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van Maanen R, Trinks-Roerdink EM, Rutten FH, Geersing GJ. A systematic review and meta-analysis of diagnostic delay in pulmonary embolism. Eur J Gen Pract 2022; 28:165-172. [PMID: 35730378 PMCID: PMC9246192 DOI: 10.1080/13814788.2022.2086232] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Diagnostic delay in patients with pulmonary embolism (PE) is typical, yet the proportion of patients with PE that experienced delay and for how many days is less well described, nor are determinants for such delay. Objectives This study aimed to assess the prevalence and extent of delay in diagnosing PE. Methods A systematic literature search was performed to identify articles reporting delays in diagnosing PE. The primary outcome was mean delay (in days) or a percentage of patients with diagnostic delay (defined as PE diagnosis more than seven days after symptom onset). The secondary outcome was determinants of delay. Random-effect meta-analyses were applied to calculate a pooled estimate for mean delay and to explore heterogeneity in subgroups. Results The literature search yielded 10,933 studies, of which 24 were included in the final analysis. The pooled estimate of the mean diagnostic delay based on 12 studies was 6.3 days (95% prediction interval 2.5 to 15.8). The percentage of patients having more than seven days of delay varied between 18% and 38%. All studies assessing the determinants of coughing (n = 3), chronic lung disease (n = 6) and heart failure (n = 8) found a positive association with diagnostic delay. Similarly, all studies assessing recent surgery (n = 7) and hypotension (n = 6), as well as most studies assessing chest pain (n = 8), found a negative association with diagnostic delay of PE. Conclusion Patients may have symptoms for almost one week before PE is diagnosed and in about a quarter of patients, the diagnostic delay is even longer.
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Affiliation(s)
- R van Maanen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - E M Trinks-Roerdink
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - F H Rutten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - G J Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Swan D, Hitchen S, Klok FA, Thachil J. The problem of under-diagnosis and over-diagnosis of pulmonary embolism. Thromb Res 2019; 177:122-129. [PMID: 30889517 DOI: 10.1016/j.thromres.2019.03.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 03/02/2019] [Accepted: 03/13/2019] [Indexed: 12/14/2022]
Abstract
Pulmonary embolism (PE) is an increasingly recognised condition which is associated with significant morbidity and mortality. Despite the better awareness of this serious condition, the diagnosis is still overlooked in many cases with sometimes fatal consequences. Under-diagnosis may be due to several reasons including reliance on non-specific 'classic' symptoms, belief that bedside measurements will likely be abnormal in the setting of acute PE, and confounding factors like co-existent cardiorespiratory diseases or being in an intensive care unit, where the diagnosis may not be considered. At the same time, incidental diagnosis of PE is occurring more often due to frequent use of imaging investigations alongside advancements in CT technology, and dilemma exists as to whether the chance finding of PE requires anticoagulation, especially when identified only at the subsegmental level. This article reviews these two issues of under-diagnosis and over-diagnosis of PE in the current era.
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Affiliation(s)
- Dawn Swan
- Department of Haematology, University Hospital Galway, Galway, Ireland.
| | - Sophy Hitchen
- Department of Haematology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Jecko Thachil
- Department of Haematology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
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Klok FA, Barco S, Konstantinides SV, Dartevelle P, Fadel E, Jenkins D, Kim NH, Madani M, Matsubara H, Mayer E, Pepke-Zaba J, Delcroix M, Lang IM. Determinants of diagnostic delay in chronic thromboembolic pulmonary hypertension: results from the European CTEPH Registry. Eur Respir J 2018; 52:13993003.01687-2018. [PMID: 30409820 DOI: 10.1183/13993003.01687-2018] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Accepted: 09/23/2018] [Indexed: 11/05/2022]
Affiliation(s)
- Frederikus A Klok
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany.,Dept of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Philippe Dartevelle
- Dept of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hôpital Marie-Lannelongue, Paris-Sud Univ., Paris, France
| | - Elie Fadel
- Univ. Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - David Jenkins
- Dept of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
| | - Nick H Kim
- Division of Pulmonary and Critical Care Medicine, University of California San Diego, La Jolla, CA, USA
| | - Michael Madani
- Division of Cardiovascular and Thoracic Surgery, University of California San Diego, La Jolla, CA, USA
| | - Hiromi Matsubara
- Dept of Clinical Science, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Eckhard Mayer
- Kerckhoff Heart and Lung Center, Bad Nauheim, Germany
| | | | - Marion Delcroix
- Dept of Pneumology, University Hospitals Leuven, Leuven, Belgium
| | - Irene M Lang
- Dept of Internal Medicine II, Division of Cardiology, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
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Goyard C, Côté B, Looten V, Roche A, Pastré J, Marey J, Planquette B, Meyer G, Sanchez O. Determinants and prognostic implication of diagnostic delay in patients with a first episode of pulmonary embolism. Thromb Res 2018; 171:190-198. [PMID: 30190113 DOI: 10.1016/j.thromres.2018.08.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 07/26/2018] [Accepted: 08/22/2018] [Indexed: 01/24/2023]
Abstract
Signs and symptoms of pulmonary embolism (PE) are not specific and this can lead to a diagnostic delay. Little is known about the determinants of this delay and its prognostic implication. We conducted a retrospective analysis of a prospective cohort involving 514 patients with a first episode of PE. The diagnostic delay was defined as a time from first symptom onset to diagnosis of >3 days, corresponding of the median time in the population. Multivariable logistic regression analysis was performed to identify determinants of diagnostic delay. Prognostic implication was measured as the occurrence of 30-day all-cause mortality, haemodynamic collapse or recurrent PE. A total of 240 (47%) among 514 patients had a time from first symptom to diagnosis > 3 days. Previous deep vein thrombosis (OR 0.55, 95% Confidence Interval (CI), 0.32-0.93), immobilization (OR 0.52, 95% CI, 0.28-0.96), surgery (OR 0.31, 95% CI, 0.16-0.62), chest pain (OR 0.58, 95% CI, 0.39-0.86), syncope (OR 0.48, 95% CI, 0.23-1.01), dyspnea (OR 2.48, 95% CI, 1.57-3.91) and hemoptysis (OR 3.57, 95% CI, 1.40-9.07) were associated with diagnostic delay. Twenty-two patients (4.3%, 95%CI, 2.8-6.5) experienced an outcome event within 30 days. Among them, 15 patients (6.2% 95%CI, 3.7-10.3) had a diagnostic delay and 7 (2.6%, 95% CI 1.1-5.4) did not (p = 0.039). In this cohort, diagnostic delay is associated with the absence of major risk factors for PE or clinical features such as chest pain or syncope and the presence of dyspnea or hemoptysis. Diagnostic delay is associated with a worse 30-day prognosis.
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Affiliation(s)
- Céline Goyard
- Université Paris Descartes, Sorbonne Paris Cité, France; Division of Respiratory and Intensive Care Medicine, Hôpital Européen Georges Pompidou, Assistance Publique Hôpitaux de Paris, France
| | - Benoit Côté
- Département de médecine interne, Hôpital de l'Enfant-Jésus du CHU de Québec, Université Laval, Québec, Canada.
| | - Vincent Looten
- Université Paris Descartes, Sorbonne Paris Cité, France; Division of Medical Informatics, Biostatistics and Public Health, Hôpital Européen Georges Pompidou, France; INSERM UMRS 1138, Paris, France
| | - Anne Roche
- Université Paris Descartes, Sorbonne Paris Cité, France; Division of Respiratory and Intensive Care Medicine, Hôpital Européen Georges Pompidou, Assistance Publique Hôpitaux de Paris, France
| | - Jean Pastré
- Université Paris Descartes, Sorbonne Paris Cité, France; Division of Respiratory and Intensive Care Medicine, Hôpital Européen Georges Pompidou, Assistance Publique Hôpitaux de Paris, France
| | - Jonathan Marey
- Université Paris Descartes, Sorbonne Paris Cité, France; Division of Respiratory and Intensive Care Medicine, Hôpital Européen Georges Pompidou, Assistance Publique Hôpitaux de Paris, France
| | - Benjamin Planquette
- Université Paris Descartes, Sorbonne Paris Cité, France; Division of Respiratory and Intensive Care Medicine, Hôpital Européen Georges Pompidou, Assistance Publique Hôpitaux de Paris, France; INSERM UMRS 1140, Paris, France; F-CRIN, INNOVTE, Saint-Etienne, France
| | - Guy Meyer
- Université Paris Descartes, Sorbonne Paris Cité, France; Division of Respiratory and Intensive Care Medicine, Hôpital Européen Georges Pompidou, Assistance Publique Hôpitaux de Paris, France; F-CRIN, INNOVTE, Saint-Etienne, France; INSERM UMRS_970 and CIC 1418, Paris, France
| | - Olivier Sanchez
- Université Paris Descartes, Sorbonne Paris Cité, France; Division of Respiratory and Intensive Care Medicine, Hôpital Européen Georges Pompidou, Assistance Publique Hôpitaux de Paris, France; INSERM UMRS 1140, Paris, France; F-CRIN, INNOVTE, Saint-Etienne, France.
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