Heart rate, a poor predictor of Pulmonary Embolism
DOI:
https://doi.org/10.26738/poem.v1i1.17Abstract
Objective: To determine if there is a significant difference in vital signs between patients with confirmed and excluded pulmonary embolism (PE) throughout their Emergency Department presentation.
Methods: We conducted a retrospective cohort study with patients presenting with suspected PE to Monash Health Emergency Departments between July 2014 and July 2019. Vital signs were compared between patients with confirmed or excluded PE as determined by imaging (CTPA or VQ). Vital signs were compared at three unique data points: initial, minimum, and maximum values.
Results: 3549 patients met inclusion criteria, 922 with confirmed PE and 2627 with excluded PE based on CTPA or VQ. Patients with PE had significant elevations in mean respiratory rates, systolic blood pressures and reduced oxygen saturations compared to patients without PE. Heart rate was not significantly different at initial and maximum datapoints.
Conclusion: Vital signs were demonstrated to be poor predictors of acute PE. Receiver operating characteristic curve analysis suggests that heart rate has poor discriminative power. AUC values for heart rate were: 0.516 (initial), 0.549 (maximum) and 0.519 (minimum). Furthermore, 95% of patients with confirmed PE did not exceed heart rates of 100 BPM during presentation to Emergency. The utility of elevated heart rate and other vital signs in predicting PE were not substantiated in this study.
References
Bĕlohlávek J, Dytrych V, Linhart A. Pulmonary embolism, part I: Epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism. Exp Clin Cardiol. 2013;18(2):129-38.
Lavorini F, Di Bello V, De Rimini ML, Lucignani G, Marconi L, Palareti G, et al. Diagnosis and treatment of pulmonary embolism: a multidisciplinary approach. Multidisciplinary Respiratory Medicine. 2013;8(1):75. DOI: 10.1186/2049-6958-8-75
Keller K, Beule J, Coldewey M, Dippold W, Balzer JO. Heart rate in pulmonary embolism. Internal and emergency medicine. 2015;10(6):663-9. DOI: 10.1007/s11739-015-1198-4
Riedel M. Acute pulmonary embolism 1: pathophysiology, clinical presentation, and diagnosis. Heart. 2001;85(2):229-40. DOI: 10.1136/heart.85.2.229
Stein PD, Beemath A, Matta F, Weg JG, Yusen RD, Hales CA, et al. Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II. Am J Med. 2007;120(10):871-9. DOI: 10.1016/j.amjmed.2007.03.024
Parmley LF, North RL, Ott BS. Hemodynamic Alterations of Acute Pulmonary Thromboembolism. Circulation Research. 1962;11(3):450-65. DOI: 10.1161/01.res.11.3.450
Douma RA, Kamphuisen PW, Büller HR. Acute pulmonary embolism. Part 1: epidemiology and diagnosis. Nature Reviews Cardiology. 2010;7(10):585-96. DOI: 10.1038/nrcardio.2010.106
Freund Y, Rousseau A, Guyot-Rousseau F, Claessens Y-E, Hugli O, Sanchez O, et al. PERC rule to exclude the diagnosis of pulmonary embolism in emergency low-risk patients: study protocol for the PROPER randomized controlled study. Trials. 2015;16:537-. DOI: 10.1186/s13063-015-1049-7
Penaloza A, Soulié C, Moumneh T, Delmez Q, Ghuysen A, El Kouri D, et al. Pulmonary embolism rule-out criteria (PERC) rule in European patients with low implicit clinical probability (PERCEPIC): a multicentre, prospective, observational study. The Lancet Haematology. 2017;4(12):e615-e21. DOI: 10.1016/S2352-3026(17)30210-7
Wolf SJ, McCubbin TR, Feldhaus KM, Faragher JP, Adcock DM. Prospective validation of Wells Criteria in the evaluation of patients with suspected pulmonary embolism. Annals of Emergency Medicine. 2004;44(5):503-10. DOI: 10.1016/j.annemergmed.2004.04.002
Klok FA, Mos ICM, Nijkeuter M, Righini M, Perrier A, Le Gal G, et al. Simplification of the Revised Geneva Score for Assessing Clinical Probability of Pulmonary Embolism. Archives of Internal Medicine. 2008;168(19):2131-6. DOI: 10.1001/archinte.168.19.2131
Aydoğdu M, Topbaşi Sinanoğlu N, Doğan NO, Oğuzülgen IK, Demircan A, Bildik F, et al. Wells score and Pulmonary Embolism Rule Out Criteria in preventing over investigation of pulmonary embolism in emergency departments. Tuberkuloz ve Toraks. 2014;62(1):12-21. DOI: 10.5578/tt.6493
Lucassen W, Geersing GJ, Erkens PM, Reitsma JB, Moons KG, Büller H, et al. Clinical decision rules for excluding pulmonary embolism: a meta-analysis. Ann Intern Med. 2011;155(7):448-60. DOI: 10.7326/0003-4819-155-7-201110040-00007
Doherty S. Pulmonary embolism: An update. Australian Family Physician. 2017;46:816-20.
Nordenholz K, Ryan J, Atwood B, Heard K. Pulmonary embolism risk stratification: pulse oximetry and pulmonary embolism severity index. J Emerg Med. 2011;40(1):95-102. DOI: 10.1016/j.jemermed.2009.06.004
Bova C, Vanni S, Prandoni P, Morello F, Dentali F, Bernardi E, et al. A prospective validation of the Bova score in normotensive patients with acute pulmonary embolism. Thrombosis Research. 2018;165:107-11. DOI: 10.1016/j.thromres.2018.04.002
Dentali F, Riva N, Turato S, Grazioli S, Squizzato A, Steidl L, et al. Pulmonary embolism severity index accurately predicts long-term mortality rate in patients hospitalized for acute pulmonary embolism. Journal of Thrombosis and Haemostasis : JTH. 2013;11(12):2103-10. DOI: 10.1111/jth.12420
Pulivarthi S, Gurram MK. Effectiveness of d-dimer as a screening test for venous thromboembolism: an update. North American Journal of Medical Sciences. 2014;6(10):491-9. DOI: 10.4103/1947-2714.143278
Le Gal G, Righini M, Roy PM, Sanchez O, Aujesky D, Perrier A, et al. Value of D-dimer testing for the exclusion of pulmonary embolism in patients with previous venous thromboembolism. Archives of Internal Medicine. 2006;166(2):176-80. DOI: 10.1001/archinte.166.2.176
Righini M, Aujesky D, Roy PM, Cornuz J, de Moerloose P, Bounameaux H, et al. Clinical usefulness of D-dimer depending on clinical probability and cutoff value in outpatients with suspected pulmonary embolism. Archives of Internal Medicine. 2004;164(22):2483-7. DOI: 10.1001/archinte.164.22.2483
Daley JI, Dwyer KH, Grunwald Z, Shaw DL, Stone MB, Schick A, et al. Increased Sensitivity of Focused Cardiac Ultrasound for Pulmonary Embolism in Emergency Department Patients With Abnormal Vital Signs. Academic Emergency Medicine. 2019;26(11):1211-20. DOI: 10.1111/acem.13774
Miniati M, Cenci C, Monti S, Poli D. Clinical presentation of acute pulmonary embolism: survey of 800 cases. PloS one. 2012;7(2):e30891-e. DOI: 10.1371/journal.pone.0030891
Keller K, Beule J, Balzer JO, Dippold W. Blood pressure for outcome prediction and risk stratification in acute pulmonary embolism. Am J Emerg Med. 2015;33(11):1617-21. DOI: 10.1016/j.ajem.2015.07.009
Meneveau N, Ming LP, Séronde MF, Mersin N, Schiele F, Caulfield F, Bernard Y, Bassand JP. In-hospital and long-term outcome after sub-massive and massive pulmonary embolism submitted to thrombolytic therapy. European Heart Journal. 2003 Aug 1;24(15):1447-54. DOI: 10.1016/s0195-668x(03)00307-5
Wicki J, Perrier A, Perneger TV, Bounameaux H, Junod AF. Predicting adverse outcome in patients with acute pulmonary embolism: a risk score. Thrombosis and Haemostasis. 2000;84(10):548-52. DOI: 10.1055/s-0037-1614065
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Copyright (c) 2023 Pourya Pouryaha, Melinda Fernando, Faris Gondal, Alastair Meyer
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