Nearly 1 in 6 patients hospitalized for a first episode of syncope had a diagnosis of pulmonary embolism (PE), a recent study found. A total of 560 patients (mean age, 76 years) were included in the study. Researchers found:

• A diagnosis of PE was ruled out in 330 of 560 (58.9%) patients.

• PE was diagnosed in 97 of the remaining 230 patients (42.2%).

• Prevalence of PE was 17.3% in the entire cohort.

• 61 patients has evidence of an embolus in a main pulmonary or lobar artery or evidence of perfusion defects larger than 25% of the total area of both lungs.

• PE was identified in 45 of 355 (12.7%) patients who had an alternative explanation for syncope and in 52 of 205 (25.4%) who did not.

Citation: Prandoni P, Lensing AWA, Prins MH, et al. Prevalence of pulmonary embolism among patients hospitalized for syncope. N Engl J Med. 2016;375:1524-1531. doi:10.1056//NEJMoa1602172.

Commentary: Thousands of patients present to emergency rooms each year with syncope. The diagnostic workup, as dictated by most guidelines, focuses on cardiac, neurologic and orthostatic causes. Life-threatening causes are perceived to be rare and health systems are under increasing pressure to provide high value care. It is with this context that this article may alter our diagnostic approach for patients with syncope. Health systems now need to consider an addition to the “usual workup”—the systematic use of the Wells score, D–dimer testing, and a search for PE in the population of patients who are either at high risk for PE or have elevated D-dimer results. When applied to patients sick enough to be hospitalized who present with first time syncope and are not already anticoagulated, the pulmonary embolism prevalence of 17.3% mandates those patients be worked up for this life-threatening condition. Anything less would be unacceptable. —Doron Schneider, MD