REBEL Cast Episode 30: The PESIT Trial
Click here for Direct Download of Podcast
What Trial are We Reviewing:
Prandoni P et al. Prevalence of Pulmonary Embolism Among Patients Hospitalized for Syncope. NEJM 2016; 375(16): 1524 – 31. [Epub Ahead of Print]
What They Did:
- Multicenter, Cross-Sectional Study from 11 Hospitals in Italy
Outcomes:
- Prevalence of Pulmonary Embolism among Patients with a First Episode of Syncope
Exclusion:
- Previous Episodes of Syncope
- On Anticoagulation Therapy
- Pregnant
- Did Not Provide Informed Consent
Results:
- 2584 Patients Screened Total (157 Excluded)
- 1857 (72%) Patients Either Not Admitted or Declined Hospitalization
- 560 Patients were included in this study
- Pulmonary Embolism ruled out (via Wells’ score + D-dimer): 330/560 patients (58.9%)
- Pulmonary Embolism was ruled in: 97/230 patients (42.2%)
- Prevalence of Pulmonary Embolism: 17.3% (Range: 15 – 20%)
- Evidence of Pulmonary Embolism on CTPA:
- Main Pulmonary Artery: 30/72 patients (41.7%)
- Lobar Pulmonary Artery on CTPA: 18/72 patients (25.0%)
- Segmental Pulmonary Artery on CTPA: 19/72 patients (26.4%)
- Subsegmental Pulmonary Artery on CTPA: 5/72 patients (6.9%)
- Evidence of Pulmonary Embolism on V/Q Scan:
- >50% of the Area of Both Lungs: 4/24 Patients (16.7%)
- 26 – 50% of the Area of Both Lungs: 8/24 Patients (33.3%)
- 1 – 25% of the Area of Both Lungs: 12/24 Patients (50.0%)
- Pulmonary Embolism Identified in Patients with an Alternative Diagnosis: 45/355 patients (12.7%)
- 31/45 Patients (68.9%) had a Lobar or More Proximal Location of the Thrombus on CTPA or Defect >25% on V/Q Scan
- Pulmonary Embolism Identified in Patients without an Alternative Diagnosis: 52/205 patients (25.4%)
Strengths:
- Multicenter study
- Presence or absence of PE assessed with a validated algorithm based on pretest clinical probability
Limitations:
- Hugely biased selection of patients (None of the discharged patients included)
- A specific syncope workup was not mandated by all hospitals involved in the study
- Imaging for PE was only performed in patients with an elevated D-Dimer and/or had a high pretest probability for PE
- Confirmation of DVT in symptomatic patients was also not mandated
- Search for other causes of syncope was left to the discretion of the physician, meaning other causes of syncope may have been under reported
- No information was collected on treatment and follow-up of patients; therefore, we don’t know what the clinical outcomes of these patients was
Discussion:
- Imaging to confirm PE was not done at admission, but up to 48 hours after admission. Immobility during hospitalization is a known to cause VTE
- Authors conclusion of PE confirmation in approximately one in every six patients (17.3%) however these numbers are grossly inflated
- 2427 patients were actually included in this study (157 were excluded). Excluding all patients will overestimate the results, as was done in this study
- 97 patients had PE confirmed so instead of 97/230 (42.2%) the number should be 97/2427 (3.9%)
- To take this one step further…if you exclude subsegmental PEs (i.e. Unclear clinical significance) the number is actually 80/2427 (3.2%)
- Average Age of the patients in this study was 76 years
- 77.7% were ≥ 70 years
- 52.5% were ≥ 80 years
- Although not studied would an age-adjusted D-Dimer [Age (years) x 10 ug/L for patients > 50 years of age] have reduced the number of tests performed
- Many patients with confirmed PE were more likely to have previous VTE, Elevated RR, Tachycardia, Hypotension, clinical signs of DVT, and Active Cancer (i.e. Evidence of PE by History & Physical). In everyday practice any patient with evidence of PE would be worked up prior to admission. This further biases and overestimates the results of this study
- Prevalence of PE in this study was 19% which is much higher than prevalence of PE in the US (i.e. 5 – 10%).
Author Conclusion: “Pulmonary embolism was identified in nearly one of every six patients hospitalized for a first episode of syncope.”
Clinical Take Home Point: Unfortunately, this study is a gross overestimation of PE, which may ultimately lead to over testing, without really knowing the clinical significance of identification as this was not truly studied.
References:
- Prandoni P et al. Prevalence of Pulmonary Embolism Among Patients Hospitalized for Syncope. NEJM 2016; 375(16): 1524 – 31. [Epub Ahead of Print]
- Huff JS et al. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with syncope. Ann Emerg Med 2007; 49(4): 431 – 44. PMID: 17370717
- Sun BC et al. Direct Medical Costs of Syncope-Related Hospitalizations in the United States. Am J Cardiol 2005; 95(5): 668 – 71. PMID: 15721118
For More Thoughts on This Topic Checkout:
- Ryan Radecki at EMLit of Note: The Impending Pulmonary Embolism Apocolypse
- Simon Carley at St. Emlyn’s: JC – Prevelance of PE in Patients with Syncope
- Rory Spiegel at EM Nerd (EMCrit): The Case of the Incidental Bystander
- PulmCCM: PESIT Investigators – The Incidence of PE in Those Hospitalized Following First Syncope
- Sindhya Rajeev at CORE EM: Prevalence of PE in First Time Syncope Admitted to the Hospital (PESIT Study)
- Justin Morgenstern at First 10 in EM: Quick PESIT Update – PE in Syncope?
Post Peer Reviewed By: Anand Swaminathan (Twitter: @EMSwami)
The post REBEL Cast Episode 30: The PESIT Trial – Do All Patients with 1st Time Syncope Need a Pulmonary Embolism Workup? appeared first on REBEL EM - Emergency Medicine Blog.