Physician-authored summaries and commentary on the most important medical research, provided by the NEJM Group, a division of the Massachusetts Medical Society.
© Massachusetts Medical SocietyApril 2023
In a large cohort, PE was diagnosed in one-third of patients.
Although dyspnoea at rest is a common symptom of pulmonary embolism (PE), whether PE causes isolated dyspnoea on exertion is unclear. Researchers analysed data from 417 consecutive patients (mean age, 58 years) who were evaluated in 14 emergency departments in Italy for moderate-to-severe exertional dyspnoea of recent onset (less than one month). Patients with previous venous thromboembolism, those on anticoagulation or those older than 75 years were excluded. PE was ruled out in patients with low pretest probability (using the simplified Wells score [https://www.mdcalc.com/calc/115/wells-criteria-pulmonary-embolism]) and normal age-adjusted D-dimer level; all other patients underwent computed tomographic (CT) pulmonary angiography.
Key findings were:
- diagnosis of PE was excluded in 32% of patients based on low pretest probability and D-dimer, excluded by CT angiography in 36% of patients, and confirmed by CT angiography in 32%
- PE was diagnosed in 44% of patients with other signs and symptoms suspicious for PE and in 20% of patients with only dyspnoea on exertion
- PE was diagnosed in 15% of patients with alternate explanations for dyspnoea on exertion.
Comment: The higher-than-expected prevalence of PE in this cohort could reflect a high testing threshold or strict inclusion criteria that enriched the study population for a high pretest probability of PE. Acknowledging that risk for PE increases with age, the exclusion of patients older than 75 years is a limitation. Nevertheless, it is notable that PE was diagnosed in one-third of patients overall, and in one in six patients with other potential explanations for new-onset exertional dyspnoea. We should have a low threshold for considering PE in such cases.
Rahul B. Ganatra, MD, MPH
Instructor in Medicine, Harvard Medical School; Director of Continuing Medical Education for the Medical Service, VA Boston Healthcare System, Boston, USA.
Prandoni P, et al. Prevalence of pulmonary embolism among patients with recent onset of dyspnea on exertion. A cross-sectional study. J Thromb Haemost 2023; 21: 68-75.
This summary is taken from the following Journal Watch titles: General Medicine, Ambulatory Medicine, Hospital Medicine