Venous thromboembolism: fatal PEs are rare.

Clinical bottom line (level 1a)

  1. One in 250 patients with a DVT have a fatal PE in the next 5 months.
  2. One in seventy patients with a PE die from a fatal PE in the next 5 months.
  3. One in 26 patients with a DVT have a recurrent nonfatal DVT or PE during anticoagulation for 3 months, rising to 1 in 16 in the next 2 months.
Douketis et al: Journal of the American Medical Association 1998; 279 (6): 458-462
Expires May 2003

The study

Systematic review of all prospective studies of
  • Patients: objectively-proven symptomatic DVT or PE, who were treated with heparin or LMWH for at least 5 days, and oral anticoagulation (target INR 2.0 to 4.5) or LMWH or heparin for 3 months
  • Outcome: fatal PE


    • Articles found in English using Medline, 1966 to Sept 1997 (search terms: thrombophlebitis, diagnosis, treatment and prognosis ) and scanning Current Contents and bibliographies of relevant articles. Studies were appraised by 2 independent authors.

    Selection criteria:
    • a priori studies
    • objectively diagnosed DVT or PE
    • all patients were followed prospectively and outcome events were recorded

    Appraisal criteria: detailed in text
    Articles excluded if:
    • initial DVT not diagnosed by venography or non-compressibility on ultrasound
    • initial PE not diagnosed by pulmonary angiography or high-probability V/Q scan
    • consecutive patients not recruited
    • not determined if qualifying event DVT or PE
    • timing of fatal PE not reported
    • reliable methods not used to diagnoise PE or DVT


    25 studies found involving 4221 patients with DVT, and 1302 patients with PE followed, for a mean of 4.6 months.
    • Patients were excluded if they received additional therapy (e.g. thrombolysis, IVF filter).

    The evidence

    outcome time to outcome number of patients/total number %
    (95% CI)    		 NNF
    (95% CI)
    fatal PE following presentation with PE 5 months 19/1302 1.5%
    (0.81% to 2.1%)    		 69
    (47 to 120)
    fatal PE following presentation with DVT 5 months 17/4221 0.40%
    (0.21% to 0.59%)    		 250
    (170 to 470)
    recurrent nonfatal VTE during anticoagulation for a DVT 5 months 156/4104 3.8%
    (3.2% to 4.4%)    		 26
    (23 to 31)
    recurrent nonfatal VTE following anticoagulation for a DVT 5 months 75/1190 6.3%
    (4.9% to 7.7%)    		 16
    (13 to 20)

    Comments

    1. All fatal PEs following a presentation with a PE occurred within the first 2 weeks.
    2. By limiting the search to only English language papers, important articles may have been missed.

    Citation

    1. Douketis JD, Kearon C, Bates S, et al: Risk of fatal pulmonary embolism in patients with treated venous thromboembolism. Journal of the American Medical Association 1998; 279 (6): 458-462
    Search Terms:
    Contributor: Chris Ball and Clare Wotton, May 2001
    Reviewer:

    Clinical Question.
    Patient venous thromboembolism
    Intervention or Exposure prevalence
    Outcome fatal pulmonary embolism, recurrent venous thromboembolism