A Rational Approach to Pulmonary Embolism Evaluation

From ACEP Now:

Emergency department over-investigation is, perhaps, nowhere more pervasive than in the workup of suspected pulmonary embolism (PE). Data from the EMPEROR Registry in 2011 found that the mortality rate directly attributable to PE was only 1 percent, while the all-cause 30-day mortality rate was 5.4 percent, and mortality from hemorrhage was 0.2 percent. Interestingly, 85 percent of deaths occurred in untreated patients while waiting for diagnostic confirmation. It appears from this data that most patients with PE die of comorbidities, such as malignancy, which might have placed the patient at risk for PE, or die from delay in treatment while waiting for imaging confirmation. Much of this decreased mortality may be related to the increase in diagnosis of clinically insignificant subsegmental PEs in the past two decades. Comparison of pooled data from uncontrolled outcome studies shows no increase in PE recurrence or death rates for patients diagnosed with isolated subsegmental PEs who were not anticoagulated compared to those who were. In the last 10 years, the incidence of diagnosed PE has doubled, despite no change in mortality, partly due to advances in CT technology and partly due to radiologists overcalling subsegmental PEs due to medico-legal concerns.

The unnecessary testing for PE, and subsequent treatments following diagnosis, may cause harm to patients, result in more follow-up testing from false-positive results, contribute to more anxiety for patients and their families, skyrocket costs, and consume valuable resources. PE costs the United States about $1.5 billion annually, with estimates of more than $30,000 per PE diagnosed.

To avoid unnecessary radiation and major bleeding complications as a result of anticoagulating patients with false-positive CT pulmonary angiogram (CTPA) results, it’s important to have a rational approach to imaging for PEs, as well as a good approach to shared decision making with our colleagues, radiologists, and patients.

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