 2.27), heart failure (OR, 1.53), or chronic lung disease (OR, 1.39).

Lack of a written diagnostic algorithm in the ED (OR, 2.54) and failure to assign risk scores (OR, 2.12) also were associated with inappropriate workup.

Comment: Use of guidelines can improve diagnostic accuracy and might reduce exposure to liability as well. To promote adherence, these simple PE guidelines should be incorporated into a departmental flowsheet or an electronic order entry system.

— J. Stephen Bohan, MS, MD, FACP, FACEP

Published in Journal Watch Emergency Medicine March 28, 2006

Citation(s):

Roy PM et al. Appropriateness of diagnostic management and outcomes of suspected pulmonary embolism. Ann Intern Med 2006 Feb 7; 144:157-64.

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