Age, Diabetes Alter Presentation of Thromboembolism
ACEP News
February 2009
By Patrice Wendling
Elsevier Global Medical News
CHICAGO - Age and diabetes mellitus appear to influence the clinical presentation of venous thromboembolism in the emergency department, according to analyses based on a prospective, multicenter observational study in 7,940 patients.
Patients aged 64 years or more with venous thromboembolism (VTE) were significantly more likely than younger patients to present with a primary symptom of dyspnea (51% vs. 36%, relative risk 1.4); and significantly less likely to complain of pleuritic chest pain than younger patients (32% vs. 58%, RR 0.55).
No significant differences were seen between older and younger patients with regard to substernal chest pain (19% vs. 23%), mean heart rate (94 beats per minute vs. 99/min), and mean respiratory rate (24 breaths per minute vs. 22/min).
The VTE rate however, was significantly higher at 11% in the 1,590 older patients than the 5.5% observed in the 6,350 younger patients (RR 2.0), principal investigator Dr. Peter B. Richman and his associates reported in a poster at the Research Forum of the American College of Emergency Physicians.
The finding that older patients with VTE have distinct clinical characteristics is analogous to that observed for acute coronary syndrome, and reinforces the general tenet that the elderly present atypically for a variety of illnesses, Dr. Richman, of Mayo Clinic Arizona, in Phoenix, said in an interview.
"We typically think of thromboembolism as pain with inspiration as the classic symptom, and yet the older patients were half as likely to have this pleuritic chest pain component as younger patients," he said. "That's a huge difference and it's an important thing to know because VTE is a diagnosis that's frequently missed, frequently results in morbidity and mortality, and frequently gets people sued."
The study, which was conducted at 12 U.S. emergency rooms, defined VTE as a positive radiologic test with a plan to treat. The absence of VTE was confirmed by a structured 45-day follow-up. The mean age was 76 years in the older group and 46 years in the younger group.
Older and younger patients were equally likely to have had surgery within the previous 4 weeks (15.6% vs. 15.7%), to have been trauma victims requiring hospitalization within the previous 4 weeks (1.7% vs. 1.7%), and to be immobilized (30% vs. 27%).
Older patients were significantly more likely to be receiving treatment for an active malignancy (35% vs. 16%), and less likely to be smokers (6% vs. 21%).
According to a second unpublished analysis of the same patient cohort, pleuritic chest pain occurred in 30% of 1,085 patients with diabetes and in 53% of 6,855 patients without diabetes, while diaphoresis occurred in 6% of diabetics and 15% of nondiabetics, Dr. Richman said.
The VTE rate was similar for diabetic (6.7%) and nondiabetic (6.5%) patients, according to the investigators, who reported no relevant conflicts of interest for either analysis.