Pulmonary embolism: Is it truly missed in the emergency department?

Abstract

Study objectives: Emergency medicine and internal medicine literature states that pulmonary embolism is a common entity that is frequently misdiagnosed in the emergency department (ED) and often fatal when untreated. Definitive diagnosis entails costly radiographic studies, and it is likely that these studies continue to be overused, especially in low-risk patients. Our goals are to review current literature for statistics about the prevalence, misdiagnosis, and mortality of pulmonary embolism and to determine whether these were applicable to the ambulatory, hemodynamically stable patient presenting to the ED with signs and symptoms consistent with pulmonary embolism. Methods: We conducted an ancestral search for epidemiology statistics for pulmonary embolism, starting with review articles on pulmonary embolism in commonly referenced emergency medicine and internal medicine textbooks and peer-reviewed publications. Results: We located 20 articles for our search. These reported an incidence of pulmonary embolism ranging from 500,000 to 780,000 annually, with more than 400,000 missed diagnoses. There was general agreement on mortality for untreated disease, approximately 30% (range 18% to 35%). Either directly or indirectly, the most commonly referenced citation was dated 1975. This citation drew from government mortality statistics from the 1960s, inpatient and autopsy study data from the 1940s to 1960s, and author estimates to extrapolate: mortality rate, total incidence of disease, and number of cases that are misdiagnosed. There were no citations that assessed this information in the ED setting. Conclusion: Current epidemiology about pulmonary embolism may be applicable to inpatients or the recently deceased but is unlikely to provide an accurate representation of disease in the outpatient setting. Studies to provide incidence and outcome data for pulmonary embolism in the ambulatory ED patient are necessary. Study objectives: Emergency medicine and internal medicine literature states that pulmonary embolism is a common entity that is frequently misdiagnosed in the emergency department (ED) and often fatal when untreated. Definitive diagnosis entails costly radiographic studies, and it is likely that these studies continue to be overused, especially in low-risk patients. Our goals are to review current literature for statistics about the prevalence, misdiagnosis, and mortality of pulmonary embolism and to determine whether these were applicable to the ambulatory, hemodynamically stable patient presenting to the ED with signs and symptoms consistent with pulmonary embolism. Methods: We conducted an ancestral search for epidemiology statistics for pulmonary embolism, starting with review articles on pulmonary embolism in commonly referenced emergency medicine and internal medicine textbooks and peer-reviewed publications. Results: We located 20 articles for our search. These reported an incidence of pulmonary embolism ranging from 500,000 to 780,000 annually, with more than 400,000 missed diagnoses. There was general agreement on mortality for untreated disease, approximately 30% (range 18% to 35%). Either directly or indirectly, the most commonly referenced citation was dated 1975. This citation drew from government mortality statistics from the 1960s, inpatient and autopsy study data from the 1940s to 1960s, and author estimates to extrapolate: mortality rate, total incidence of disease, and number of cases that are misdiagnosed. There were no citations that assessed this information in the ED setting. Conclusion: Current epidemiology about pulmonary embolism may be applicable to inpatients or the recently deceased but is unlikely to provide an accurate representation of disease in the outpatient setting. Studies to provide incidence and outcome data for pulmonary embolism in the ambulatory ED patient are necessary.