Comparison between clinical and autopsy diagnoses in a cardiology hospital

Abstract

Background: A few recent studies have evaluated diagnostic accuracy by comparison between clinical and autopsy diagnoses in a hospital specialising in cardiology. Methods: 406 consecutive autopsy cases during 2 years were studied. Patients were aged 47.4¡28.4 years; 236 (58.1%) were men and 170 (41.9%) women. Diagnostic comparison was categorised in classes I to V (I, II, III and IV: discrepancy in decreasing order of importance regarding therapy and prognosis; V: concordance). Categorisation was ranked on the basis of the highest degree of discrepancy. Statistical analysis was performed with the X 2 test and stepwise logistic regression. Results: Each age increase of 10 years added 16.2% to the risk of the diagnostic comparison to be categorised in classes I and II (major discrepancy) in comparison to classes III, IV and V (OR 1.16, 95% CI 1.07 to 1.27, p,0.001). By contrast, admission to intensive care units decreased the risk of categorisation in classes I and II by 47% (OR 0.53, 95% CI 0.32 to 0.85, p = 0.009). The most frequent diagnostic discrepancy occurred for pulmonary embolism: 30 out of 88 (34.1%) diagnoses in classes I and II. The concordance rate was 71.1% for acute myocardial infarction, 75% for aorta dissection, 73.1% for infective endocarditis and 35.2% for pulmonary embolism. Conclusion: Age and hospital ward influenced the distribution of diagnostic discrepancy or concordance between clinical and autopsy diagnoses. The lower discrepancy rate for myocardial infarction and infective endocarditis may be related to the fact that the study was carried out in a specialist hospital.

Discrepâncias clínico-patológicas e achados cardiovasculares em 409 autópsias consecutivas

“…Cardiovascular diseases were found to be the main cause of death (42.8%) of autopsy diagnoses, confirming the impact of cardiovascular findings described by other authors 6,10,13 . The 8% autopsy rate in our series is similar to hospital autopsy rates in the United States (12%) and some studies in United Kingdom (11 to 24%) 14 .…”

“…However, this fact was not observed in our series, corroborating previous investigations in wide hospitals 6,9,13 . We not observed a significant correlation between the last admission unit and the level of agreement, in contrast to Gibson et al 18 that found the lowest frequent of concordant diagnoses in the emergency room (33.6%) and the highest (68.4%) in the intensive care unit.…”

“…In cases with a poor prognosis, which are more common in elderly, it is possible that the physician and the patient's relatives decide not to proceed with clinical investigations, which can contribute to a greater chance of misdiagnosis in the older population 9 . Like this one, a large number of previous studies found no correlation between diagnosis and sex 6,7,13 .…”

“…Moreover, several studies found that pulmonary embolism has been the most common misdiagnosed condition 6,9,17 . Its clinical picture may be mild and almost asymptomatic and not easily recognized, making the diagnosis more difficult 13 . The lower incidence of error rates for congestive heart failure and acute ischemic stroke suggests that their clinical signs are often interpreted as representing of these conditions, thereby reducing the discrepancy rates.…”

Clinical setting and extent of premortem evaluation do not predict autopsy discrepancy rates

“…5 Other studies since then have shown similar results with discrepancy rates ranging from 8 to more than 30%, depending on the clinical setting. [5][6][7][8][9][10][11] No study to date has adequately addressed the hypothesis that the intensity and the extent of antemortem diagnostic evaluation correlate with an actual decrease in the number of unexpected discrepancies at autopsy. We retrospectively reviewed all adult autopsies performed at a tertiary care center over a 4-year period to assess whether the discrepancy rate correlated with an index of diagnostic intensity.…”