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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)
Study Questions:
What are the measured presentation features, testing, treatment strategies, and outcomes of patients diagnosed with pulmonary embolism (PE) in emergency departments (EDs)?
Methods:
Participating institutions included 22 US EDs (academic and community) experienced with ED registries. 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:
Of the 2,408 patients, 1,880 (78%) with confirmed acute PE were enrolled. PE was based on positive results of computerized tomographic pulmonary angiogram in most cases (n = 1,654 [88%]). D-dimer was elevated in 87%. Gender, racial, and ethnic composition paralleled the overall US ED population. Heparin of any type was administered to 84% of patients in the ED and before the results of diagnostic imaging in 173 of 1,880 (9%). Based on the Wells’ score, the pretest probabilities were low or moderate in 90% in this group. 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%-1.6%). Mortality from hemorrhage was 0.2%, and the all-cause 30-day mortality rate was 5.4% (95% CI, 4.4%-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 US 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.
Perspective:
There are data demonstrating that delay of anticoagulation is associated with an increase in adverse events. The degree of delay from presentation to treatment (equivalent to door to open vessel in acute coronary syndrome with percutaneous coronary intervention) was not presented, but would be interesting. The safety and efficacy of anticoagulation therapy prior to confirmation of suspected PE will require a very large study based on the results of this prospective registry. ED physicians could consider empiric heparin products in PE suspects at low risk for anticoagulants, and even thrombolytic therapy in patients with systemic hypotension and high risk for PE.
Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Invasive Cardiovascular Angiography and Intervention, Vascular Medicine, Anticoagulation Management and ACS, Interventions and ACS, Interventions and Vascular Medicine
Keywords: Registries, Acute Coronary Syndrome, Follow-Up Studies, Emergency Medicine, Pulmonary Embolism, Heparin, Percutaneous Coronary Intervention
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