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CLINICAL RESEARCH: PULMONARY EMBOLISM

Clinical Characteristics, Management, and Outcomes of Patients Diagnosed With Acute Pulmonary Embolism in the Emergency Department

Initial Report of EMPEROR (Multicenter Emergency Medicine Pulmonary Embolism in the Real World Registry)

Charles V. Pollack, MD^_*, Donald Schreiber, MD, Samuel Z. Goldhaber, MD, David Slattery, MD, John Fanikos, RPh, MBA^||, Brian J. O'Neil, MD^¶, James R. Thompson, MD^#, Brian Hiestand, MD^_**, Beau A. Briese, MA, MD, Robert C. Pendleton, MD, Chadwick D. Miller, MD, MS and Jeffrey A. Kline, MD^||||,_*

^_* Department of Emergency Medicine, Pennsylvania Hospital, Philadelphia, Pennsylvania
Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California
Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
Department of Emergency Medicine, University Medical Center of Southern Nevada, Las Vegas, Nevada
^|| Pharmacy Department, Brigham and Women's Hospital, Boston, Massachusetts
^¶ Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan
^# Department of Emergency Medicine, University of Mississippi Health Center, Jackson, Mississippi
^_** Department of Emergency Medicine, Ohio State University College of Medicine, Columbus, Ohio
Stanford/Kaiser Emergency Medicine Residency Program, Stanford, California
Department of Medicine, University of Utah Medical Center, Salt Lake City, Utah
Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
^|||| Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina

Manuscript received February 12, 2010; revised manuscript received May 3, 2010, accepted May 17, 2010.

^_* Reprint requests and correspondence: Dr. Jeffrey A. Kline, Department of Emergency Medicine, Carolinas Medical Center, PO Box 32861, 1000 Blythe Boulevard, Charlotte, North Carolina 28232 (Email: jkline{at}carolinas.org).

Objectives: In a large U.S. sample, this study measured the presentation features, testing, treatment strategies, and outcomes of patients diagnosed with pulmonary embolism (PE) in the emergency department (ED).

Background: No data have quantified the demographics, clinical features, management, and outcomes of outpatients diagnosed with PE in the ED in a large, multicenter U.S. study.

Methods: Patients of any hemodynamic status were enrolled from the ED after confirmed acute PE or with a high clinical suspicion prompting anticoagulation before imaging for PE. Exclusions were inability to provide informed consent (where required) or unavailability for follow-up.

Results: A total of 1,880 patients with confirmed acute PE were enrolled from 22 U.S. EDs. Diagnosis of PE was based upon positive results of computerized tomographic pulmonary angiogram in most cases (n = 1,654 [88%]). Patients represented both sexes equally, and racial and ethnic composition paralleled the overall U.S. ED population. Most (79%) patients with PE were employed, and one-third were older than age 65 years. The mortality rate directly attributed to PE was 20 in 1,880 (1%; 95% confidence interval [CI]: 0% to 1.6%). Mortality from hemorrhage was 0.2%, and the all-cause 30-day mortality rate was 5.4% (95% CI: 4.4% to 6.6%). Only 3 of 20 patients with major PE that ultimately proved fatal had systemic anticoagulation initiated before diagnostic confirmation, and another 3 of these 20 received a fibrinolytic agent.

Conclusions: Patients diagnosed with acute PE in U.S. EDs have high functional status, and their mortality rate is low. These registry data suggest that appropriate initial medical management of ED patients with severe PE with anticoagulation is poorly standardized and indicate a need for research to determine the appropriate threshold for empiric treatment when PE is suspected before diagnostic confirmation.

Key Words: anticoagulation • epidemiology • fibrinolysis • pulmonary embolism • venous thromboembolism

Abbreviations and Acronyms   BNP = brain natriuretic protein   CTPA = computerized tomographic pulmonary angiogram   DVT = deep venous thrombosis   ED = emergency department   PE = pulmonary embolism   PESI = Pulmonary Embolism Severity Index   RV = right ventricular   SBP = systolic blood pressure   VQ = ventilation-perfusion   VTE = venous thromboembolism

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