0
Clinical Investigations: ASTHMA |

Mortality From Acute Pulmonary Embolism According to Season* FREE TO VIEW

Paul D. Stein, MD; Fadi Kayali, MD; Afzal Beemath, MD; Elias Skaf, MD; Majd Alnas, MD; Issa Alesh, MD; Ronald E. Olson, PhD
Author and Funding Information

*From St. Joseph Mercy Oakland Hospital (Drs. Kayali, Beemath, Skaf, Alnas, and Alesh), Pontiac; Wayne State University (Dr. Stein), Detroit; and Oakland University (Dr. Olson), Rochester, MI.

Correspondence to: Paul D. Stein, MD, Saint Joseph Mercy Oakland, 44555 Woodward Ave, Suite 107, Pontiac, MI 48341-2985; e-mail: steinp@trinity-health.org



Chest. 2005;128(5):3156-3158. doi:10.1378/chest.128.5.3156
Text Size: A A A
Published online

Background: Varying observations have been made on seasonal differences of mortality from acute pulmonary embolism (PE).

Methods: The number of deaths each year from PE, from 1980 through 1998, based on death certificates, was obtained from the US National Center for Health Statistics Multiple Cause-of-Death Files.

Results: Acute PE as the cause of death ranged from 0.91 to 1.03 PE deaths per quarter per 100,000 population. Small differences were statistically significant due to the large number of patients evaluated. Quarterly mortality rates from PE in the northeast, south, midwest, and west, where seasonal weather varies widely, showed no meaningful seasonal differences.

Conclusion: Mortality rates from PE do not vary to a meaningful extent according to season.

Varying observations have been reported on seasonal differences of mortality from acute pulmonary embolism (PE). Several investigators15 reported peak mortality rates in the first quarter of the year, sometimes with overlap in the last quarter,6 and sometimes with second peaks in the third quarter.12 Others79 reported peak mortality rates in the second quarter, sometimes with second peaks in the third and fourth quarter,7or fourth quarter alone.8 And still others10reported peaks only in the third and fourth quarters. More frequent fatal PE during “fine weather phases” of the year and “at the beginning of fine weather” has been reported.11No reported quarterly variation has also been reported.1213 Many of these investigations13,56 were based on observations in < 200 patients. The largest investigation included < 1,500 patients.11 We report data from the US National Center for Health Statistics, which includes an order of magnitude more data than has previously been published.

The number of deaths each year from PE, based on death certificates, was obtained from the US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, Multiple Cause-of-Death Files.14 Data were available from 1980 through 1998. During those years, deaths were coded with the International Classification of Diseases, Ninth Revision, Clinical Modification, for identification of patients with PE (codes 415.1, 634.6, 635.6, 636.6, 637.6, 638.6, and 673.2).

The average quarterly mortality rate of PE over an interval of 18 years was calculated by dividing the 18-year quarterly sum of patients whose death certificates listed PE as the cause of death by the 18-year sum of the yearly populations. The population estimates were derived from the US Bureau of the Census estimates of national and state resident populations.15States comprising regions of the United States, as defined by the National Hospital Discharge Survey, were described previously.16 Two-way analysis of variance (regions by seasons) was calculated using software (SPSS version 13.0; SPSS; Chicago, IL).

Acute PE as the cause of death at autopsy was reported on death certificates in 184,201 patients from 1980 through 1998. Quarterly mortality rates throughout the entire United States ranged from 0.91 to 1.03 PE deaths per quarter per 100,000 population (Table 1 ). Seasonal and regional mortality rates from PE were evaluated and are presented in Table 1. There was an overall significant difference in mortality for the four seasons and four regions. There was no significant interaction for regions by seasons. All were within one PE death per quarter per 100,000 population. Small differences were statistically significant due to the large number of patients evaluated.

The diagnosis of fatal PE based on death certificates should be used with caution to study the epidemiology of PE because of inaccuracies.17 The death certificate diagnosis of fatal or large PE was accurate in only 32 to 35% of patients.1718 Recognizing this, we assume that whatever inaccuracy exists in the death certificates is constant throughout the seasons.

We previously reported no quarterly (seasonal) differences in the rate of diagnosis of PE among hospitalized patients.19 The results of that investigation and the present investigation were strengthened by evaluations of regions of the United States, which have widely varying weather conditions. Rates of diagnosis of PE, deep venous thrombosis, and venous thromboembolism and mortality rates are lower in the western region than in other regions.16 The reason is unclear. Although the population is somewhat younger in the western region, differences were shown among patients ≥ 65 years of age.16 Also, although there are more Asian Americans in the western region, and the Asian population has lower rates of venous thromboembolism,20 the western region also had lower rates of diagnosis and lower mortality rates among whites and blacks.16 None of the regions showed meaningful quarterly (seasonal) differences in the rate of diagnosis19 or mortality rate from PE. This investigation reports data on many thousands of patients. Although there was a trace higher mortality rate in January to March, such differences were ≤ 1 PE death/quarter/100,000 population. Such differences would not be observable in studies of only a few hundred patients. The absence of meaningful seasonal variation in mortality from PE shown in this investigation, and the absence of seasonal variation of the rate of diagnosis in hospitalized patients, shown previously,19 indicate that PE is not affected by the season, contrary to reports111 based on smaller investigations.

Abbreviation: PE = pulmonary embolism

Table Graphic Jump Location
Table 1. Average Quarterly Rate of Deaths From PE, 1980–1998 (PE Deaths/100,000 Population)
* 

Differences between regions: south greater than northeast, midwest, and west (p < 0.05); northeast and midwest greater than west (p < 0.05).

 

Differences between seasons: January to March greater than April to June, July to September, and October to December (p < 0.05); October to December greater than April to June, and July to September (p < 0.05).

Chau, KY, Yuen, ST, Wong, MP (1995) Seasonal variation in the necropsy incidence of pulmonary thromboembolism in Hong Kong.J Clin Pathol48,578-579. [CrossRef] [PubMed]
 
Colantonio, D, Casale, R, Natali, G, et al Seasonal periodicity in fatal pulmonary thromboembolism.Lancet1990;335,56-57
 
Gallerani, M, Manfredini, R, Ricci, L, et al Sudden death from pulmonary thromboembolism: chronobiological aspects.Eur Heart J1992;13,661-665. [PubMed]
 
Mobius, C, Gunther, U, Klinker, L, et al Meteoropathologic effects on the development of fatal lung embolism [in German].Z Gesamte Hyg1989;35,391-392. [PubMed]
 
Manfredini, R, Gallerani, M, Salmi, R, et al Fatal pulmonary embolism in hospitalized patients: evidence for a winter peak.J Int Med Res1994;22,85-89. [PubMed]
 
Wroblewski, BM, Siney, PD, White, R Fatal pulmonary embolism after total hip arthroplasty: seasonal variation.Clin Orthop Relat Res1992;276,222-224. [PubMed]
 
Green, J, Edwards, C Seasonal variation in the necropsy incidence of massive pulmonary embolism.J Clin Pathol1994;47,58-60. [CrossRef] [PubMed]
 
Hackl, H Environmental effects and pulmonary embolism.Dtsch Med J1968;19,475-477. [PubMed]
 
Montes Santiago, J, Rey Garcia, G, Mediero Dominguez, A Seasonal variations in morbidity and mortality for pulmonary embolism [in Spanish].An Med Interna2003;20,457-460. [PubMed]
 
Steiner, I, Matejek, T Pulmonary embolism: temporal aspects.Cesk Patol2003;39,185-188. [PubMed]
 
Putzke, HP, Mobius, C, Gunther, U, et al The incidence of fatal lung emboli with special reference to the underlying disease and the effect of weather [in German].Z Gesamte Inn Med1989;44,106-110. [PubMed]
 
Coon, WW, Coller, FA Some epidemiologic considerations of thromboembolism.Surg Gynecol Obstet1959;109,487-501. [PubMed]
 
Golin, V, Sprovieri, SR, Bedrikow, R, et al Pulmonary thromboembolism: retrospective study of necropsies performed over 24 years in a university hospital in Brazil.Sao Paulo Med J2002;120,105-108. [PubMed]
 
United States Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, Multiple Cause-of-Death Files, NCHS CD-ROM Series 20, 1980–1998. Hyattsville, MD: National Center for Health Statistics.
 
Bureau of the Census, Department of Commerce, United States Department of Health and Human Services (US DHHS), Centers for Disease Control and Prevention (CDC), CDC WONDER. Available at: wonder.cdc.gov/census.shtml. Accessed October 18, 2005.
 
Stein, PD, Kayali, F, Olson, RE Regional differences in rates of diagnosis and mortality of pulmonary thromboembolism.Am J Cardiol2004;93,1194-1197. [CrossRef] [PubMed]
 
Dismuke, SE, VanderZwaag, R Accuracy and epidemiological implications of the death certificate diagnosis of pulmonary embolism.J Chronic Dis1984;37,67-73. [CrossRef] [PubMed]
 
Attems, J, Arbes, S, Bohm, G, et al The clinical diagnostic accuracy rate regarding the immediate cause of death in a hospitalized geriatric population; an autopsy study of 1594 patients.Wien Med Wochenschr2004;154,159-162. [CrossRef] [PubMed]
 
Stein, PD, Kayali, F, Olson, RE Analysis of occurrence of venous thromboembolic disease in the four seasons.Am J Cardiol2004;93,511-513. [CrossRef] [PubMed]
 
Stein, PD, Kayali, F, Olson, RE, et al Pulmonary thromboembolism in Asian-Pacific Islanders in the United States: analysis of data from the National Hospital Discharge Survey and the United States Bureau of the Census.Am J Med2004;116,435-442. [CrossRef] [PubMed]
 

Figures

Tables

Table Graphic Jump Location
Table 1. Average Quarterly Rate of Deaths From PE, 1980–1998 (PE Deaths/100,000 Population)
* 

Differences between regions: south greater than northeast, midwest, and west (p < 0.05); northeast and midwest greater than west (p < 0.05).

 

Differences between seasons: January to March greater than April to June, July to September, and October to December (p < 0.05); October to December greater than April to June, and July to September (p < 0.05).

References

Chau, KY, Yuen, ST, Wong, MP (1995) Seasonal variation in the necropsy incidence of pulmonary thromboembolism in Hong Kong.J Clin Pathol48,578-579. [CrossRef] [PubMed]
 
Colantonio, D, Casale, R, Natali, G, et al Seasonal periodicity in fatal pulmonary thromboembolism.Lancet1990;335,56-57
 
Gallerani, M, Manfredini, R, Ricci, L, et al Sudden death from pulmonary thromboembolism: chronobiological aspects.Eur Heart J1992;13,661-665. [PubMed]
 
Mobius, C, Gunther, U, Klinker, L, et al Meteoropathologic effects on the development of fatal lung embolism [in German].Z Gesamte Hyg1989;35,391-392. [PubMed]
 
Manfredini, R, Gallerani, M, Salmi, R, et al Fatal pulmonary embolism in hospitalized patients: evidence for a winter peak.J Int Med Res1994;22,85-89. [PubMed]
 
Wroblewski, BM, Siney, PD, White, R Fatal pulmonary embolism after total hip arthroplasty: seasonal variation.Clin Orthop Relat Res1992;276,222-224. [PubMed]
 
Green, J, Edwards, C Seasonal variation in the necropsy incidence of massive pulmonary embolism.J Clin Pathol1994;47,58-60. [CrossRef] [PubMed]
 
Hackl, H Environmental effects and pulmonary embolism.Dtsch Med J1968;19,475-477. [PubMed]
 
Montes Santiago, J, Rey Garcia, G, Mediero Dominguez, A Seasonal variations in morbidity and mortality for pulmonary embolism [in Spanish].An Med Interna2003;20,457-460. [PubMed]
 
Steiner, I, Matejek, T Pulmonary embolism: temporal aspects.Cesk Patol2003;39,185-188. [PubMed]
 
Putzke, HP, Mobius, C, Gunther, U, et al The incidence of fatal lung emboli with special reference to the underlying disease and the effect of weather [in German].Z Gesamte Inn Med1989;44,106-110. [PubMed]
 
Coon, WW, Coller, FA Some epidemiologic considerations of thromboembolism.Surg Gynecol Obstet1959;109,487-501. [PubMed]
 
Golin, V, Sprovieri, SR, Bedrikow, R, et al Pulmonary thromboembolism: retrospective study of necropsies performed over 24 years in a university hospital in Brazil.Sao Paulo Med J2002;120,105-108. [PubMed]
 
United States Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, Multiple Cause-of-Death Files, NCHS CD-ROM Series 20, 1980–1998. Hyattsville, MD: National Center for Health Statistics.
 
Bureau of the Census, Department of Commerce, United States Department of Health and Human Services (US DHHS), Centers for Disease Control and Prevention (CDC), CDC WONDER. Available at: wonder.cdc.gov/census.shtml. Accessed October 18, 2005.
 
Stein, PD, Kayali, F, Olson, RE Regional differences in rates of diagnosis and mortality of pulmonary thromboembolism.Am J Cardiol2004;93,1194-1197. [CrossRef] [PubMed]
 
Dismuke, SE, VanderZwaag, R Accuracy and epidemiological implications of the death certificate diagnosis of pulmonary embolism.J Chronic Dis1984;37,67-73. [CrossRef] [PubMed]
 
Attems, J, Arbes, S, Bohm, G, et al The clinical diagnostic accuracy rate regarding the immediate cause of death in a hospitalized geriatric population; an autopsy study of 1594 patients.Wien Med Wochenschr2004;154,159-162. [CrossRef] [PubMed]
 
Stein, PD, Kayali, F, Olson, RE Analysis of occurrence of venous thromboembolic disease in the four seasons.Am J Cardiol2004;93,511-513. [CrossRef] [PubMed]
 
Stein, PD, Kayali, F, Olson, RE, et al Pulmonary thromboembolism in Asian-Pacific Islanders in the United States: analysis of data from the National Hospital Discharge Survey and the United States Bureau of the Census.Am J Med2004;116,435-442. [CrossRef] [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

CHEST Journal Articles
PubMed Articles
Outpatient versus inpatient treatment for acute pulmonary embolism. Cochrane Database Syst Rev Published online Nov 20, 2014.;
Surgical embolectomy for intermediate-risk acute pulmonary embolism. Interact Cardiovasc Thorac Surg Published online Nov 18, 2014.;
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543