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Prevalence of Pulmonary Embolism in Patients With Syncope

Educational Objective
To estimate the prevalence of pulmonary embolism among patients presenting to the emergency department for evaluation of syncope.
1 Credit CME
Key Points

Question  What is the estimated prevalence of pulmonary embolism in patients who present to the emergency department with syncope?

Findings  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.

Meaning  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.

Abstract

Importance  Sparse data and conflicting evidence exist on the prevalence of pulmonary embolism (PE) in patients with syncope.

Objective  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.

Results  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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Article Information

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 (giorgic2@gmail.com).

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.

References
1.
Soteriades  ES, Evans  JC, Larson  MG,  et al.  Incidence and prognosis of syncope.  N Engl J Med. 2002;347(12):878-885. doi:10.1056/NEJMoa012407PubMedGoogle ScholarCrossref
2.
Costantino  G, Perego  F, Dipaola  F,  et al; STePS Investigators.  Short- and long-term prognosis of syncope, risk factors, and role of hospital admission: results from the STEPS (Short-Term Prognosis of Syncope) study.  J Am Coll Cardiol. 2008;51(3):276-283. doi:10.1016/j.jacc.2007.08.059PubMedGoogle ScholarCrossref
3.
Reed  MJ, Newby  DE, Coull  AJ, Prescott  RJ, Jacques  KG, Gray  AJ.  The ROSE (Risk Stratification of Syncope in the Emergency Department) study.  J Am Coll Cardiol. 2010;55(8):713-721.PubMedGoogle ScholarCrossref
4.
Quinn  JV, Stiell  IG, McDermott  DA, Sellers  KL, Kohn  MA, Wells  GA.  Derivation of the San Francisco Syncope Rule to predict patients with short-term serious outcomes.  Ann Emerg Med. 2004;43(2):224-232.PubMedGoogle ScholarCrossref
5.
Thiruganasambandamoorthy  V, Kwong  K, Wells  GA,  et al.  Development of the Canadian Syncope Risk Score to predict serious adverse events after emergency department assessment of syncope.  CMAJ. 2016;188(12):E289-E298. doi:10.1503/cmaj.151469PubMedGoogle ScholarCrossref
6.
Costantino  G, Casazza  G, Reed  M,  et al.  Syncope risk stratification tools vs clinical judgment: an individual patient data meta-analysis.  Am J Med. 2014;127(11):1126.e13-1126.e25. doi:10.1016/j.amjmed.2014.05.022PubMedGoogle ScholarCrossref
7.
Saccilotto  RT, Nickel  CH, Bucher  HC, Steyerberg  EW, Bingisser  R, Koller  MT.  San Francisco Syncope Rule to predict short-term serious outcomes: a systematic review.  CMAJ. 2011;183(15):E1116-E1126. doi:10.1503/cmaj.101326PubMedGoogle ScholarCrossref
8.
Serrano  LA, Hess  EP, Bellolio  MF,  et al.  Accuracy and quality of clinical decision rules for syncope in the emergency department: a systematic review and meta-analysis.  Ann Emerg Med. 2010;56(4):362-373.e1.PubMedGoogle ScholarCrossref
9.
Blanc  J-J, L’Her  C, Touiza  A, Garo  B, L’Her  E, Mansourati  J.  Prospective evaluation and outcome of patients admitted for syncope over a 1 year period.  Eur Heart J. 2002;23(10):815-820. doi:10.1053/euhj.2001.2975PubMedGoogle ScholarCrossref
10.
Silverstein  MD, Singer  DE, Mulley  AG, Thibault  GE, Barnett  GO.  Patients with syncope admitted to medical intensive care units.  JAMA. 1982;248(10):1185-1189.PubMedGoogle ScholarCrossref
11.
Frizell  A, Fogel  N, Steenblik  J, Carlson  M, Bledsoe  J, Madsen  T.  Prevalence of pulmonary embolism in patients presenting to the emergency department with syncope  [published online July 31, 2017].  Am J Emerg Med. doi:10.1016/j.ajem.2017.07.090PubMedGoogle Scholar
12.
Prandoni  P, Lensing  AWA, Prins  MH,  et al; PESIT Investigators.  Prevalence of pulmonary embolism among patients hospitalized for syncope.  N Engl J Med. 2016;375(16):1524-1531. doi:10.1056/NEJMoa1602172PubMedGoogle ScholarCrossref
13.
Verma  AA, Masoom  H, Rawal  S, Guo  Y, Razak  F; GEMINI Investigators.  Pulmonary embolism and deep venous thrombosis in patients hospitalized with syncope: a multicenter cross-sectional study in Toronto, Ontario, Canada.  JAMA Intern Med. 2017;177(7):1046-1048. doi:10.1001/jamainternmed.2017.1246PubMedGoogle ScholarCrossref
14.
Costantino  G, Sun  BC, Barbic  F,  et al.  Syncope clinical management in the emergency department: a consensus from the first international workshop on syncope risk stratification in the emergency department.  Eur Heart J. 2016;37(19):1493-1498. doi:10.1093/eurheartj/ehv378PubMedGoogle ScholarCrossref
15.
Hutchinson  BD, Navin  P, Marom  EM, Truong  MT, Bruzzi  JF.  Overdiagnosis of pulmonary embolism by pulmonary CT angiography.  AJR Am J Roentgenol. 2015;205(2):271-277. doi:10.2214/AJR.14.13938PubMedGoogle ScholarCrossref
16.
Batty  JA, Tang  M.  Pulmonary embolism in patients hospitalized for syncope.  N Engl J Med. 2017;376(5):494-495. doi:10.1056/NEJMc1615913PubMedGoogle ScholarCrossref
17.
Ataya  A, Cope  J, Alnuaimat  H.  Pulmonary embolism in patients hospitalized for syncope.  N Engl J Med. 2017;376(5):496-497. doi:10.1056/NEJMc1615913PubMedGoogle Scholar
18.
Radecki  RP, Spiegel  R, Carley  S.  Pulmonary embolism in patients hospitalized for syncope.  N Engl J Med. 2017;376(5):496. doi:10.1056/NEJMc1615913#SA5PubMedGoogle Scholar
19.
Badertscher  P, du Fay de Lavallaz  J, Mueller  CH.  Pulmonary embolism in patients hospitalized for syncope.  N Engl J Med. 2017;376(5):494. doi:10.1056/NEJMc1615913PubMedGoogle ScholarCrossref
20.
Le Gal  G, Righini  M, Roy  PM,  et al.  Prediction of pulmonary embolism in the emergency department: the revised Geneva score.  Ann Intern Med. 2006;144(3):165-171. doi:10.1016/j.jemermed.2006.05.013PubMedGoogle ScholarCrossref
21.
Righini  M, Le Gal  G, Aujesky  D,  et al.  Diagnosis of pulmonary embolism by multidetector CT alone or combined with venous ultrasonography of the leg: a randomised non-inferiority trial.  Lancet. 2008;371(9621):1343-1352. doi:10.1016/S0140-6736(08)60594-2PubMedGoogle ScholarCrossref
22.
Konstantinides  SV, Torbicki  A, Agnelli  G,  et al; Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC).  2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism.  Eur Heart J. 2014;35(43):3033-3069, 3069a-3069k.PubMedGoogle ScholarCrossref
23.
Joy  PS, Kumar  G, Olshansky  B.  Pulmonary embolism in patients hospitalized for syncope.  N Engl J Med. 2017;376(5):495. doi:10.1056/NEJMc1615913#SA3PubMedGoogle Scholar
24.
D’Ascenzo  F, Biondi-Zoccai  G, Reed  MJ,  et al.  Incidence, etiology and predictors of adverse outcomes in 43,315 patients presenting to the emergency department with syncope: an international meta-analysis.  Int J Cardiol. 2013;167(1):57-62. doi:10.1016/j.ijcard.2011.11.083PubMedGoogle ScholarCrossref
25.
Righini  M, Van Es  J, Den Exter  PL,  et al.  Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study.  JAMA. 2014;311(11):1117-1124. doi:10.1001/jama.2014.2135PubMedGoogle ScholarCrossref
26.
Sun  BC, Costantino  G, Barbic  F,  et al.  Priorities for emergency department syncope research.  Ann Emerg Med. 2014;64(6):649-655.e2. doi:10.1016/j.annemergmed.2014.04.014PubMedGoogle ScholarCrossref
27.
Oqab  Z, Ganshorn  H, Sheldon  R.  Prevalence of pulmonary embolism in patients presenting with syncope: a systematic review and meta-analysis  [published online September 14, 2017].  Am J Emerg Med. doi:10.1016/j.ajem.2017.09.015PubMedGoogle Scholar
28.
Costantino  G, Norsa  AH, Amadori  R,  et al.  Interobserver agreement in the interpretation of computed tomography in acute pulmonary embolism.  Am J Emerg Med. 2009;27(9):1109-1111. doi:10.1016/j.ajem.2008.08.019PubMedGoogle ScholarCrossref
29.
Porzio  M, Cernuschi  G, Vespro  V, Costantino  G.  Unsuspected pulmonary embolism: a diagnostic dilemma.  Intern Emerg Med. 2016;11(7):977-979. doi:10.1007/s11739-016-1514-7PubMedGoogle ScholarCrossref
30.
Jaeschke  R, Guyatt  G, Sackett  DL; Evidence-Based Medicine Working Group.  Users’ guides to the medical literature, III: how to use an article about a diagnostic test: A. are the results of the study valid ?  JAMA. 1994;271(5):389-391. doi:10.1001/jama.1993.03510170086037PubMedGoogle ScholarCrossref
31.
Ruwald  MH, Hansen  ML, Lamberts  M,  et al.  Accuracy of the ICD-10 discharge diagnosis for syncope.  Europace. 2013;15(4):595-600. doi:10.1093/europace/eus359PubMedGoogle ScholarCrossref
32.
Burles  K, Innes  G, Senior  K, Lang  E, McRae  A.  Limitations of pulmonary embolism ICD-10 codes in emergency department administrative data: let the buyer beware.  BMC Med Res Methodol. 2017;17(1):89. doi:10.1186/s12874-017-0361-1PubMedGoogle ScholarCrossref
33.
Ruwald  MH, Hansen  ML, Lamberts  M,  et al.  Prognosis among healthy individuals discharged with a primary diagnosis of syncope.  J Am Coll Cardiol. 2013;61(3):325-332.PubMedGoogle ScholarCrossref
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