139 Admit or Discharge: Management of Incidental Pulmonary Embolism in an Emergency Center

Abstract

It is common for incidental pulmonary emboli (IPE) to be detected by computed tomography (CT) scans performed during a cancer evaluation. Our purpose was to describe outcomes in cancer patients presenting to an emergency department (ED) with a diagnosis of IPE. Retrospective chart review of patients presenting to the ED of a major cancer hospital from Jan 1, 2013 to Dec 31, 2014. Eligibility criteria included all age >18 y cancer patients undergoing an out-patient lung CT scan for cancer staging. Exclusion criteria were patients with known pulmonary embolism (PE) within 1 year prior, on anticoagulation therapy for Venous Thromboembolism (VTE), CT scan obtained for suspected PE, against medical advice discharge, or being a non-malignant cancer patient. Medical records were reviewed and data extracted for demographics, cancer type and stage, comorbidities, performance status, vitals, location of the emboli, anticoagulation, ED disposition, and cause of death. Of 1411 newly diagnosed PE patients during the study period, 208 (15%) presented to the ED met the entry criteria of IPE found during routine cancer staging. Of IPE patients, 15 were excluded (12 recurrent PE, 1 benign tumor, and 2 left against medical advice). Of the study cohort consisting of 193 patients, 111 (58%) were male, mean age was 63.37 years (SD=12.09), 139 (72%) were white, 27 (14%) black, 17 (9%) Hispanic, and 10 (5%) of other race/ethnicity. The majority of IPE patients had solid tumors (n=174, 90%) and 69% of patients (n=133) were discharged home on low molecular weight heparin. Cox regression analysis showed that sex, race, Charlson Comorbidity Index (age unadjusted), cancer stage, performance status, tachycardia, hypoxia and location of the emboli were associated with hospital admission. Admitted patients were more likely to die within 30 days, 16 of 60 (27%), than discharged patients, 0 (0%, Fisher exact test; p<0.001). Half of the admitted patients died within 180 days compared with 25 of 133 (19%) of the discharged patients (p<0.001). The risk of death within 30 days was higher if the emboli was located in the saddle or main pulmonary artery (PA) (40%) than those with lobar, segmental or sub-segmental PA (10%, 6% and 5 %, respectively). Multivariate analyses suggest that tachypnea and location of the emboli are associated with 30 day survival (p<0.05), and that performance status and location of the emboli are associated with 180 day survival and overall survival (p<0.05 for all). A cohort of selected ED cancer patients diagnosed with IPE may be identified for outpatient anticoagulation treatment and may be safely discharged.