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Low prevalence of pulmonary embolism in patients who present to ED with syncope
Clinical Question
What is the prevalence of pulmonary embolism in patients who present to the emergency department with syncope?
Bottom line
In this large cohort of 1.7 million patients, pulmonary embolism (PE) was uncommon in patients who presented to the emergency department (ED) with syncope, even in the subset that was hospitalized. Routine evaluation for PE in all patients who present with syncope may not be warranted. 2b
Reference
Study design: Cross-sectional
Funding: Government
Setting: Emergency department
Synopsis
This study used 3 administrative databases from Canada, Denmark, and Italy, and 2 from the United States to identify almost 1.7 million adult patients who presented to the ED with syncope during a 6-year period. The primary outcome was a diagnosis of PE as identified by discharge codes. Among the 5 databases, prevalence of PE during first ED evaluation ranged from 0.06% to 0.55%. Even for the patients who were hospitalized for syncope, prevalence of PE remained low, ranging from 0.15% to 2.1%. Presence of any venous thromboembolism at 90 days ranged from 0.3% to 1.37% for all patients and 0.75% to 3.86% for hospitalized patients. This is different from the PESIT study (https://www.essentialevidenceplus.com/content/poem/181201), which found a 17% prevalence of PE in patients hospitalized with first episode of syncope. The PESIT study used a structured algorithm to evaluate for PE in all patients who presented with syncope, which may have led to false-positive results, as well as to more PEs being found, whether or not they were clinically relevant. The PESIT study population also included hospitalized patients only, who may have been sicker overall than the population represented by this study's databases. The results from this study suggest that PE is rare in patients who present with syncope.
Reviewer
Nita Shrikant Kulkarni, MD
Assistant Professor in Hospital Medicine
Northwestern University
Chicago, IL
Comments
Anyway, syncope is not a common clinical feature that we expect from a non submassive PE. But it can be a significant clinical feature with a massive PE, therefore ignoring PE in your diffferential who presents with syncope is not advisable.
choosing wisely : no CT ?
Needs more clinical assessment for clinical indication : top down study rather than bottom up study ( like current study ) and see where they meet in the middle.
The person who wrote the capsule summary presents a way over simplistic perspective which if adopted by docs without significant clinical experience could lead them to not to other considering PE in the diffDx of syncope. There is a difference in how I think about a 35 yo healthy female with syncope with no risk factors and a similar female who is on OCAs and just took a flight home from Australia. Listen the proportion of syncope patients with Brugada syndrome is also low but that doesn't mean it shouldn't be considered and investigated for. I am not at all happy with this review.
Good poem
This makes sense. I think we diagnose more people with PE than those all who are really affected by the situation. I think that this might explain the results from the PESIT study.
I think that in these patients doing a simple clinical evaluation and then doing a D Dimer in those where it makes some sense would help to direct their investigations.
Just because the risks are low does not change the fact that the possibility has to be considered and ruled out.