SGEM#416: She’s Always A Woman, Query PE?

Date: September 28, 2023 Reference: Jarman et al. Sex Differences in Guideline-Consistent Diagnostic Testing for Acute Pulmonary Embolism Among Adult Emergency Department Patients Aged 18-49. AEM September 2023 Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine. Case: During a shift in the emergency department (ED), you see two patients with pleuritic chest pain, one female and one male. Pulmonary embolism (PE) is a diagnosis you are considering for both. After d-dimer testing your female patient, you order a CT scan of the chest for the male patient. One of the nurses on shift asks you why you didn’t order a d-dimer for the male, like you did the female patient. Background: PE is commonly considered during ED workups for chest pain and shortness of breath (1). We have covered the topic of PE more than ten times on the SGEM: SGEM#51: Home (Discharging Patients with Acute Pulmonary Emboli Home from the Emergency Department) SGEM#118: I Hope you Had a Negative D-dimer (ADJUST PE Study) SGEM#126: Take me to the Rivaroxaban – Outpatient treatment of VTE SGEM#163: Shuffle off to Buffalo to Talk Thrombolysis for Acute Pulmonary Embolism SGEM#184: We Weren’t Born to Follow-Up – The PEITHO Long-Term Follow-up Study SGEM#219: Shout, Shout, PERC Rule Them Out SGEM#276: FOCUS on PE in Patients with Abnormal Vital Signs SGEM#277: In the Pregnant YEARS – Diagnosing Pulmonary Embolism SGEM#282: It’s All ‘bout that Bayes, ‘Bout that Bayes- No Trouble – In Diagnosing Pulmonary Embolism SGEM#295: Teacher, Teacher – Tell Me How to Do It (Diagnose a PE) SGEM#323: Mama I’m Comin’ Home – For Outpatient Treatment of a Pulmonary Embolism Many patients may be able to have PE ruled out without imaging, after risk stratification with one of several decision tools (2). A very common clinical decision instrument is the Well’s Criteria. It has seven items with each item having a weighting from 1 to 3. The score is added up and then can be applied in a three-tiered model (low, moderate, or high risk) two-tiered model (PE is unlikely or likely). Another common tool is the revised Geneva Score (rGS). It is an eight-item clinical decision instrument for risk stratification. Each item in this tool also has different weight assigned to the items. Patients are considered low, intermediate, or high-risk depending on their total score. Neither of these two scores considers the sex of the patient for risk stratification. However, sex differences exist in the workup of PE, with females receiving more diagnostic testing, but with a lower diagnostic yield. Female patients are also more likely to undergo diagnostic imaging, and females who undergo imaging are less likely to be diagnosed with PE (3-5). Clinical Question: Are male and female patients equally likely to receive care consistent with guidelines for suspected PE? Reference: Jarman et al. Sex Differences in Guideline-Consistent Diagnostic Testing for Acute Pulmonary Embolism Among Adult Emergency Department Patients Aged 18-49. AEM September 2023 Population: Patients 18-49 years of age presenting with chest pain, shortness of breath, hemoptysis, or syncope alone or in combination Excluded: Pregnancy or incomplete ED visits Exposure: Objective testing for PE Comparison: Sex (male or female) Outcome: Primary Outcome: Receipt of guideline-consistent care based on revised Geneva Score (rGS) Secondary Outcomes: Rates of d-dimer testing, d-dimer positivity, rates of CT-pulmonary artery scanning (CTPA), overall yield of testing. Type of Study: A retrospective cohort study conducted at two U.S. academic tertiary care hospitals Dr. Angela Jarman This is an SGEMHOP episode which means we have the lead author on the show.  Dr. Angela Jarman is an Assistant Professor and the Director of Sex & Gender in Emergency Medici...