Pulmonary Embolism In Elderly Patients Research Articles

Pulmonary embolism and atrial fibrillation: analysis of data from the SIRENA Russian registry

Aim. To present the clinical characteristics and in-hospital prognosis in patients with pulmonary embolism (PE) and atrial fibrillation (AF).Material and methods. On the initiative of a working group of physicians, the basic principles of an observational prospective study (SIRENA registry) have been developed.Results. Among the 660 patients included in the registry, AF was diagnosed in almost every fourth patient — in 22,9% of cases (n=151), which reflects its high incidence in relation to PE. The prevalence of AF corresponded to such conditions as heart failure (HF) (23,2%; n=153), diabetes (15,6%; n=103), and hypertension (HTN) (65,7% n=400). The diagnosis of AF in most patients is based on the history data (n=144; 95,4%), while the first registered AF episode was verified in 7 patients (4,6%). Patients with AF were characterized by older age, significantly higher prevalence of HF (51,2%), HTN (80,8%), chronic kidney disease (18,5%), stroke or transient ischemic attack (23,2%). It is important to note the low prevalence of anticoagulant therapy (15,3%) in the group of patients with previously diagnosed AF (n=144). The prevalence of thrombolytic therapy in patients with AF was significantly lower than among patients without AF (13,9 vs 25,8% (p=0,026)), which is due to contraindications and underdiagnosis of PE. Given the predominantly senile age, high comorbidity rate in patients with AF, as well as the absence of outpatient anticoagulant therapy, in-hospital mortality in patients with PE and AF was 31,1%, and significantly differed from that in those without AF 12,6% (p=0,001). In the general group, post-mortem diagnosis of PE was noted in 7,7% of cases (n=51), of which the proportion of patients with AF was 54,9% (n=28). A possible explanation for the underestimation of PE in AF patients was an erroneous explanation of its manifestations (tachypnea, tachycardia, lower limb edema) due to concomitant HF.Conclusion. Suspicion for PE in elderly patients with AF and manifestations of HF decompensation, as well as the timely administration of anticoagulant therapy, will prevent both arterial and venous embolism.

Clinical and prognostic analysis of acute pulmonary thromboembolism in the elderly

Objective: To analyse the clinical characteristics and to explore the prognostic factors of acute pulmonary thromboembolism in the elderly. Methods: The medical records of inpatients with acute pulmonary thromboembolism discharged from Peking Union Medical College Hospital from January 1, 2012, to February 1, 2019 were retrospectively reviewed. The eligible patients were divided into elderly group (≥ 60 years old) and non-elderly group (<60 years old). The clinical symptoms, complications, laboratory results, pulmonary embolism severity index (PESI) and mortality were compared between the two groups. Mortality was further compared among elderly patients of different age groups. Cox regression analysis was used to analyze the risk factors of 7-day and 30-day death in elderly patients with pulmonary embolism. Results: A total of 503 patients with acute pulmonary embolism were included, including 279 cases in the elderly group and 224 cases in the non-elderly group. The incidence of cardiac arrest was higher in the elderly group compared with non-elderly group, while the incidence of chest pain and hemoptysis was less common in the elderly group. The proportions of comorbidities, including diabetes, hypertension, and coronary heart disease were higher in the elderly group while the proportion of autoimmune diseases was higher in the non-elderly group. In terms of prognosis, the PESI score and 7-day and 30-day mortality in the elderly group were higher than those in the non-elderly group. The mortality of elderly patients increased with age. Cox univariate regression analysis showed that infection, hypoalbuminemia, hypocalcemia, elevated cardiac troponin(cTnI), elevated N-terminal prohormone of brain natriuretic pepride(NT-proBNP) and PESI grade were associated with 30-day death. Multivariate Cox regression analysis showed that PESI grade and decreased serum calcium concentration were independent risk factors for 7-day death of pulmonary embolism in elderly patients. PESI grade, decreased serum calcium concentration and infection were independent risk factors for 30-day death. Conclusions: The mortality of elderly patients with pulmonary embolism was higher than that of non-elderly patients, and the mortality increased gradually with age. PESI grade, decreased serum calcium concentration and infection were independent risk factors for 30-day death of pulmonary embolism in elderly patients.

Current status of rivaroxaban in elderly patients with pulmonary embolism (Review).

Acute pulmonary embolism (PE) occurs with a high incidence rate in elderly patients, demonstrating complex clinical manifestations, as well as a difficult anticoagulant treatment strategy. Currently, there is limited understanding of the selection criteria for anticoagulant treatment in elderly patients with PE. In fact, the vitamin K antagonist warfarin, a commonly prescribed anticoagulant, has multiple disadvantages, including a narrow therapeutic range, unpredictable pharmacokinetics, multiple food and drug interactions and genetic polymorphisms resulting in poor response to this therapy; therefore, routine laboratory monitoring is required. Most elderly patients with PE fail to adhere to the treatment regimen or even discontinue it, and clinicians are equally hesitant to initiate oral anticoagulants in elderly patients with PE. This leads to a dilemma regarding the use of anticoagulation therapies and a worse prognosis for the patients. Rivaroxaban, a direct Xa factor inhibitor, has demonstrated considerable practical and clinical advantages, exhibits fast-start action pharmacokinetic and pharmacodynamic characteristics, and has an enhanced predictable anticoagulant effect with fewer drug-drug interactions. Based on randomized controlled trials and real-world clinical practice, rivaroxaban has also been recognized as a safe and effective anticoagulant, and these advantages have improved the therapeutic compliance of elderly patients with PE. Thus, this review focused on the current status of rivaroxaban treatment for elderly patients with PE, and described its significance in changing the current anticoagulation treatment regimens for patients. It is expected that rivaroxaban will become a good choice for the treatment of PE in elderly patients.

Clinical and Laboratory Aspects of the Severity of Pulmonary Embolism in Elderly Patients versus Adult Patients A single centre study

Pulmonary thromboembolism is currently one of the leading causes of disease burden and mortality in Europe, also known as the great masquerader, for its ability to mimic other diseases or to present itself with few symptoms, especially when the pulmonary embolism is very small. With aging population, increased survival of cancer patients and the addition of multiple debilitating diseases such as dementia, heart failure, chronic kidney disease the rate of pulmonary embolism is spiking, with more and more small pulmonary embolism being diagnosed, that may have no immediate impact on mortality, but which may contribute to an increase in morbidity. We have examined retrospectively 108 consecutively cases of pulmonary thromboembolism that have presented in the Emergency Department of Municipal Hospital in Timisoara, Romania over the course of twenty-one months from September 2016 to May 2018 and we evaluated the clinical and laboratory findings in studying the influence of age over the severity of pulmonary embolism.

Clinical and Laboratory Aspects of the Severity of Pulmonary Embolism in Elderly Patients versus Adult Patients A single centre study

Pulmonary thromboembolism is currently one of the leading causes of disease burden and mortality in Europe, also known as the great masquerader, for its ability to mimic other diseases or to present itself with few symptoms, especially when the pulmonary embolism is very small. With aging population, increased survival of cancer patients and the addition of multiple debilitating diseases such as dementia, heart failure, chronic kidney disease the rate of pulmonary embolism is spiking, with more and more small pulmonary embolism being diagnosed, that may have no immediate impact on mortality, but which may contribute to an increase in morbidity. We have examined retrospectively 108 consecutively cases of pulmonary thromboembolism that have presented in the Emergency Department of Municipal Hospital in Timisoara, Romania over the course of twenty-one months from September 2016 to May 2018 and we evaluated the clinical and laboratory findings in studying the influence of age over the severity of pulmonary embolism.

Pulmonary embolism in very elderly patients. A diagnostic challenge

BackgroundDiagnosing pulmonary embolisms can be challenging, given that its presentation shares clinical manifestations with other conditions. For patients 80 years of age or older, the healthcare challenge increases due to associated comorbidity when compared with younger patients (<80 years). ObjectiveThe aim of our study was to report the incidence of pulmonary embolism in elderly patients in our setting and identify differences in the clinical manifestations, comorbidity and laboratory parameters between these 2 groups of patients. MethodWe conducted a hospital-based, case–control study to review the pulmonary embolisms diagnosed in our center using computed tomography pulmonary angiography between 2013 and 2016. ResultsThe study included 413 patients, 124 of whom were 80 years of age or older, with a median age of 72 years (IQR, 58–81). The typical presentation triad was uncommon and showed no differences between subgroups. The main symptoms presented by these groups were dyspnea (73.4% vs. 63.7% for the elderly and younger groups, respectively; p=.055), chest pain (26.6% vs. 39.5%; p=.013) and cough/haemoptysis (31.1% vs. 18.9%; p=.021). The elderly group had more comorbidity (4.88±2.55 vs. 2.89±2.85; p=.0001). ConclusionThirty percent of the pulmonary embolisms occurred in the elderly group. The typical presentation form was uncommon. We detected significant differences in individual symptoms, comorbidity and laboratory parameters compared with the younger patients.

Embolia pulmonar en los pacientes muy ancianos. Un reto diagnóstico

BackgroundDiagnosing pulmonary embolisms can be challenging, given that its presentation shares clinical manifestations with other conditions. For patients 80 years of age or older, the healthcare challenge increases due to associated comorbidity when compared with younger patients (<80 years). ObjectiveThe aim of our study was to report the incidence of pulmonary embolism in elderly patients in our setting and identify differences in the clinical manifestations, comorbidity and laboratory parameters between these 2 groups of patients. MethodWe conducted a hospital-based, case-control study to review the pulmonary embolisms diagnosed in our centre using computed tomography pulmonary angiography between 2013 and 2016. ResultsThe study included 413 patients, 124 of whom were 80 years of age or older, with a median age of 72 years (IQR, 58-81). The typical presentation triad was uncommon and showed no differences between subgroups. The main symptoms presented by these groups were dyspnoea (73.4% vs. 63.7% for the elderly and younger groups, respectively; P=.055), chest pain (26.6% vs. 39.5%; P=.013) and cough/haemoptysis (31.1% vs. 18.9%; P=.021). The elderly group had more comorbidity (4.88±2.55 vs. 2.89±2.85; P=.0001). ConclusionThirty percent of the pulmonary embolisms occurred in the elderly group. The typical presentation form was uncommon. We detected significant differences in individual symptoms, comorbidity and laboratory parameters compared with the younger patients.

Permanent atrial fibrillation and pulmonary embolism in elderly patients without deep vein thrombosis: is there a relationship?

Permanent Atrial Fibrillation (pAF) is associated with increased risk of embolic complications. The relationship between pAF and pulmonary embolism (PE) has not been extensively investigated in elderly patients. Here, we aim at verifying whether pAF is associated to an increased risk of PE in a cohort of elderly patients with and without Deep Vein Thrombosis (DVT). 235 patients older than 65years with PE with or without pAF were retrospectively enrolled and stratified by the absence or presence of DVT. The diagnosis of PE was performed by computed tomography angiography (CTA). Right echocardiographic parameters were monitored. The severity of PE was evaluated by CTA quantization (PE score = 1, involvement of main branches of pulmonary artery) and by dimer-D (> 3000µg/L). DVT was identified only in 51 cases of PE (21.7%). pAF prevalence was higher in PE without than in those with DVT (64.9% vs. 35.1%, p < 0.01). PE severity was more evident in pAF patients without than in those with DVT. Multivariate analysis of the role of pAF on PE severity confirms these results (RR = 3.41 for PE score = 1, and 8.55 for dimer-D > 3000µg/L). We conclude that in elderly patients with PE, the prevalence of pFA was doubled, in the absence of DVT, and it is associated with a more severe PE in the absence than in the presence of DVT. Thus, in the absence of DVT, pFA should be considered as cause of PE.

ŪMINĖ PLAUČIŲ ARTERIJOS TROMBINĖ EMBOLIJA: WELLS IR MODIFIKUOTOS GENEVA SKALIŲ BEI D-DIMERŲ KONCENTRACIJOS PROGNOSTINĖS VERTĖS SENYVO AMŽIAUS PACIENTAMS

Įvadas: nėra būdingų klinikinių simptomų, fizinio ištyrimo ir laboratorinių tyrimų duomenų, kurie patikimai atmestų plaučių arterijos trombinę emboliją. Klinikinį ligonio, kuriam įtariama PATE, įvertinimą gali palengvinti klinikinės PATE tikimybės skalės. Tikslas: nustatyti ūminės plaučių arterijos trombinės embolijos (PATE) D-dimerų koncentracijos, Wells ir modifikuotos Geneva skalių bei jų kombinacijų su D-dimerų koncentracija prognostines vertes senyvo amžiaus (≥ 65 m.) pacientams. Metodika: retrospektyviai analizuotos 2013 m. – 2014 m. laikotarpiu Vilniaus universiteto ligoninės Santaros klinikų priėmimo skyriuje dėl įtariamos ūminės PATE hospitalizuotų pacientų ligos istorijos. Rinkti demografiniai, anamnezės, apžiūros, laboratoriniai ir KT angiografijos duomenys. Remiantis klinikine išraiška, apskaičiuotos Wells ir modifikuotos Geneva skalių teigiamos prognostinės vertės bei kiekvienos iš jų kombinacijos su D-dimerų koncentracija neigiamos prognostinės vertės &amp;lt; 65 m. ir ≥ 65 m. amžiaus pacientams. Duomenys apdoroti Microsoft Excel, SPSS V.22, MedCalc 11.5.0 programomis. Pasirinktas reikšmingumo lygmuo p &amp;lt; 0,05. Rezultatai: tyrimo imtis 516 pacientų: ≥ 65 m. amžiaus grupę sudarė 330 (61,4 proc.), &amp;lt; 65 m. amžiaus grupę – 186 (38,6 proc.) pacientai. KT angiografijos metu ūmi PATE patvirtinta 150 (45,5 proc.) ≥ 65 m. amžiaus ir 69 (37 proc.) &amp;lt; 65 m. amžiaus pacientams. ≥ 65 m. grupėje Wells skalės teigiama prognostinė vertė 74,3 proc. (95% CI: 65,06 – 82,20), modifikuotos Geneva skalės – 49,6 proc. (95% CI: 43,49 – 55,77), p &amp;lt; 0,001. &amp;lt; 65 m. amžiaus grupėje – 66,1 proc. (95% CI: 52,99 77,67) ir 50,5 proc. (95% CI: 40,36 – 60,60), p &amp;lt; 0,001. Neigiama prognostinė D-dimerų vertė ≥ 65 m. grupėje 96,30 proc. (95% CI: 81,03 – 99,91), &amp;lt; 65 m. grupėje 95,74 proc. (95% CI: 85,46 – 99,48). D-dimerų ir Wells bei D-dimerų ir modifikuotos Geneva testų kombinacijos neigiama prognostinė vertė ≥ 65 m. grupėje: 100,00 proc. (95% CI: 84,56 – 100,00) ir 100,00 proc. (95% CI: 59,04 – 100,00); &amp;lt; 65 m. amžiaus grupėje 100,00 proc. (95% CI: 91,40 – 100,00) ir 100,00 proc. (95% CI: 89,11 – 100,00). Išvados: Wells skalės teigiama prognostinė vertė aukštesnė nei modifikuotos Geneva skalės teigiama prognostinė vertė. Atmetant PATE diagnozę D-dimerų ir Wells bei D-dimerų ir modifikuotos Geneva skalių kombinacijos neigiama prognostinė vertė aukštesnė nei vien D-dimerų koncentracijos neigiama prognostinė vertė.

0231 : Clinical features of pulmonary embolism in elderly

The aim of this study was to determine the clinical features of pulmonary embolism in elderly patients (≥70 years). All patients hospitalized for PE in our cardiology department from January 2013 to December 2014 were included in the study. The aim was to compare the features of pulmonary embolism in elderly patients (≥70 years) (Group 1) to those of patients younger than 70 years (Group 2). The following data were recorded: past medical history, risk factors for venous thrombo-embolism (VTE), clinical features, and echocardiographic data. The population was composed of 50 patients (women 78%) with a median age of 55,4 years ± 15,8. There was no statistical difference for risk factors of VTE. Syncope/faintness was more frequent in elderly patients (21% versus 0%, P=0.019). On admission we note the predominance of shock in group 1 (42% versus 11%, p=0.020). The diagnosis of PE was often mentioned and even confirmed by Transthoracic echocardiography allowing us to start thrombolysis without waiting for confirmation by chest CT. TTE has shown a thrombus in the right cavities in 35% of patients in Group 1 against only 2.7% of patients in group 2 (P=0.005) and right ventricular (RV) dysfunction in 85% of group 1 versus 25% group 2 (P <0.0001), as well as RV dilatation, the paradoxical septum and pulmonary hypertension who were more frequently found in elderly subjects (100% vs 63% P = 0.010; 92% vs 61% P=0.039 and 71% vs 38% P=0.039 respectively). Was used to thrombolysis in 6 patients (42%) in group 1 vs 3 patients (8%) in group 2 (P=0.009). Our work emphasizes the seriousness of pulmonary embolism in the elderly. We confirm the difficulty of diagnosis of PE in this population. The author hereby declares no conflict of interest

Effect of Bone Cement Implantation on Haemodynamics in Elderly Patients and Preventive Measure in Cemented Hemiarthroplasty.

This study was to investigate the influence of bone cement implantation on haemodynamics and the preventive effect of epinephrine hydrochloride on pulmonary embolism in elderly patients with cemented semihip replacement. 128 patients were retrospectively analyzed. The patients were treated with (group A, 64 cases) or without (group B, 64 cases) epinephrine hydrochloride saline. The monitoring indicators included systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate (HR), and pulse oxygen saturation (SPO2). The indicators of the two groups were compared before and 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 minutes after bone cement implantation. Analysis of variance and SNK-q test were used for the statistical analysis. Blood pressure and SPO2 of group B decreased with statistical difference (P < 0.05) and HR increased without statistical significance, comparing with those of group A. In group A, SBP, DBP, MAP, HR, and SPO2 after bone cement implantation did not change significantly at each time point comparing with before implantation (P > 0.05). Bone cement implantation has significant influence on hemodynamics in elderly patients with hemiarthroplasty. Flushing the bone marrow cavity with saline epinephrine hydrochloride is an effective measure to reduce the incidence of bone cement pulmonary embolism.

Pulmonary embolism in elderly patients: Prognostic impact of the Cumulative Illness Rating Scale (CIRS) on short-term mortality

BackgroundPulmonary embolism (PE) is associated with high short-term mortality in elderly patients, even when hemodynamically stable. MethodsOne hundred and seventy hemodynamically stable patients with confirmed PE (41<65years and 129≥65years) were prospectively followed for one month in order to assess whether comorbidities can predict short-term mortality in elderly patients. Upon admission, patients’ clinical characteristics (including instrumental and laboratory parameters) were evaluated, and two clinical scores were calculated: the Cumulative Illness Rating Scale (CIRS), commonly used to evaluate comorbidities in elderly patients, and the Pulmonary Embolism Severity Index (PESI). ResultsFifteen patients (all elderly) died within one month from their PE diagnosis (mortality rate=8.8%; 95%CI:4.6-13.1%). In these non survivors, arterial partial oxygen pressure (p<0.0001) and saturation (p<0.0001), pH (p=0.001) and systolic blood pressure (p=0.017) at admission were significantly lower than in survivors, whereas their respiratory rate (p<0.0001), white blood cells (p<0.0001), lactate dehydrogenase (p<0.0001), troponin T (p=0.001) and D-dimer (p=0.023) were significantly higher. CIRS correlated with PESI (rho=0.54, p<0.0001), and was higher in non-survivors (p=0.002). The age- and sex-adjusted odds ratio of 1-month mortality was 1.91 (95%CI:1.24-2.95) for every 1-point increase in CIRS. The AUC was 0.78 (95%CI:0.67-0.89) for the logistic model containing CIRS, and 0.88 (95%CI:0.79-0.96) for that containing PESI (p=0.059). ConclusionsIn elderly patients with PE, CIRS demonstrated a fairly good performance in predicting short-term mortality. Its easiness and suitability for use in common clinical practice make CIRS a potentially useful prognostic score for short-term mortality in these patients.

Comparison of clinical characters of pulmonary embolism in elderly and non-elderly patients

The clinical materials of pulmonary embolism in 130 elderly patients (>65 years) and 66 non-elderly patients (≤65 years) were retrospectively analyzed. The most common risk factors for pulmonary embolism in elderly patients were cardiovascular disease, chronic obstructive pulmonary disease and deep venous disease. And the most common risk factors for pulmonary embolism in non-elderly patients were deep venous disease and surgery. Correct first diagnosis rate in elderly group was less than that in non-elderly group(102/130 vs. 62/66) while misdiagnosis rate in elderly group was more than that in non-elderly group(28/130 vs. 4/66). Consistency of revised Geneva score and ventilation and perfusion V/Q scanning was excellent in elderly group while poor in non-elderly group. Key words: Pulmonary embolism; Age factors

Particularités cliniques de l’embolie pulmonaire chez la personne âgée : étude comparative de 64 patients

PurposeTo date only a few studies regarding pulmonary embolism (PE) in elderly have been published. The aim of this study was to determine the clinical features of PE in elderly patients (≥75years). MethodsAll patients hospitalized for PE in our internal medicine department from January 2005 to December 2010 were included in the study. The aim was to compare the features of PE in elderly patients (≥75years) to those of patients younger than 75years. The following data were recorded: past medical history, risk factors for venous thrombo-embolism (VTE), clinical features, and PE etiologies. ResultsThe population was composed of 64 patients (women 56%) with a median age of 82years (IQR: 13.5). There was no statistical difference for risk factors of VTE. Syncope was more frequent in elderly patients (33% versus 7%, P=0.04) whereas thoracic pain predominated in younger patients (36,5% versus 7%, P=0.005). Chronic obstructive pulmonary disease was more frequent in the past medical history of elderly patients. The diagnostic of PE was less suspected in elderly patients (47% versus 72%, P=0.035). The etiologies were similar between the two groups. ConclusionOur study highlights the frequency of syncope as the presenting feature of PE in elderly, whereas thoracic pain is uncommon. We confirmed the difficulty to diagnose PE in elderly population.

PREDICTIVE VALUES OF THE WELLS AND REVISED GENEVA SCORES COMBINED WITH D-DIMER FOR SUSPECTED PULMONARY EMBOLISM IN ELDERLY PATIENTS

ObjectivesTo compare the predictive values of the Wells and revised Geneva scores combined with D-dimer for suspected pulmonary embolism (PE) in elderly patients, and to explore suitable and simple predictive...

Evaluation of B-type natriuretic peptide to predict complicated pulmonary embolism in patients aged 65 years and older: brief report

Purposes We evaluated the use of plasma B-type natriuretic peptide (BNP) levels for risk stratification in elderly patients with acute pulmonary embolism (PE). Basic Procedures Bedside BNP assay was performed blindly at admission in consecutive patients older than 65 years with acute PE. A complicated PE was defined as any of the following: death, cardiopulmonary resuscitation, mechanical ventilation, use of vasopressors, thrombolysis, surgical embolectomy, or admission in intensive care unit. Main Findings Fifty-one patients (age, 79 ± 9 years) were included. Thirteen patients had adverse events: 11 were admitted in the intensive care unit and 3 died. The median BNP level (95% confidence interval [CI]) was higher in the group of patients with complicated PE, 274 pg/mL (95% CI, 142-581 pg/mL) vs 78 pg/mL (95% CI, 33-230 pg/mL) ( P < .05), respectively. The receiver operating characteristic curve showed that BNP significantly predicted a complicated PE with an area under the receiver operating characteristic curve of 0.72 (95% CI, 0.58-0.83) ( P < .05). The best threshold value was 200 pg/mL with a sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 0.69 (0.43-0.87), 0.63 (0.47-0.77), 0.39 (0.22-0.59), 0.86 (0.69-0.94), and 0.65 (0.51-0.77), respectively. Conclusion Our study suggests that BNP is not a reliable marker of complicated PE in elderly patients.

The Challenge of Diagnosing Pulmonary Embolism in Elderly Patients: Influence of Age on Commonly Used Diagnostic Tests and Strategies

Pulmonary embolism (PE) is a potentially fatal disease if left untreated. The prevalence of PE increases markedly with age, and its diagnosis in elderly people is difficult because many cardiopulmonary conditions may mimic clinical presentation of PE, and age may unfavorably influence the characteristics of diagnostic tests for PE. The modern approach to PE is based on sequential diagnostic strategies based on clinical probability, D-dimer measurement, lower limb compression ultrasonography, ventilation-perfusion lung scan, and helical computed tomography (hCT). Pulmonary angiogram is rarely necessary because the noninvasive diagnostic evaluation is usually conclusive. Age reduces the clinical usefulness of D-dimer and ventilation-perfusion lung scan. D-dimer allows excluding PE in only 5% of patients aged 80 and older, compared with 60% younger than 40. Similarly, the rate of inconclusive ventilation-perfusion lung scans is almost twice as high (58%) in patients older than 70 and in patients younger than 40 (32%). In contrast, aging does not change the diagnostic accuracy of clinical probability assessment, whether empirical or as determined by prediction rules, nor appear to influence the diagnostic characteristics of lower limb compression ultrasonography and hCT. Therefore, a rational diagnostic approach to PE in older people should rest mainly on the sequential use of those tests that have demonstrated strong diagnostic yield, accuracy, and safety in this population.

Thirty-Day Case-Fatality Rates for Pulmonary Embolism in the Elderly

Short-term race- and sex-specific case- fatality rates for pulmonary embolism (PE) in the elderly have not been studied previously, to our knowledge. To examine 30-day race- and sex-specific case-fatality rates of PE in the Medicare population and to determine the risk of fatality when PE was a secondary diagnosis in 6 primary concurrent conditions and 3 surgical procedures. Case-fatality rates were determined using the Medicare Provider Analysis and Review Record tiles from 1984 through 1991. All Medicare Part A beneficiaries aged 65 years or older were included, yielding more than 400,000 patients with PE. Case-fatality rates 30 days from hospital admission were calculated for both a primary discharge diagnosis of PE and a secondary discharge diagnosis of PE. Blacks with PE as a primary discharge diagnosis had an overall age-adjusted case-fatality rate of 16.1% compared with a rate of 12.9% for whites. When PE was a secondary diagnosis, blacks also had higher rates than whites (34.7% vs 30.2%). Men had a fatality rate of 13.7% whereas women had a rate of 12.8% when PE was the primary diagnosis. For a secondary diagnosis of PE, men had a rate of 32.8% compared with a rate of 28.6% for women. The risk of fatality was very high when PE was a secondary discharge diagnosis in 6 primary concurrent conditions (congestive heart failure, cancer, chronic obstructive pulmonary disease, myocardial infarction, hip fracture, and stroke) and 3 common surgical procedures (coronary artery bypass graft, hip replacement, and knee replacement) relative to the case-fatality rate when PE was not present in these conditions. Our results indicate that there are racial and gender differences in 30-day case-fatality rates for PE in elderly patients. The high fatality risk associated with PE as a comorbid factor among common primary concurrent conditions and procedures calls attention to the need for more effective prophylaxis of deep vein thrombosis and rapid diagnosis and treatment of PE when it occurs.

Alveolar-arterial oxygen gradients in elderly patients with suspected pulmonary embolism

To determine the usefulness of the alveolar-arterial oxygen gradient for detecting pulmonary embolism in elderly patients presenting to the emergency department. Retrospective cohort analysis. Two university-affiliated community hospitals. Consecutive patients more than 64 years old who underwent pulmonary angiography for the presumed diagnosis of acute pulmonary embolism. Arterial blood gas samples were chosen for comparative analysis only if obtained when the pulmonary embolism first was suspected clinically (before lung scans or angiograms) and the patient was breathing room air. Predicted PaO2 and alveolar-arterial gradients were calculated for each patient. A total of 123 patients met all study criteria; mean +/- SD patient age was 74 +/- 6 years. Fifty-four patients (44%) had angiographically documented emboli. In this cohort, the mean PaO2 was 61.4 mm Hg (range, 34.3 to 83.8 mm Hg), and the mean alveolar-arterial gradient was 46.6 mm Hg (range, 19 to 75 mm Hg). In three patients, the alveolar-arterial gradient was normal for their age. However, in comparison with the 69 patients with normal pulmonary angiograms, there was no significant difference in PaO2 (mean, 59.9 mm Hg) or the alveolar-arterial gradient (mean, 46.0 mm Hg). An elevated alveolar-arterial oxygen gradient is entirely nonspecific in the elderly population and is of minimal use in the diagnosis of acute pulmonary embolism. A normal alveolar-arterial gradient should not preclude further diagnostic procedures if there is a high index of suspicion.

Incidence of Pulmonary Embolism in Elderly Patients Newly Admitted to an Acute Geriatric Unit: A Prospective Study

To study the incidence of pulmonary embolism (PE) in elderly patients newly admitted to an acute geriatric unit, the authors carried out ventilation perfusion scans on 33 patients, 25 women and 8 men, mean age 79 years, consecutively admitted to the geriatric wards. The first scan was done within 5 days of admission and repeated between days 10 and 20. Where possible, patients with a positive second scan had a repeat scan at 2-3 months. Six (18%) patients were found to have a high probability of PE, 4 (12%) at the time of admission and two (6%) after admission. Three patients (9%) were considered to suffer from chronic pulmonary artery disease. Mortality was 5 for the whole group (15%) and 1 of 6 (17%) with a high probability of PE; this patient was suffering from carcinomatosis. The only patient who was anticoagulated suffered serious side effects. In no patient was PE clinically suspected. The authors conclude that PE is common in sick elderly patients newly admitted to acute geriatric wards, that rehabilitation with mobilization may precipitate new PE, and that nonanticoagulated PE does not seem to appreciably shorten the prognosis for life. Treatment with anticoagulants may be more dangerous than not treating PE in this older age group.