Pollack, Charles V, Donald Schreiber, Samuel Z Goldhaber, David Slattery, John Fanikos, Brian J O’Neil, James R Thompson, et al. “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)..” Journal of the American College of Cardiology 57, no. 6: 700–706. doi:10.1016/j.jacc.2010.05.071. PMID 21292129
- this was a large ED based registry study from multiple US EDs to see how PE patients present and what happened to them
- it included both people who ended up having a confirmed PE and those empirically treated for PE awaiting tests and ultimately ruled out for PE
- PE diagnosis could be based on lots of different tests (all appropriate I think)
- 2400 pts, 1800 who had PE
- vast majority (90%) diagnosed by CT
- 3% were hypotensive on presentation
- SOB, pain, and symptoms suggesting DVT were commonest presenting complaints
- 5% presented with syncope: it happens but it’s not common
- of those who got echoes (only a quarter) there was RV dyskinesia in half
- 85% of those with PE got anti-coagulated in the ED – this is lower than I expected, though presumably because they had contra-indications.
- mortality rate attributable to PE was 1.1% (though all cause mortality was 5.4% meaning that lots of sick people get PEs and die of something else)
I grew up with the notion that PE killed roughly 1 in 5 of those with the disease. That’s kind of scary. That’s similar to STEMI mortality. There is no doubt that there was a time when the PEs we diagnosed carried that type of mortality. Big feck-off PEs that is.
As the technology has changed we have created a new disease – let’s call them pulmonary fluff instead of pulmonary emboli. Emboli are terrifying, fluff not so much.
We have presumed that pulmonary fluff is the same disease as the big bad pulmonary emboli.
We are left with, i think, with two possible conclusions
- we seem to have discovered a treatment (in heparin) that reduces mortality from 20% to 1%. An absolute risk reduction (ARR) of 19%. Considering that lytics for STEMI probably by you a 2% ARR we should be absolutely stunned.
- The alternative is that we are now diagnosing lots of pulmonary fluff and the mortality rate from pulmonary fluff is 1% at a baseline and giving all this people heparin to treat their fluff does nothing; an ARR of 0%.
It may be somewhere in between those 2 answers but we have yet to make up our mind which.