Key result
Unsuspected fatal PE presents with ~35% less dyspnea and fewer active malignancies than suspected cases.
Why the study?
Since the adoption of clinical prediction scores and widespread CT-pulmonary angiogram availability, few reports describe clinical presentations of hospitalized patients dying from PE, which is often unsuspected.
What are the differences in clinical signs, symptoms, and comorbidities between hospitalized patients with fatal pulmonary embolism that was suspected versus unsuspected antemortem?
Case-Control (n=52)
No
What are the differences in clinical signs, symptoms, and comorbidities between hospitalized patients with fatal pulmonary embolism that was suspected versus unsuspected antemortem?
Fatal pulmonary embolism remains frequently unsuspected in hospitalized patients, particularly among those lacking typical symptoms like dyspnea or risk factors like active malignancy.
Answers are grounded in this paper and cite their sources.
Heightened PE suspicion warranted in hospitalized patients lacking dyspnea or malignancy; leaves open better antemortem detection strategies.
BACKGROUND: Pulmonary embolism (PE) is often unsuspected by treating clinicians. Since the adoption of clinical prediction scores for PE and the widespread availability of computed tomography (CT)-pulmonary angiogram, there are few reports of clinical presentations of hospitalized patients who died of PE. OBJECTIVES: To compare the clinical signs, symptoms, and comorbidities of hospitalized patients who died of PE for whom PE was suspected versus not suspected antemortem. STUDY DESIGN AND METHODS: Case-control study from January 1999 to December 2018 in one Veterans Affairs (VA) hospital. We compared groups to examine differences in clinical presentations of fatal PE over the two decades. RESULTS: Among 1345 autopsies performed during the study period, 52 patients (4%) with fatal PE were included in the final analyses. PE was unsuspected before death in 29/52 patients (56%). Comparing groups, there were significant differences for: dyspnea (suspected 91%; unsuspected: 59%, p = 0.01); active malignancy (suspected 74%; unsuspected: 28%, p = 0.002); and atrioventricular (AV) nodal blocking treatment (suspected: 62%; unsuspected 30%,p= 0.03). A greater proportion of patients with unsuspected PE lacked symptoms of PE (suspected 0%; unsuspected: 31%, p = 0.003). CONCLUSIONS: Fatal PE remains a common, unsuspected cause of inpatient death in the modern era. Symptoms of PE, active malignancy, and potentially confounding AV nodal blocking treatment were less frequent in patients with unsuspected PE. These data highlight the variation in presentation and the challenge of making the diagnosis in many hospitalized patients, particularly those without typical symptoms.
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Hagan et al. (2024) conducted a case-control in Fatal pulmonary embolism (n=52). Suspected PE antemortem vs. Unsuspected PE antemortem was evaluated on Dyspnea (p=0.01). Among hospitalized patients with fatal PE, those with unsuspected PE were less likely to have dyspnea (59% vs 91%, p=0.01) or active malignancy (28% vs 74%, p=0.002) than those with suspected PE.
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