December 8, 1997

The Clinical Course of Patients With Suspected Pulmonary Embolism

Author Affiliations

From the Center for Hemostasis, Thrombosis, Atherosclerosis and Inflammation Research (Drs van Beek, Kuijer, Büller, and ten Cate), the Departments of Radiology (Dr van Beek), Internal Medicine (Dr Kuijer), and Clinical Epidemiology and Biostatistics, Academic Medical Center (Dr Bossuyt), and the Department of Internal Medicine, Slotervaart Hospital (Dr Brandjes), Amsterdam, the Netherlands.

Arch Intern Med. 1997;157(22):2593-2598. doi:10.1001/archinte.1997.00440430075009

Background:  The outcome of patients with suspected pulmonary embolism is known to a limited extent only.

Objective:  To address this limited knowledge in a cohort in whom pulmonary embolism was proved or ruled out.

Methods:  Consecutive patients with clinically suspected pulmonary embolism underwent lung scintigraphy and angiography if required. Pulmonary embolism was excluded by normal results of a lung scan or angiogram, and, if so, anticoagulant therapy was withheld. Pulmonary embolism was proved with a high-probability perfusion-ventilation lung scan or a confirmatory angiogram if a nondiagnostic lung scan was obtained. These patients were treated with heparin intravenously and anticoagulants orally on a long-term basis. All patients were followed up for 6 months, with a special focus on recurrent thromboembolism, bleeding complications, and mortality.

Results:  A total of 487 consecutive inpatients and outpatients were included. Pulmonary embolism was excluded or proved in 243 and 193 patients, respectively. In 51 patients a definite diagnosis could not be established. The overall prevalence of pulmonary embolism was 39%. In patients in whom pulmonary embolism was proved, excluded, or uncertain, recurrent venous thromboembolism was observed in 2.6%, 0.9%, and 2%, respectively. Serious bleeding complications occurred in 7 patients (3.3%; 95% confidence interval [CI], 1.8%6.3%), 2 cases of which were fatal. The total mortality after 6 months in patients with proved or excluded pulmonary embolism was 17% (95% CI, 12%-23%) and 11% (95% CI, 7%-15%), respectively. Death was related to (recurrent) pulmonary embolism in 5% and 0% of these cases, respectively.

Conclusions:  During a 6-month period, recurrent pulmonary embolism occurred in approximately 5 patients (2.5%) who were treated for a previous episode. Fatal bleeding complications attributable to the use of anticoagulants were encountered in 1%. The mortality among patients with suspected pulmonary embolism was considerable. However, most deaths were unrelated to pulmonary embolism, but were the result of serious underlying illnesses.Arch Intern Med. 1997;157:2593-2598