Int J Emerg Med. 2017 Dec;10(1):19. doi: 10.1186/s12245-017-0144-9. Epub 2017 Jun 06.
Discharge or admit? Emergency department management of incidental pulmonary embolism in patients with cancer: a retrospective study.
International journal of emergency medicine
Srinivas R Banala, Sai-Ching Jim Yeung, Terry W Rice, Cielito C Reyes-Gibby, Carol C Wu, Knox H Todd, W Frank Peacock, Kumar Alagappan
Affiliations
Affiliations
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1468, Houston, TX, 77030, USA.
- Present address: Emergency Department, Caboolture Hospital, McKean Street, Caboolture, Queensland, 4510, Australia.
- Department of Diagnostic Radiology - Thoracic Imaging, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1478, Houston, TX, 77030, USA.
- Present address: EMLine.org, Mendoza, Argentina.
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, 77030, USA.
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1468, Houston, TX, 77030, USA. [email protected].
PMID: 28589462
PMCID: PMC5461224 DOI: 10.1186/s12245-017-0144-9
Abstract
BACKGROUND: Hospitalization and early anticoagulation therapy remain standard care for patients who present to the emergency department (ED) with pulmonary embolism (PE). For PEs discovered incidentally, however, optimal therapeutic strategies are less clear-and all the more so when the patient has cancer, which is associated with a hypercoagulable state that exacerbates the threat of PE.
METHODS: We conducted a retrospective review of a historical cohort of patients with cancer and incidental PE who were referred for assessment to the ED in an institution whose standard of care is outpatient treatment of selected patients and use of low-molecular-weight heparin for anticoagulation. Eligible patients had received a diagnosis of incidental PE upon routine contrast enhanced chest CT for cancer staging. Survival data was collected at 30 days and 90 days from the date of ED presentation and at the end of the study.
RESULTS: We identified 193 patients, 135 (70%) of whom were discharged and 58 (30%) of whom were admitted to the hospital. The 30-day survival rate was 92% overall, 99% for the discharged patients and 76% for admitted patients. Almost all (189 patients, 98%) commenced anticoagulation therapy in the ED; 170 (90%) of these received low-molecular-weight heparin. Patients with saddle pulmonary artery incidental PEs were more likely to die within 30 days (43%) than were those with main or lobar (11%), segmental (6%), or subsegmental (5%) incidental PEs. In multivariate analysis, Charlson comorbidity index (age unadjusted), hypoxemia, and incidental PE location (P = 0.004, relative risk 33.5 (95% CI 3.1-357.4, comparing saddle versus subsegmental PE) were significantly associated with 30-day survival. Age, comorbidity, race, cancer stage, tachycardia, hypoxemia, and incidental PE location were significantly associated with hospital admission.
CONCLUSIONS: Selected cancer patients presenting to the ED with incidental PE can be treated with low-molecular-weight heparin anticoagulation and safely discharged. Avoidance of unnecessary hospitalization may decrease in-hospital infections and death, reduce healthcare costs, and improve patient quality of life. Because the natural history and optimal management of this condition is not well described, information supporting the creation of straightforward evidence-based practice guidelines for ED teams treating this specialized patient population is needed.
Keywords: Cancer; Emergency; Incidental pulmonary embolism; Outpatient
References
- Int Emerg Nurs. 2016 Jan;24:35-8 - PubMed
- Ann Intern Med. 2007 Feb 6;146(3):204-10 - PubMed
- Eur Heart J. 2008 Sep;29(18):2276-315 - PubMed
- Acad Emerg Med. 2016 Nov;23 (11):1280-1286 - PubMed
- Thromb Res. 2010 Jun;125(6):518-22 - PubMed
- Ann Emerg Med. 1996 Mar;27(3):305-8 - PubMed
- Semin Oncol. 2006 Apr;33(2 Suppl 4):S17-25; quiz S41-2 - PubMed
- J Thromb Haemost. 2010 Nov;8(11):2406-11 - PubMed
- Chest. 2005 Sep;128(3):1601-10 - PubMed
- Acad Emerg Med. 2015 Mar;22(3):299-307 - PubMed
- J Thromb Haemost. 2012 Dec;10(12):2602-4 - PubMed
- Swiss Med Wkly. 2009 Nov 28;139(47-48):685-90 - PubMed
- J Thromb Haemost. 2010 Nov;8(11):2412-7 - PubMed
- J Clin Epidemiol. 1994 Nov;47(11):1245-51 - PubMed
- Br J Haematol. 2015 Sep;170(5):640-8 - PubMed
- Circulation. 2003 Jun 17;107(23 Suppl 1):I17-21 - PubMed
- Ann Emerg Med. 2001 Mar;37(3):251-8 - PubMed
- Ann Emerg Med. 2005 Apr;45(4):448-51 - PubMed
- Thorax. 2003 Jun;58(6):470-83 - PubMed
- Cochrane Database Syst Rev. 2008 Oct 08;(4):CD007491 - PubMed
- Cancer. 2011 Apr 1;117(7):1334-49 - PubMed
- Arch Intern Med. 2006 Feb 27;166(4):458-64 - PubMed
- Chest. 2012 Feb;141(2 Suppl):e419S-e496S - PubMed
- Chest. 2010 Jun;137(6):1382-90 - PubMed
- N Engl J Med. 2000 Dec 21;343(25):1846-50 - PubMed
- Am J Clin Oncol. 1982 Dec;5(6):649-55 - PubMed
- J Thromb Haemost. 2011 Aug;9(8):1500-7 - PubMed
- Clin Exp Emerg Med. 2016 Sep 30;3(3):126-131 - PubMed
- Am J Respir Crit Care Med. 2013 Jun 15;187(12):1369-73 - PubMed
- J Natl Cancer Inst. 2011 Jan 19;103(2):117-28 - PubMed
- Int J Cardiol. 2005 Mar 18;99(2):213-6 - PubMed
- Ann Emerg Med. 2012 Nov;60(5):651-662.e4 - PubMed
- N Engl J Med. 1992 May 7;326(19):1240-5 - PubMed
- Intern Emerg Med. 2014 Jun;9(4):375-84 - PubMed
- Clin Radiol. 2006 Jan;61(1):81-5 - PubMed
Publication Types
Grant support