Physician practices in the diagnosis and management of patients with pulmonary embolism

To examine the diagnostic work-up and subsequent management of patients with pulmonary embolism, we retrospectively reviewed the medical records of 60 patients who had arteriographically proven pulmonary embolism. Ventilation-perfusion scans were utilized in 47 patients and were classified as showing a high (55.3%), moderate (14.9%), low (8.5%), or indeterminate (21.3%) probability of pulmonary embolism. Of the 33 patients treated with anticoagulation, complications occurred in 10 (30.3%). Of the 39 patients treated with inferior vena cava filters, complications occurred in 16 (41.0%) patients, with the most clinically significant complication being recurrent pulmonary embolism, found to occur in one (2.6%) patient. For patients treated with anticoagulation, heparin was started an average of 0.3 (+/- 0.5) days following the initial suspicion of a pulmonary embolism. The average time to reach a therapeutic partial thromboplastin time level was 2.0 (+/- 1.8) days, and warfarin was started an average of 6.2 (+/- 4.1) days after heparin was begun. Among the 60 patients, five (8.3%) died from the pulmonary embolism, and two of these had at least a five day delay before diagnosis was made by pulmonary arteriography. Since the ventilation-perfusion scan had a sensitivity of 70.2% and a false negative rate of 8.5%, it is not always sufficiently accurate in making final treatment decisions, so there should be less hesitation in attaining pulmonary arteriograms. Therapeutic partial thromboplastin time levels should be more aggressively sought. Warfarin should be started within the first few days of heparin therapy. Inferior vena cava filters should be utilized in patients who have a contraindication to anticoagulation therapy or a complication from anticoagulation therapy.