Prognostic significance of delays in diagnosis of pulmonary embolism.

STUDY OBJECTIVE: To investigate the prognostic significance of a diagnostic delay of greater than 1 week after symptom onset in patients with pulmonary embolism (PE). DESIGN: Prospective cohort study. LOCATION: Emergency Department of Ramón y Cajal Hospital, a 1500-bed tertiary-care center in Madrid, Spain. PATIENTS: Diagnosed with PE by objective testing between January 1, 2003, and June 30, 2005. INTERVENTIONS: All patients received standard anticoagulation therapy during follow-up. ENDPOINTS: Death from any cause or symptomatic recurrent venous thromboembolism (VTE), confirmed by standard objective testing, within 3 months after PE diagnosis. RESULTS: Of the 397 patients with acute PE, 72 (18%) had a diagnostic delay while 325 (82%) did not. The all-cause mortality rate was 13.1% at 3 months (95% CI=9.8-16.4%); due to 9 (12.5%) deaths in the diagnostic delay group and 43 (13.2%) deaths in the group without diagnostic delay (OR 0.9; 95% CI=0.4-2.0). Though multivariate analysis of clinical variables at the time of PE diagnosis identified active cancer, heart failure and immobility for more than 4 days as independent risk factors for death, diagnostic delay was not predictive. Recurrent VTE was observed in 3 (4.2%) of 72 patients with diagnostic delay and in 15 (4.6%) of 325 patients without diagnostic delay (odds ratio: 0.9; 95% CI=0.2-3.2). None of the variables analysed, including diagnostic delay, was associated with an increased risk of recurrent VTE during follow-up. CONCLUSIONS: Among survivors diagnosed with acute PE in the Emergency Department, we did not detect an association between a delay in diagnosis and an increased risk of death or VTE recurrence during the ensuing 3 months of treatment.

Monotherapy with enoxaparin for the prevention of recurrent venous thromboembolism.

This study aimed to determine whether a weight-adjusted dose of subcutaneous enoxaparin is as effective and safe as oral acenocoumarol for the secondary prophylaxis of pulmonary embolism. Three hundred and eighty consecutive noncancer outpatients hospitalized with an episode of symptomatic pulmonary embolism selected treatment with acenocoumarol or enoxaparin at a dose of 1 mg/kg once daily after being informed of the type of administration and expected frequency of laboratory monitoring for both medicinal products. Endpoints were symptomatic recurrent thromboembolic events evaluated by standard objective testing, and a composite endpoint of recurrent venous thromboembolism, major bleeding, and death from any cause. One hundred and ninety-nine patients (52%) chose acenocoumarol therapy and 181 chose enoxaparin monotherapy. Four patients in the enoxaparin group (2.2%) and six patients in the acenocoumarol group (3%) had an objective thromboembolic recurrence (hazard ratio, 1.35; 95% confidence interval, 0.38-4.79; P = 0.64). Nine patients in the enoxaparin group (5.0%) had a hemorrhagic complication compared with 11 in the acenocoumarol group (5.5%) (P = 0.81). The hospital length of stay was shorter with enoxaparin compared with acenocoumarol (11 versus 16 days, P = 0.0001). Enoxaparin is as effective and safe as acenocoumarol in the secondary prevention of recurrent thromboembolic disease and is associated with shorter hospitalization.