Pulmonary Embolism Misdiagnosed in 1 of 3 ED Patients

One third of patients who arrived at the emergency department with pulmonary embolism (PE) were misdiagnosed before being sent home or hospitalized, according to a retrospective observational study. Chronic lung conditions such as asthma frequently contributed to the delay in diagnosis.

Juan Torres-Macho, PhD, from the Emergency Department, Hospital Universitario Infanta Cristina, Parla, and Department of Medicine, Complutense University, Madrid, Spain, and colleagues report their findings in an article published online September 23 in the American Journal of Emergency Medicine.

Although prompt diagnosis can improve patients' health outcomes, correctly diagnosing PE remains challenging.

The researchers studied the clinical charts of patients older than 18 years who had been admitted to 3 university-affiliated hospitals in Madrid, Spain, with a diagnosis of acute symptomatic PE from April 2008 to December 2011. Of 436 patients included in the study, 146, or 33.5%, had a delayed diagnosis of PE.

In a multivariate analysis, the investigators found that patients with a history of chronic obstructive pulmonary disease were more likely to have a delayed diagnosis (odds ratio [OR], 4.3; 95% confidence interval [CI], 2.2 - 8.6; P = .00), as were those with a history of asthma (OR, 3.4; 95% CI, 1.2 - 9.7; P = .01). Patients with a cough (OR, 2.5; 95% CI, 1.4 - 4.7; P = .002) or the absence of syncope (OR, 4.3; 95% CI, 1.2 - 14.7; P = .02) on clinical presentation were also more likely to have delays in diagnosis. Other factors associated with delayed PE diagnosis included dyspnea (OR, 2.3; 95% CI, 1.1 - 4.8; P = .02), the presence of pleuro-mechanic thoracic pain (OR, 3.6; 95% CI, 1.3 - 9.5; P = .01), fever (OR, 2.7; 95% CI, 1.2 - 7.8; P = .04), hemoptysis (OR, 5; 95% CI, 1.4 - 17.1; P = .009), and the presence of a pulmonary infiltrate on chest radiography (OR, 2.5; 95% CI, 1.1 - 6.2; P = .04).

Despite the delay in accurately diagnosing PE, the researchers did not find significant differences in mortality in hospitalized patients; higher mortality rates in patients who were sent home may be more closely linked to other health conditions, the researchers write.

"[O]ur study shows that delay in diagnosis of acute PE is frequent despite current diagnostic strategies," the authors conclude. "These findings support the need for a high degree of vigilance for PE in this subgroup of patients, and clinicians should be aware of these factors to provide expedited management of acute PE."

Am J Emerg Med. Published online September 23, 2013. Abstract

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