Clinical question: What is the prevalence of pulmonary embolism (PE) among emergency department (ED) patients with recent onset (less than one month) of exertional dyspnea?
Dr. Chockalingam
Background: PE is often associated with the diagnostic triad of pleuritic chest pain, dyspnea, and occasional hemoptysis. Non-specific symptoms, such as subacute dyspnea on exertion, may delay the diagnosis of PE. Despite the plausibility of PE presenting with dyspnea on exertion with or without other symptoms, no prior studies have established the rate of PE among patients with recent-onset exertional dyspnea. Guidelines and pretest probability calculators do not address this population’s risk.
Study design: Multi-center prospective cross-sectional study
Setting: 14 Italian EDs from September 2018 to August 2020
Synopsis: In 417 patients with severe (grade 3-4 on the modified Medical Research Council dyspnea scale) acute-onset dyspnea, PE was excluded in 32.1% (n = 134) using age-adjusted d-dimer and low-risk simplified Wells score. CT pulmonary angiograms identified PE in 47.3% of the remaining 283 patients. PE was found in 32.1% (95% CI, 27.8 to 36.8) of the 417 participants. PE was more frequent (44.1%) in those with other signs/symptoms of venous thromboembolism (n = 213), and less frequent (19.6%) in those with isolated exertional dyspnea (n = 204). Among those with isolated exertional dyspnea, prevalence was lower (14.6%) in those with alternative diagnosis for dyspnea (n = 96), and higher (24.1%) in those without alternative diagnosis (n = 108). All PEs except one were in segmental or larger arteries. The trial was stopped early according to predetermined rules after an interim analysis showed PE prevalence greater than 20%.
Exclusion criteria included age greater than 75, prior history of venous thromboembolism, current anticoagulation, chronic dyspnea (greater than one month), and less severe dyspnea.
Bottom line: In this sample, PEs were found in one-third of all patients with acute-onset exertional dyspnea, and almost half of those with positive d-dimers and/or elevated pretest probability.
Citation: Prandoni P, Lensing AWA, et al. Prevalence of pulmonary embolism among patients with recent onset of dyspnea on exertion. A cross-sectional study. J Thromb Haemost. 2023;21(1):68-75.
Dr. Chockalingam is an instructor in the division of hospital medicine at the University of Colorado Anshutz Medical Campus in Aurora, Colo.