Faculty Collaboration Database

Adverse Clinical Outcomes Among Patients With Acute Low-risk Pulmonary Embolism and Concerning Computed Tomography Imaging Findings. JAMA Netw Open 2023 May 01;6(5):e2311455

Date

05/31/2023

Pubmed ID

37256624

Pubmed Central ID

PMC10233419

DOI

10.1001/jamanetworkopen.2023.11455

Scopus ID

2-s2.0-85160965792 (requires institutional sign-in at Scopus site)   7 Citations

Abstract

IMPORTANCE: Most patients presenting to US emergency departments (EDs) with acute pulmonary embolism (PE) are hospitalized, despite evidence from multiple society-based guidelines recommending consideration of outpatient treatment for those with low risk stratification scores. One barrier to outpatient treatment may be clinician concern regarding findings on PE-protocol computed tomography (CTPE), which are perceived as high risk but not incorporated into commonly used risk stratification tools.

OBJECTIVE: To evaluate the association of concerning CTPE findings with outcomes and treatment of patients in the ED with acute, low-risk PE.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study used a registry of all acute PEs diagnosed in the adult ED of an academic medical center from October 10, 2016, to December 31, 2019. Acute PE cases were divided into high- and low-risk groups based on PE Severity Index (PESI) class alone or using a combination of PESI class and biomarker results. The low-risk group was further divided based on the presence of concerning CTPE findings: (1) bilateral central embolus, (2) right ventricle-to-left ventricle ratio greater than 1.0, (3) right ventricle enlargement, (4) septal abnormality, or (5) pulmonary infarction. Data analysis was conducted from June to October 2022.

MAIN OUTCOMES AND MEASURES: The primary outcome was all-cause mortality at 7 and 30 days. Secondary outcomes included hospitalization, length of stay, need for intensive care, use of echocardiography and/or bedside ultrasonography, and activation of the PE response team (PERT) .

RESULTS: Of 817 patients (median [IQR] age, 58 [47-71] years; 417 (51.0%) female patients; 129 [15.8%] Black and 645 [78.9%] White patients) with acute PEs, 331 (40.5%) were low risk and 486 (59.5%) were high risk by PESI score. Clinical outcomes were similar for all low-risk patients, with no 30-day deaths in the low-risk group with concerning CTPE findings (0 of 151 patients) vs 4 of 180 (2.2%) in the low-risk group without concerning CTPE findings and 88 (18.1%) in the high-risk group (P < .001). Low-risk patients with concerning CTPE findings were less frequently discharged from the ED than those without concerning CTPE findings (3 [2.0%] vs 14 [7.8%]; P = .01) and had more frequent echocardiography (87 [57.6%] vs 49 [27.2%]; P < .001) and PERT activation for consideration of advanced therapies (34 [22.5%] vs 11 [6.1%]; P < .001).

CONCLUSIONS AND RELEVANCE: In this single-center study, CTPE findings widely believed to confer high risk were associated with increased hospitalization and resource utilization in patients with low-risk PE but not short-term adverse clinical outcomes.

Author List

O'Hare C, Grace KA, Schaeffer WJ, Hyder SN, Stover M, Liles AL, Khaja MS, Cranford JA, Kocher KE, Barnes GD, Greineder CF

Author

William J. Schaeffer DO Assistant Professor in the Emergency Medicine department at Medical College of Wisconsin

MESH terms used to index this publication - Major topics in bold

Adult
Biomarkers
Cohort Studies
Female
Humans
Male
Middle Aged
Pulmonary Embolism
Risk Factors
Tomography, X-Ray Computed