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CTPA may lead to overdiagnosis of pulmonary embolism
Wiener R. Arch Intern Med. 2011;171:831-837.
Tapson V. Arch Intern Med. 2011;171:837-838.
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Use of computed tomographic pulmonary angiography was shown to significantly increase the incidence of pulmonary embolism when compared with before the modality was introduced, with only a modest improvement in mortality noted between periods.
Researchers conducted the study by using Nationwide Inpatient Sample and Multiple Cause-of-Death databases to compare age-adjusted incidence, mortality and treatment complications of pulmonary embolism in US adults before (1993-1998) and after (1998-2006) introduction of computed tomographic pulmonary angiography (CTPA).
They found that incidence of pulmonary embolism did not change to a significant extent between 1993 and 1998, but there was a change after CTPA introduction (62.1 to 112.3 per 100,000 US adults; P<.001). Also reported was a decrease in pulmonary embolism mortality between both periods, with a greater decrease reported before (13.4 to 12.3 per 100,000; P<.001) vs. after (12.3 to 11.9; P=.02) introduction.
Conversely, case fatality improved most in the period after CTPA introduction (13.2% to 12.1%; P=.02) compared with before (12.1% to 7.8%; P<.001). However, presumed complications due to anticoagulation for pulmonary embolism increased most prominently after introduction (3.1 to 5.3 per 100,000; P<.001) vs. before introduction (2.7 to 3.1 per 100,000; P=.24).
“As use of CT scans continues to rise, the problem of overdiagnosis and overtreatment of pulmonary embolism will likely continue to grow,” the study researchers concluded. “Because the harms of treatment can be substantial … it is imperative that we do not turn the problem of underdiagnosis into one of overdiagnosis. It is time to strengthen the evidence base: A trial randomizing stable patients with small emboli to observation vs. anticoagulation would help determine whether all patients with pulmonary embolism require treatment.”
In an accompanying editorial, Victor F. Tapson, MD, with the Center of Pulmonary Vascular Disease, Duke University Medical Center, Durham, N.C., wrote that although he agrees that acute pulmonary embolism may be diagnosed, other research, including autopsy studies, suggests that it is, in fact, underdiagnosed.
“Most patients who die from acute pulmonary embolism are not only not diagnosed until death but are not even suspected,” he said. “Prevention remains crucial, and recent data continue to suggest that under-prophylaxis is a worldwide problem.”
Disclosure: Dr. Tapson reports no relevant financial disclosures.
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