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What is the estimated prevalence of pulmonary embolism in patients who present to the emergency department with syncope?
In this study of 5 administrative databases that included more than 1.5 million people from 4 different countries, pulmonary embolism was identified in less than 1% of patients with syncope.
Although pulmonary embolism should be considered at first evaluation in every patient with syncope, not all patients warrant a diagnostic algorithm to exclude it, and the algorithm may increase false-positive results and overtreatment, resulting in more adverse events.
Sparse data and conflicting evidence exist on the prevalence of pulmonary embolism (PE) in patients with syncope.
To estimate the prevalence of PE among patients presenting to the emergency department (ED) for evaluation of syncope.
Design, Setting, and Participants
This retrospective, observational study analyzed longitudinal administrative data from 5 databases in 4 different countries (Canada, Denmark, Italy, and the United States). Data from all adult patients (aged ≥18 years) who presented to the ED were screened to identify those with syncope codes at discharge. Data were collected from January 1, 2000, through September 30, 2016.
Main Outcomes and Measures
The prevalence of PE at ED and hospital discharge, identified using codes from the International Classification of Diseases, was considered the primary outcome. Two sensitivity analyses considering prevalence of PE at 90 days of follow-up and prevalence of venous thromboembolism were performed.
A total of 1 671 944 unselected adults who presented to the ED for syncope were included. The prevalence of PE, according to administrative data, ranged from 0.06% (95% CI, 0.05%-0.06%) to 0.55% (95% CI, 0.50%-0.61%) for all patients and from 0.15% (95% CI, 0.14%-0.16%) to 2.10% (95% CI, 1.84%-2.39%) for hospitalized patients. The prevalence of PE at 90 days of follow-up ranged from 0.14% (95% CI, 0.13%-0.14%) to 0.83% (95% CI, 0.80%-0.86%) for all patients and from 0.35% (95% CI, 0.34%-0.37%) to 2.63% (95% CI, 2.34%-2.95%) for hospitalized patients. Finally, the prevalence of venous thromboembolism at 90 days ranged from 0.30% (95% CI, 0.29%-0.31%) to 1.37% (95% CI, 1.33%-1.41%) for all patients and from 0.75% (95% CI, 0.73%-0.78%) to 3.86% (95% CI, 3.51%-4.24%) for hospitalized patients.
Conclusions and Relevance
Pulmonary embolism was rarely identified in patients with syncope. Although PE should be considered in every patient, not all patients should undergo evaluation for PE.
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Accepted for Publication: November 28, 2017.
Corresponding Author: Giorgio Costantino, MD, Dipartimento di Medicina Interna, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda, Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122 Milano, Italy (firstname.lastname@example.org).
Published Online: January 29, 2018. doi:10.1001/jamainternmed.2017.8175
Author Contributions: Drs Costantino and Casazza had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Costantino, Montano, Russo, Sheldon, Sun, Casazza.
Acquisition, analysis, or interpretation of data: Costantino, Ruwald, Quinn, Camargo, Dalgaard, Gislason, Goto, Hasegawa, Kaul, Numé, Russo, Sheldon, Solbiati, Sun, Casazza.
Drafting of the manuscript: Costantino, Quinn, Russo, Sheldon, Solbiati, Casazza.
Critical revision of the manuscript for important intellectual content: Costantino, Ruwald, Camargo, Dalgaard, Gislason, Goto, Hasegawa, Kaul, Montano, Numé, Russo, Sheldon, Solbiati, Sun, Casazza.
Statistical analysis: Quinn, Goto, Hasegawa, Kaul, Numé, Russo, Casazza.
Obtained funding: Kaul, Russo.
Administrative, technical, or material support: Ruwald, Gislason, Numé, Russo, Casazza.
Study supervision: Costantino, Quinn, Camargo, Goto, Montano, Russo, Solbiati.
Conflict of Interest Disclosures: Dr Sun reports receiving support from grant R01HL111033 from the National Institutes of Health (NIH) and serving as a consultant for Medtronic. No other disclosures were reported.
Funding/Support: This study was supported by National Center for Advancing Translational Science Clinical and Translational Science Award UL1 TR001085 from the National Institutes of Health and by internal funding from Stanford University for access to the Clinformatics Data Mart database using the Stanford Center for Population Health Sciences Data Core.
Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
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