Clinical features from the history and physical examination that predict the presence or absence of pulmonary embolism in symptomatic emergency department patients: results of a prospective, multicenter study.

Clinical features from the history and physical examination that predict the presence or absence of pulmonary embolism in symptomatic emergency department patients: results of a prospective, multicenter study.

MedLine Citation:	PMID: 20045580 Owner: NLM Status: MEDLINE
Abstract/OtherAbstract:	STUDY OBJECTIVE: Prediction rules for pulmonary embolism use variables explicitly shown to estimate the probability of pulmonary embolism. However, clinicians often use variables that have not been similarly validated, yet are implicitly believed to modify probability of pulmonary embolism. The objective of this study is to measure the predictive value of 13 implicit variables. METHODS: Patients were enrolled in a prospective cohort study from 12 centers in the United States; all had an objective test for pulmonary embolism (D-dimer, computed tomographic angiography, or ventilation-perfusion scan). Clinical features including 12 predefined previously validated (explicit) variables and 13 variables not part of existing prediction rules (implicit) were prospectively recorded at presentation. The primary outcome was venous thromboembolism (pulmonary embolism or deep venous thrombosis), diagnosed by imaging up to 45 days after enrollment. Variables with adjusted odds ratios from logistic regression with 95% confidence intervals not crossing unity were considered significant. RESULTS: Seven thousand nine hundred forty patients (7.2% venous thromboembolism positive) were enrolled. Mean age was 49 years (standard deviation 17 years) and 67% were female patients. Eight of 13 implicit variables were significantly associated with venous thromboembolism; those with an adjusted odds ratio (OR) greater than 1.5 included non-cancer-related thrombophilia (OR 1.99), pleuritic chest pain (OR 1.53), and family history of venous thromboembolism (OR 1.51). Implicit variables that predicted no venous thromboembolism outcome included substernal chest pain, female sex, and smoking. Nine of 12 explicit variables predicted a positive outcome of venous thromboembolism, including patient history of pulmonary embolism or deep venous thrombosis in the past, unilateral leg swelling, recent surgery, estrogen, hypoxemia, and active malignancy. CONCLUSION: In symptomatic outpatients being considered for possible pulmonary embolism, non-cancer-related thrombophilia, pleuritic chest pain, and family history of venous thromboembolism increase probability of pulmonary embolism or deep venous thrombosis. Other variables that are part of existing pretest probability systems were validated as important predictors in this diverse sample of US emergency department patients.

Authors:	D Mark Courtney; Jeffrey A Kline; Christopher Kabrhel; Christopher L Moore; Howard A Smithline; Kristen E Nordenholz; Peter B Richman; Michael C Plewa
Publication Detail:	Type: Journal Article; Multicenter Study; Research Support, N.I.H., Extramural Date: 2010-01-01
Journal Detail:	Title: Annals of emergency medicine Volume: 55 ISSN: 1097-6760 ISO Abbreviation: Ann Emerg Med Publication Date: 2010 Apr
Date Detail:	Created Date: 2010-03-29 Completed Date: 2010-04-19 Revised Date: 2011-07-27
Medline Journal Info:	Nlm Unique ID: 8002646 Medline TA: Ann Emerg Med Country: United States
Other Details:	Languages: eng Pagination: 307-315.e1 Citation Subset: AIM; IM
Copyright Information:	Copyright (c) 2009 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.
Affiliation:	Department of Emergency Medicine, Northwestern University, Chicago, IL, USA.
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MeSH Terms
Descriptor/Qualifier:	Adult Chest Pain / diagnosis Confidence Intervals Emergency Service, Hospital* Female Humans Logistic Models Male Medical History Taking* Middle Aged Odds Ratio Physical Examination* Predictive Value of Tests Prospective Studies Pulmonary Embolism / diagnosis* Risk Factors Sex Factors Thrombophilia / diagnosis Tomography, X-Ray Computed Venous Thromboembolism / diagnosis Venous Thrombosis / diagnosis
Grant Support
ID/Acronym/Agency:	1K23HL077404-01/HL/NHLBI NIH HHS; 2R42HL074415-02A1/HL/NHLBI NIH HHS; 5K23HL077404(01-05/HL/NHLBI NIH HHS; 5R42HL074415-03/HL/NHLBI NIH HHS; K23 HL077404-01/HL/NHLBI NIH HHS; K23 HL077404-02/HL/NHLBI NIH HHS; K23 HL077404-03/HL/NHLBI NIH HHS; K23 HL077404-04/HL/NHLBI NIH HHS; K23 HL077404-05/HL/NHLBI NIH HHS; L30 HL081998-01/HL/NHLBI NIH HHS; R01HL074384/HL/NHLBI NIH HHS; R41 HL074415-01/HL/NHLBI NIH HHS; R41HL074415/HL/NHLBI NIH HHS; R42 HL074415-02A1/HL/NHLBI NIH HHS; R42 HL074415-03/HL/NHLBI NIH HHS; R42HL074415/HL/NHLBI NIH HHS
Comments/Corrections
Comment In:	Ann Emerg Med. 2010 Nov;56(5):584-5; author reply 586-7 [PMID: 21036302 ]

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