title: Impact of delay in clinical presentation on the diagnostic management and prognosis of patients with suspected pulmonary embolism.
abstract: BACKGROUND
  The nonspecific clinical presentation of pulmonary embolism (PE) frequently leads to delay in its diagnosis.
  
  
  OBJECTIVE
  This study aimed to assess the impact of delay in presentation on the diagnostic management and clinical outcome of patients with suspected PE.
  
  
  METHODS
  In 4,044 consecutive patients with suspected PE, patients presenting more than 7 days from the onset of symptoms were contrasted with those presenting within 7 days as regards the safety of excluding PE on the basis of a clinical decision rule combined with D-dimer testing. Patients were followed for 3 months to assess the rates of recurrent venous thromboembolism and mortality.
  
  
  RESULTS
  A delayed presentation (presentation >7 d) was present in 754 (18.6%) of the patients. The failure rate of an unlikely clinical probability and normal D-dimer test was 0.5% (95% confidence interval [CI], 0.01-2.7) for patients with and 0.5% (95% CI, 0.2-1.2) for those without diagnostic delay. D-dimer testing yielded a sensitivity of 99% (95% CI, 96-99%) and 98% (95% CI, 97-99%) in these groups, respectively. Patients with PE with diagnostic delay more frequently had centrally located PE (41% vs. 26%; P < 0.001). The cumulative rates of recurrent venous thromboembolism (4.6% vs. 2.7%; P = 0.14) and mortality (7.6% vs. 6.6%; P = 0.31) were not different for patients with and without delayed presentation.
  
  
  CONCLUSIONS
  PE can be safely excluded based on a clinical decision rule and D-dimer testing in patients with a delayed clinical presentation. A delayed presentation for patients who survived acute PE was associated with a more central PE location, although this did not affect the clinical outcome at 3 months.
authors.affiliation: Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands. p.l.den_exter@lumc.nl
authors.forename: Paul L
authors.initials: PL
authors.lastname: den Exter
authors.forename: Josien
authors.initials: J
authors.lastname: van Es
authors.forename: Petra M G
authors.initials: PM
authors.lastname: Erkens
authors.forename: Mark J G
authors.initials: MJ
authors.lastname: van Roosmalen
authors.forename: Pim
authors.initials: P
authors.lastname: van den Hoven
authors.forename: Marcel M C
authors.initials: MM
authors.lastname: Hovens
authors.forename: Pieter W
authors.initials: PW
authors.lastname: Kamphuisen
authors.forename: Frederikus A
authors.initials: FA
authors.lastname: Klok
authors.forename: Menno V
authors.initials: MV
authors.lastname: Huisman
mesh_terms: D057210:Delayed Diagnosis; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011446:Prospective Studies; D011655:Pulmonary Embolism / Q000175:diagnosis*