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Marsden L, Woodley J. Bilateral lower limb examinations for deep vein thrombosis: A single-centre pilot study comparing request and report parameters for bilateral and unilateral referrals. Radiography (Lond) 2024; 30:1053-1059. [PMID: 38723446 DOI: 10.1016/j.radi.2024.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 03/31/2024] [Accepted: 04/22/2024] [Indexed: 07/03/2024]
Abstract
INTRODUCTION Deep vein thrombosis (DVT) is a common pathology with significant morbidity and mortality, often occurring in the lower limb. Ultrasound is the modality of choice for diagnosis of DVT, but all guidance in the United Kingdom assumes a single leg referral. Few studies have addressed the question of bilateral referrals and bilateral DVTs, and it is not known how these should be included in ultrasound protocols. This study aims to compare the request and report parameters of bilateral examinations with those for single leg examinations over a six-month period. METHODS A single-centre feasibility study collected data on all single and bilateral leg examinations performed by sonographers, over a six-month period at a small general hospital. Data collected for each examination included the referral and report findings. These were compared using basic statistical methods to compare DVT yield by laterality, referrer, DVT site, and patient factors. RESULTS Six hundred and thirty examinations were included, eighteen of which were bilateral examinations. Although the bilateral leg cohort was small, there were significant differences in DVT yield between the groups, with single leg referrals more than eight times more likely to demonstrate a DVT at ultrasound. CONCLUSION In a context of limited ultrasound resource, the low DVT yield of bilateral examinations has implications for service design. Further data collection will be needed to validate initial results, and to establish suitable criteria for acceptance of bilateral DVT referrals. IMPLICATIONS FOR PRACTICE Low yield of DVTs in bilateral examinations can be validated via further research. Bilateral examinations can be explicitly included in DVT service design.
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Affiliation(s)
- L Marsden
- Wye Valley NHS Trust, United Kingdom.
| | - J Woodley
- University of the West of England, United Kingdom
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Luijten D, de Jong CMM, Ninaber MK, Spruit MA, Huisman MV, Klok FA. Post-Pulmonary Embolism Syndrome and Functional Outcomes after Acute Pulmonary Embolism. Semin Thromb Hemost 2023; 49:848-860. [PMID: 35820428 DOI: 10.1055/s-0042-1749659] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Survivors of acute pulmonary embolism (PE) are at risk of developing persistent, sometimes disabling symptoms of dyspnea and/or functional limitations despite adequate anticoagulant treatment, fulfilling the criteria of the post-PE syndrome (PPES). PPES includes chronic thromboembolic pulmonary hypertension (CTEPH), chronic thromboembolic pulmonary disease, post-PE cardiac impairment (characterized as persistent right ventricle impairment after PE), and post-PE functional impairment. To improve the overall health outcomes of patients with acute PE, adequate measures to diagnose PPES and strategies to prevent and treat PPES are essential. Patient-reported outcome measures are very helpful to identify patients with persistent symptoms and functional impairment. The primary concern is to identify and adequately treat patients with CTEPH as early as possible. After CTEPH is ruled out, additional diagnostic tests including cardiopulmonary exercise tests, echocardiography, and imaging of the pulmonary vasculature may be helpful to rule out non-PE-related comorbidities and confirm the ultimate diagnosis. Most PPES patients will show signs of physical deconditioning as main explanation for their clinical presentation. Therefore, cardiopulmonary rehabilitation provides a good potential treatment option for this patient category, which warrants testing in adequately designed and executed randomized trials. In this review, we describe the definition and characteristics of PPES and its diagnosis and management.
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Affiliation(s)
- Dieuwke Luijten
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Cindy M M de Jong
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Maarten K Ninaber
- Department of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
| | - Martijn A Spruit
- Department of Research & Development, Ciro, Horn, The Netherlands
- Department of Respiratory Medicine, Maastricht University Medical Centre, NUTRIM School of Nutrition and Translational Research in Metabolism, Faculty of Health, Medicine and Life Sciences, Maastricht, The Netherlands
| | - Menno V Huisman
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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3
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de Vries JJ, Visser C, van Ommen M, Rokx C, van Nood E, van Gorp ECM, Goeijenbier M, van den Akker JPC, Endeman H, Rijken DC, Kruip MJHA, Weggeman M, Koopman J, de Maat MPM. Levels of Fibrinogen Variants Are Altered in Severe COVID-19. TH OPEN 2023; 7:e217-e225. [PMID: 37501780 PMCID: PMC10370639 DOI: 10.1055/a-2102-4521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 04/28/2023] [Indexed: 07/29/2023] Open
Abstract
Background Fibrinogen variants as a result of alternative messenger RNA splicing or protein degradation can affect fibrin(ogen) functions. The levels of these variants might be altered during coronavirus disease 2019 (COVID-19), potentially affecting disease severity or the thrombosis risk. Aim To investigate the levels of fibrinogen variants in plasma of patients with COVID-19. Methods In this case-control study, we measured levels of functional fibrinogen using the Clauss assay. Enzyme-linked immunosorbent assays were used to measure antigen levels of total, intact (nondegraded Aα chain), extended Aα chain (α E ), and γ' fibrinogen in healthy controls, patients with pneumococcal infection in the intensive care unit (ICU), ward patients with COVID-19, and ICU patients with COVID-19 (with and without thrombosis, two time points). Results Healthy controls and ward patients with COVID-19 ( n = 10) showed similar fibrinogen (variant) levels. ICU patients with COVID-19 who later did ( n = 19) or did not develop thrombosis ( n = 18) and ICU patients with pneumococcal infection ( n = 6) had higher absolute levels of functional, total, intact, and α E fibrinogen than healthy controls ( n = 7). The relative α E fibrinogen levels were higher in ICU patients with COVID-19 than in healthy controls, while relative γ' fibrinogen levels were lower. After diagnosis of thrombosis, only the functional fibrinogen levels were higher in ICU patients with COVID-19 and thrombosis than in those without, while no differences were observed in the other fibrinogen variants. Conclusion Our results show that severe COVID-19 is associated with increased levels of α E fibrinogen and decreased relative levels of γ' fibrinogen, which may be a cause or consequence of severe disease, but this is not associated with the development of thrombosis.
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Affiliation(s)
- Judith J de Vries
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Chantal Visser
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Casper Rokx
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Els van Nood
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Eric C M van Gorp
- Department of Internal Medicine, Erasmus MC, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Viroscience, Erasmus MC, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marco Goeijenbier
- Department of Viroscience, Erasmus MC, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Adult Intensive Care, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Henrik Endeman
- Department of Adult Intensive Care, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dingeman C Rijken
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marieke J H A Kruip
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | | | - Moniek P M de Maat
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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4
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Sutanto H, Soegiarto G. Risk of Thrombosis during and after a SARS-CoV-2 Infection: Pathogenesis, Diagnostic Approach, and Management. Hematol Rep 2023; 15:225-243. [PMID: 37092518 PMCID: PMC10123679 DOI: 10.3390/hematolrep15020024] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/07/2023] [Accepted: 03/24/2023] [Indexed: 04/05/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) increases the risk of thromboembolic events, especially in patients with severe infections requiring intensive care and cardiorespiratory support. COVID-19 patients with thromboembolic complications have a higher risk of death, and if they survive, these complications are expected to negatively affect these patients’ quality of life. Moreover, recent data reported that the risk of thromboembolism remains high months after a COVID-19 infection. Therefore, understanding the pathogenesis of thrombosis in the setting of COVID-19 may facilitate the early prevention and treatment of COVID-19-associated thromboembolism to reduce concomitant morbidity, mortality, and disability. This review will first discuss the clinical characteristics of COVID-19 infections, particularly with regard to the underlying pathophysiology. Then, the pathogenesis of COVID-19-associated thrombosis at the molecular and cellular levels will be comprehensively reviewed. Next, the clinical manifestations of venous and arterial thromboembolism in COVID-19 as well as the potential benefits of several laboratory markers of thrombosis will be further discussed. Lastly, the preventive and therapeutic management of thromboembolism during and after COVID-19 will also be explained.
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Affiliation(s)
- Henry Sutanto
- Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya 60132, Indonesia
- Department of Internal Medicine, Dr. Soetomo Teaching Hospital, Surabaya 60286, Indonesia
| | - Gatot Soegiarto
- Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya 60132, Indonesia
- Department of Internal Medicine, Dr. Soetomo Teaching Hospital, Surabaya 60286, Indonesia
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya 60132, Indonesia
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5
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de Jong CMM, Visser C, Bemelmans RHH, Boersma WG, van den Borst B, Burggraaf JLI, Cannegieter SC, Ten Cate-Hoek AJ, Croles FN, Faber HJ, Faber LM, Hellemons ME, Hessels LM, Huisman MV, Kamphuisen PW, Koster SCE, Kroft LJM, van der Lee I, Leentjens J, Meijer K, Ninaber MK, Sondermeijer BM, Stads S, Vonk Noordegraaf A, Winckers K, Kruip MJHA, Klok FA. Chronic thromboembolic pulmonary hypertension and clot resolution after COVID-19-associated pulmonary embolism. Eur Respir J 2023; 61:13993003.00171-2023. [PMID: 37080574 PMCID: PMC10116061 DOI: 10.1183/13993003.00171-2023] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 02/20/2023] [Indexed: 04/22/2023]
Affiliation(s)
- Cindy M M de Jong
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Chantal Visser
- Department of Haematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Remy H H Bemelmans
- Department of Internal Medicine, Hospital Gelderse Vallei, Ede, The Netherlands
| | - Wim G Boersma
- Department of Pulmonology, North West Hospital Alkmaar, Alkmaar, The Netherlands
| | - Bram van den Borst
- Department of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J Louise I Burggraaf
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Suzanne C Cannegieter
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Arina J Ten Cate-Hoek
- Thrombosis Expertise Center Maastricht and Department of Internal Medicine, Section Vascular Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - F Nanne Croles
- Department of Internal Medicine, Hospital St. Jansdal, Harderwijk, The Netherlands
| | - Harald J Faber
- Department of Intensive Care, Wilhelmina Hospital Assen, Assen, The Netherlands
| | - Laura M Faber
- Department of Internal Medicine, Rode Kruis Hospital, Beverwijk, The Netherlands
| | - Merel E Hellemons
- Department of Respiratory Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
- Erasmus MC Transplant Institute, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Lisa M Hessels
- Department of Pulmonology, North West Hospital Alkmaar, Alkmaar, The Netherlands
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Pieter W Kamphuisen
- Department of Internal Medicine, Tergooi Hospital, Hilversum, The Netherlands
- Department of Vascular Medicine, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | | | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ivo van der Lee
- Department of Pulmonology, Spaarne Hospital, Haarlem, The Netherlands
| | - Jenneke Leentjens
- Department of Internal Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Karina Meijer
- Department of Haematology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Maarten K Ninaber
- Department of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Susanne Stads
- Department of Intensive Care, Ikazia Hospital, Rotterdam, The Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Kristien Winckers
- Thrombosis Expertise Center Maastricht and Department of Internal Medicine, Section Vascular Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Marieke J H A Kruip
- Department of Haematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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6
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Ghossein-Doha C, Wintjens MSJN, Janssen EBNJ, Klein D, Heemskerk SCM, Asselbergs FW, Birnie E, Bonsel GJ, van Bussel BCT, Cals JWL, Ten Cate H, Haagsma J, Hemmen B, van der Horst ICC, Kietselaer BLJH, Klok FA, de Kruif MD, Linschoten M, van Santen S, Vernooy K, Willems LH, Westerborg R, Warle M, van Kuijk SMJ. Prevalence, pathophysiology, prediction and health-related quality of life of long COVID: study protocol of the longitudinal multiple cohort CORona Follow Up (CORFU) study. BMJ Open 2022; 12:e065142. [PMID: 36446465 PMCID: PMC9709810 DOI: 10.1136/bmjopen-2022-065142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION The variety, time patterns and long-term prognosis of persistent COVID-19 symptoms (long COVID-19) in patients who suffered from mild to severe acute COVID-19 are incompletely understood. Cohort studies will be combined to describe the prevalence of long COVID-19 symptoms, and to explore the pathophysiological mechanisms and impact on health-related quality of life. A prediction model for long COVID-19 will be developed and internally validated to guide care in future patients. METHODS AND ANALYSIS Data from seven COVID-19 cohorts will be aggregated in the longitudinal multiple cohort CORona Follow Up (CORFU) study. CORFU includes Dutch patients who suffered from COVID-19 at home, were hospitalised without or with intensive care unit treatment, needed inpatient or outpatient rehabilitation and controls who did not suffer from COVID-19. Individual cohort study designs were aligned and follow-up has been synchronised. Cohort participants will be followed up for a maximum of 24 months after acute infection. Next to the clinical characteristics measured in individual cohorts, the CORFU questionnaire on long COVID-19 outcomes and determinants will be administered digitally at 3, 6, 12, 18 and 24 months after the infection. The primary outcome is the prevalence of long COVID-19 symptoms up to 2 years after acute infection. Secondary outcomes are health-related quality of life (eg, EQ-5D), physical functioning, and the prevalence of thromboembolic complications, respiratory complications, cardiovascular diseases and endothelial dysfunction. A prediction model and a patient platform prototype will be developed. ETHICS AND DISSEMINATION Approval was obtained from the medical research ethics committee of Maastricht University Medical Center+ and Maastricht University (METC 2021-2990) and local committees of the participating cohorts. The project is supported by ZonMW and EuroQol Research Foundation. Results will be published in open access peer-reviewed scientific journals and presented at (inter)national conferences. TRIAL REGISTRATION NUMBER NCT05240742.
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Affiliation(s)
- Chahinda Ghossein-Doha
- Department of Cardiology, Maastricht UMC+, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Marieke S J N Wintjens
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht UMC+, Maastricht, The Netherlands
- Intensive Care Medicine, Maastricht UMC+, Maastricht, The Netherlands
| | - Emma B N J Janssen
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Obstetrics and Gynaecology, Maastricht UMC+, Maastricht, The Netherlands
| | - Dorthe Klein
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht UMC+, Maastricht, The Netherlands
- Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Stella C M Heemskerk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht UMC+, Maastricht, The Netherlands
- Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Folkert W Asselbergs
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
- Institute of Cardiovascular Science, Faculty of Population Health Sciences, Health Data Research UK and Institute of Health Informatics, University College London, London, UK
| | - Erwin Birnie
- Scientific Department, EuroQol Research Foundation, Rotterdam, The Netherlands
- Department of Genetics, University Medical Centre Groningen, Groningen, The Netherlands
| | - Gouke J Bonsel
- Scientific Department, EuroQol Research Foundation, Rotterdam, The Netherlands
| | - Bas C T van Bussel
- Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
- Department of Intensive Care, Maastricht UMC+, Maastricht, The Netherlands
| | - Jochen W L Cals
- Department of Family Medicine, Maastricht University, Maastricht, The Netherlands
- Care and Public Health Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Hugo Ten Cate
- Department of Biochemistry, Department of Internal Medicine, Thrombosis Expert Centre, Maastricht, The Netherlands
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Juanita Haagsma
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - Bena Hemmen
- Care and Public Health Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
- Department of Rehabilitation Medicine, Functioning, Participation & Rehabilitation, Maastricht University, Maastricht, The Netherlands
| | - Iwan C C van der Horst
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Bastiaan L J H Kietselaer
- Department of Cardiology, Zuyderland Medical Centre Heerlen, Heerlen, The Netherlands
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota, USA
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Martijn D de Kruif
- Department of Pulmonology, Zuyderland Medical Centre Heerlen, Heerlen, The Netherlands
| | - Marijke Linschoten
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
- Netherlands Heart Institute, Utrecht, The Netherlands
| | - Susanne van Santen
- Department of Intensive Care, Maastricht UMC+, Maastricht, The Netherlands
- Care and Public Health Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Maastricht UMC+, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Loes H Willems
- Department of Surgery, Radboudumc Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Rosa Westerborg
- Department of Pulmonology, Zuyderland Medical Centre Heerlen, Heerlen, The Netherlands
| | - Michiel Warle
- Department of Surgery, Radboudumc Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht UMC+, Maastricht, The Netherlands
- Care and Public Health Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
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7
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Noordermeer T, Schutgens REG, Visser C, Rademaker E, de Maat MPM, Jansen AJG, Limper M, Cremer OL, Kruip MJHA, Endeman H, Maas C, de Laat B, Urbanus RT. Lupus anticoagulant associates with thrombosis in patients with COVID-19 admitted to intensive care units: A retrospective cohort study. Res Pract Thromb Haemost 2022; 6:e12809. [PMID: 36178455 PMCID: PMC9481876 DOI: 10.1002/rth2.12809] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/22/2022] [Accepted: 08/24/2022] [Indexed: 12/20/2022] Open
Abstract
Background Thrombosis is a frequent and severe complication in patients with coronavirus disease 2019 (COVID‐19) admitted to the intensive care unit (ICU). Lupus anticoagulant (LA) is a strong acquired risk factor for thrombosis in various diseases and is frequently observed in patients with COVID‐19. Whether LA is associated with thrombosis in patients with severe COVID‐19 is currently unclear. Objective To investigate if LA is associated with thrombosis in critically ill patients with COVID‐19. Patients/Methods The presence of LA and other antiphospholipid antibodies was assessed in patients with COVID‐19 admitted to the ICU. LA was determined with dilute Russell's viper venom time (dRVVT) and LA‐sensitive activated partial thromboplastin time (aPTT) reagents. Results Of 169 patients with COVID‐19, 116 (69%) tested positive for at least one antiphospholipid antibody upon admission to the ICU. Forty (24%) patients tested positive for LA; of whom 29 (17%) tested positive with a dRVVT, 19 (11%) tested positive with an LA‐sensitive aPTT, and 8 (5%) tested positive on both tests. Fifty‐eight (34%) patients developed thrombosis after ICU admission. The odds ratio (OR) for thrombosis in patients with LA based on a dRVVT was 2.5 (95% confidence interval [CI], 1.1–5.7), which increased to 4.5 (95% CI, 1.4–14.3) in patients at or below the median age in this study (64 years). LA positivity based on a dRVVT or LA‐sensitive aPTT was only associated with thrombosis in patients aged less than 65 years (OR, 3.8; 95% CI, 1.3–11.4) and disappeared after adjustment for C‐reactive protein. Conclusion Lupus anticoagulant on admission is strongly associated with thrombosis in critically ill patients with COVID‐19, especially in patients aged less than 65 years.
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Affiliation(s)
- Tessa Noordermeer
- Center for Benign Hematology, Thrombosis and Haemostasis, Van Creveldkliniek University Medical Center Utrecht, Utrecht University Utrecht The Netherlands
| | - Roger E G Schutgens
- Center for Benign Hematology, Thrombosis and Haemostasis, Van Creveldkliniek University Medical Center Utrecht, Utrecht University Utrecht The Netherlands
| | - Chantal Visser
- Department of Hematology, Erasmus MC Erasmus University Medical Center Rotterdam Rotterdam The Netherlands
| | - Emma Rademaker
- Julius Center for Health Sciences and Primary Care University Medical Center Utrecht Utrecht The Netherlands
| | - Moniek P M de Maat
- Department of Hematology, Erasmus MC Erasmus University Medical Center Rotterdam Rotterdam The Netherlands
| | - A J Gerard Jansen
- Department of Hematology, Erasmus MC Erasmus University Medical Center Rotterdam Rotterdam The Netherlands
| | - Maarten Limper
- Department of Rheumatology and Clinical Immunology University Medical Center Utrecht, Utrecht University Utrecht The Netherlands
| | - Olaf L Cremer
- Intensive Care Center University Medical Center Utrecht Utrecht The Netherlands
| | - Marieke J H A Kruip
- Department of Hematology, Erasmus MC Erasmus University Medical Center Rotterdam Rotterdam The Netherlands
| | - Henrik Endeman
- Department of Intensive Care Medicine, Erasmus MC University Medical Center Rotterdam Rotterdam The Netherlands
| | - Coen Maas
- Central Diagnostic Laboratory University Medical Center Utrecht, Utrecht University Utrecht The Netherlands
| | - Bas de Laat
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM) Maastricht University, Maastricht, the Netherlands Synapse Research Institute Maastricht The Netherlands
| | - Rolf T Urbanus
- Center for Benign Hematology, Thrombosis and Haemostasis, Van Creveldkliniek University Medical Center Utrecht, Utrecht University Utrecht The Netherlands
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8
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Overton PM, Toshner M, Mulligan C, Vora P, Nikkho S, Jan de Backer, Lavon BR, Klok FA. Pulmonary thromboembolic events in COVID‐19 – a systematic literature review. Pulm Circ 2022; 12:e12113. [PMID: 35942076 PMCID: PMC9349961 DOI: 10.1002/pul2.12113] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/28/2022] [Accepted: 07/10/2022] [Indexed: 11/15/2022] Open
Abstract
Pulmonary thromboembolic events have been linked to coronavirus disease 2019 (COVID‐19), but their incidence and long‐term sequelae remain unclear. We performed a systematic literature review to investigate the incidence of pulmonary embolism (PE), microthrombi, thrombosis in situ (thromboinflammatory disease), and chronic thromboembolic pulmonary hypertension (CTEPH) during and after COVID‐19. PubMed and the World Health Organization Global Research Database were searched on May 7, 2021. Hospital cohort and database studies reporting data for ≥1000 patients and autopsy studies reporting data for ≥20 patients were included. Results were summarized descriptively. We screened 1438 records and included 41 references (32 hospital/database studies and 9 autopsy studies). The hospital/database studies reported the incidence of PE but not CTEPH, microthrombi, or thromboinflammatory disease. PE incidence varied widely (0%–1.1% of outpatients, 0.9%–8.2% of hospitalized patients, and 1.8%–18.9% of patients in intensive care). One study reported PE events occurring within 45 days after hospital discharge (incidence in discharged patients: 0.2%). Segmental arteries were generally the most common location for PE. In autopsy studies, PE, thromboinflammatory disease, and microthrombi were reported in 6%–23%, 43%–100%, and 45%–84% of deceased patients, respectively. Overall, the included studies mostly focused on PE during the acute phase of COVID‐19. The results demonstrate the challenges of identifying and characterizing vascular abnormalities using current protocols (e.g., visual computed tomography reads). Further research is needed to detect subtle pulmonary vascular abnormalities, distinguish thromboinflammatory disease from PE, optimize treatment, and assess the incidence of long‐term sequelae after COVID‐19.
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Affiliation(s)
| | - Mark Toshner
- Department of Medicine, School of Clinical Medicine University of Cambridge UK
| | | | | | | | | | | | - Frederikus A. Klok
- Department of Medicine–Thrombosis and Hemostasis Leiden University Medical Center Leiden the Netherlands
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Tricarico G, Travagli V. Approach to the management of COVID-19 patients: When home care can represent the best practice. INTERNATIONAL JOURNAL OF RISK & SAFETY IN MEDICINE 2022; 33:249-259. [PMID: 35786662 DOI: 10.3233/jrs-210064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The pandemic that began around February 2020, caused by the viral pathogen SARS-CoV-2 (COVID-19), has still not completed its course at present in June 2022. OBJECTIVE The open research to date highlights just how varied and complex the outcome of the contagion can be. METHOD The clinical pictures observed following the contagion present variabilities that cannot be explained completely by the patient's age (which, with the new variants, is rapidly changing, increasingly affecting younger patients) nor by symptoms and concomitant pathologies (which are no longer proving to be decisive in recent cases) in relation to medium-to-long term sequelae. In particular, the functions of the vascular endothelium and vascular lesions at the pre-capillary level represent the source of tissue hypoxia and other damage, resulting in the clinical evolution of COVID-19. RESULTS Keeping the patient at home with targeted therapeutic support, aimed at not worsening vascular endothelium damage with early and appropriate stimulation of endothelial cells, ameliorates the glycocalyx function and improves the prognosis and, in some circumstances, could be the best practice suitable for certain patients. CONCLUSION Clinical information thus far collected may be of immense value in developing a better understanding of the present pandemic and future occurrences regarding patient safety, pharmaceutical care and therapy liability.
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Affiliation(s)
| | - Valter Travagli
- Dipartimento di Biotecnologie, Chimica e Farmacia, Università degli Studi di Siena, Siena, Italy.,Dipartimento di Eccellenza Nazionale, Università degli Studi di Siena, Siena, Italy
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10
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de Vries JJ, Visser C, Geers L, Slotman JA, van Kleef ND, Maas C, Bax HI, Miedema JR, van Gorp ECM, Goeijenbier M, van den Akker JPC, Endeman H, Rijken DC, Kruip MJHA, de Maat MPM. Altered fibrin network structure and fibrinolysis in intensive care unit patients with COVID-19, not entirely explaining the increased risk of thrombosis. J Thromb Haemost 2022; 20:1412-1420. [PMID: 35316570 PMCID: PMC9115158 DOI: 10.1111/jth.15708] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 03/11/2022] [Accepted: 03/16/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Severe acute respiratory syndrome coronavirus 2 infection is associated with an increased incidence of thrombosis. OBJECTIVES By studying the fibrin network structure of coronavirus disease 2019 (COVID-19) patients, we aimed to unravel pathophysiological mechanisms that contribute to this increased risk of thrombosis. This may contribute to optimal prevention and treatment of COVID-19 related thrombosis. PATIENTS/METHODS In this case-control study, we collected plasma samples from intensive care unit (ICU) patients with COVID-19, with and without confirmed thrombosis, between April and December 2020. Additionally, we collected plasma from COVID-19 patients admitted to general wards without thrombosis, from ICU patients with pneumococcal infection, and from healthy controls. Fibrin fiber diameters and fibrin network density were quantified in plasma clots imaged with stimulated emission depletion microscopy and confocal microscopy. Finally, we determined the sensitivity to fibrinolysis. RESULTS COVID-19 ICU patients (n = 37) and ICU patients with pneumococcal disease (n = 7) showed significantly higher fibrin densities and longer plasma clot lysis times than healthy controls (n = 7). No differences were observed between COVID-19 ICU patients with and without thrombosis, or ICU patients with pneumococcal infection. At a second time point, after diagnosis of thrombosis or at a similar time point in patients without thrombosis, we observed thicker fibers and longer lysis times in COVID-19 ICU patients with thrombosis (n = 19) than in COVID-19 ICU patients without thrombosis (n = 18). CONCLUSIONS Our results suggest that severe COVID-19 is associated with a changed fibrin network structure and decreased susceptibility to fibrinolysis. Because these changes were not exclusive to COVID-19 patients, they may not explain the increased thrombosis risk.
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Affiliation(s)
- Judith J de Vries
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Chantal Visser
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Lotte Geers
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Johan A Slotman
- Erasmus Optical Imaging Centre, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nadine D van Kleef
- Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Coen Maas
- Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hannelore I Bax
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Internal Medicine, Section of Infectious Diseases, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jelle R Miedema
- Department of Pulmonary Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Eric C M van Gorp
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Viroscience, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marco Goeijenbier
- Department of Viroscience, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Johannes P C van den Akker
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Henrik Endeman
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dingeman C Rijken
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marieke J H A Kruip
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Moniek P M de Maat
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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11
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Bikdeli B. To escalate thromboprophylacic heparin intensity in COVID‐19 or not? That is still the question. Res Pract Thromb Haemost 2022; 6:e12738. [PMID: 35664534 PMCID: PMC9148841 DOI: 10.1002/rth2.12738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 05/03/2022] [Accepted: 05/05/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Behnood Bikdeli
- Cardiovascular Medicine Division Brigham and Women’s Hospital Harvard Medical School Boston Massachusetts USA
- Thrombosis Research Group Brigham and Women’s Hospital Harvard Medical School Boston Massachusetts USA
- YNHH/Yale Center for Outcomes Research and Evaluation (CORE) New Haven Connecticut USA
- Cardiovascular Research Foundation (CRF) New York New York USA
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12
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Javaid U, Young P, Gill G, Bhargava P. Acute complete splenic infarction secondary to COVID-19 infection. Radiol Case Rep 2022; 17:1402-1406. [PMID: 35242265 PMCID: PMC8889326 DOI: 10.1016/j.radcr.2022.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 01/28/2022] [Accepted: 02/02/2022] [Indexed: 12/23/2022] Open
Abstract
Splenic infarction in COVID-19 patients is a rare entity with few documented cases. We report a case of symptomatic complete splenic infarction and discuss COVID-19 related thrombosis, splenic infarction, diagnostic imaging for splenic infarction, and the management. Thrombotic events related to COVID-19 have been reported in unusual locations, and our case highlights an example of one such location, the splenic artery. Contrast enhanced Computed Tomography (CT) is the standard diagnostic modality and will typically reveal foci of hypo-enhancement, peripheral and wedge-shaped. CT angiography can be performed to evaluate the arteries and diagnose thrombosis. The primary treatment is aimed at addressing the underlying cause and includes supportive care. It is important that physicians consider splenic infarction as an explanation for abdominal pain in COVID-19 patients.
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13
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Camilleri E, van Rein N, van der Meer FJM, Nierman MC, Lijfering WM, Cannegieter SC. Stability of vitamin K antagonist anticoagulation after COVID-19 diagnosis. Res Pract Thromb Haemost 2021; 5:e12597. [PMID: 34667920 PMCID: PMC8511881 DOI: 10.1002/rth2.12597] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 07/14/2021] [Accepted: 08/02/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Coagulopathy has been reported in severely ill patients with coronavirus disease 2019 (COVID-19). It is unclear whether outpatients with COVID-19 who are treated with vitamin K antagonists (VKAs) have unstable anticoagulation. OBJECTIVE To assess the stability of VKA therapy in patients with COVID-19 through a case-crossover study. METHODS Between February and July 2020, we included patients who tested positive for COVID-19 from two anticoagulant clinics in the Netherlands. We collected international normalized ratios (INRs) determined between 26 weeks before infection and 12 weeks after. Time in therapeutic range (TTR) and the variance growth rate (VGR) were calculated within patients. RESULTS Fifty-one patients with COVID-19 (mean age, 84 years) were included, of whom 15 (29%) were men. Mean TTR in the 26 weeks before COVID-19 was 80% (95% confidence interval [CI], 75-85) compared to 59% (95% CI, 51-68) in the 6 weeks after infection. Mean TTR difference was -23% (95% CI, -32 to -14) with a time above therapeutic range of 38% (95% CI, 30-47) in the 6 weeks after infection. The TTR rose again to 79% (95% CI, 69-89) between 6 and 12 weeks after infection. Also, VGR increased, with a mean increase of 4.8 (95% CI, 2.1-7.5) in the 6 weeks after infection. In the 26 weeks before infection, we registered 19 of 641 (3%) of INR ≥5.0 compared with 35 of 247 (14%) in the 6 weeks after (risk ratio, 4.4; 95% CI, 2.7-7.3). CONCLUSIONS COVID-19 is associated with a strong decrease in TTR and in therapeutic stability in patients taking VKAs. Additional monitoring in these patients is advised to maximize therapeutic stability.
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Affiliation(s)
- Eleonora Camilleri
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Nienke van Rein
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
- Department of PharmacyAmsterdam University Medical Centers – Location AMC, University of AmsterdamAmsterdamThe Netherlands
| | - Felix J. M. van der Meer
- Anticoagulation Clinic LeidenLeidenThe Netherlands
- Department of Internal Medicine, Division of Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Melchior C. Nierman
- Department of Thrombosis and AnticoagulationAtalmedial Medical Diagnostics CentersAmsterdamThe Netherlands
| | - Willem M. Lijfering
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
- Department of Internal Medicine, Division of Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Suzanne C. Cannegieter
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
- Department of Internal Medicine, Division of Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
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14
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Stals MAM, Kaptein FHJ, Bemelmans RHH, van Bemmel T, Boukema IC, Braeken DCW, Braken SJE, Bresser C, Cate HT, Deenstra DD, Dooren YPAV, Faber LM, Grootenboers MJJH, Haan LRD, Haazer C, Sol AID, Kelliher S, Koster T, Kroft LJM, Meijer RI, Pals F, van Thiel ERE, Westerweel PE, Wolde MT, Klok FA, Huisman MV. Ruling out Pulmonary Embolism in Patients with (Suspected) COVID-19-A Prospective Cohort Study. TH OPEN 2021; 5:e387-e399. [PMID: 34541450 PMCID: PMC8443402 DOI: 10.1055/s-0041-1735155] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 07/07/2021] [Indexed: 01/08/2023] Open
Abstract
Background
Diagnostic strategies for suspected pulmonary embolism (PE) have not been prospectively evaluated in COVID-19 patients.
Methods
Prospective, multicenter, outcome study in 707 patients with both (suspected) COVID-19 and suspected PE in 14 hospitals. Patients on chronic anticoagulant therapy were excluded. Informed consent was obtained by opt-out approach. Patients were managed by validated diagnostic strategies for suspected PE. We evaluated the safety (3-month failure rate) and efficiency (number of computed tomography pulmonary angiographies [CTPAs] avoided) of the applied strategies.
Results
Overall PE prevalence was 28%. YEARS was applied in 36%, Wells rule in 4.2%, and “CTPA only” in 52%; 7.4% was not tested because of hemodynamic or respiratory instability. Within YEARS, PE was considered excluded without CTPA in 29%, of which one patient developed nonfatal PE during follow-up (failure rate 1.4%, 95% CI 0.04–7.8). One-hundred seventeen patients (46%) managed according to YEARS had a negative CTPA, of whom 10 were diagnosed with nonfatal venous thromboembolism (VTE) during follow-up (failure rate 8.8%, 95% CI 4.3–16). In patients managed by CTPA only, 66% had an initial negative CTPA, of whom eight patients were diagnosed with a nonfatal VTE during follow-up (failure rate 3.6%, 95% CI 1.6–7.0).
Conclusion
Our results underline the applicability of YEARS in (suspected) COVID-19 patients with suspected PE. CTPA could be avoided in 29% of patients managed by YEARS, with a low failure rate. The failure rate after a negative CTPA, used as a sole test or within YEARS, was non-negligible and reflects the high thrombotic risk in these patients, warranting ongoing vigilance.
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Affiliation(s)
- Milou A M Stals
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, South-Holland, The Netherlands
| | - Fleur H J Kaptein
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, South-Holland, The Netherlands
| | - Remy H H Bemelmans
- Department of Internal Medicine, Hospital Gelderse Vallei, Ede, Gelderland, The Netherlands
| | - Thomas van Bemmel
- Department of Internal Medicine, Gelre Ziekenhuizen Apeldoorn, Apeldoorn, Gelderland, The Netherlands
| | - Inge C Boukema
- Department of Internal Medicine, Amsterdam UMC Locatie VUmc, Amsterdam, Noord-Holland, The Netherlands
| | - Dionne C W Braeken
- Thrombosis Expertise Center, Maastricht University Medical Center, Maastricht, Limburg, the Netherlands
| | - Sander J E Braken
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, South-Holland, The Netherlands
| | - Carlinda Bresser
- Department of Hematology, Red Cross Hospital, Beverwijk, Noord-Holland, The Netherlands
| | - Hugo Ten Cate
- Thrombosis Expertise Center, Maastricht University Medical Centre + , Maastricht, Limburg, The Netherlands
| | - Duco D Deenstra
- Department of Pulmonology, Catharina Hospital, Eindhoven, North Brabant, The Netherlands
| | - Yordi P A van Dooren
- Department of Pulmonology, Groene Hart Hospital, Gouda, Zuid-Holland, The Netherlands
| | - Laura M Faber
- Department of Hematology, Red Cross Hospital, Beverwijk, Noord-Holland, The Netherlands
| | | | - Lianne R de Haan
- Department of Internal Medicine, Flevo Hospital, Almere, Flevoland, The Netherlands
| | - Carolien Haazer
- Department of Internal Medicine, Reinier de Graaf Hospital, Delft, Zuid-Holland, The Netherlands
| | - Antonio Iglesias Del Sol
- Department of Internal Medicine, Alrijne Hospital Location Leiderdorp, Leiderdorp, Zuid-Holland, The Netherlands
| | - Sarah Kelliher
- Department of Hematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Ted Koster
- Department of Internal Medicine, Groene Hart Hospital, Gouda, Zuid-Holland, The Netherlands
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Rick I Meijer
- Department of Internal Medicine Amsterdam UMC Locatie VUMC, Amsterdam, Noord-Holland, The Netherlands
| | - Fleur Pals
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, South-Holland, The Netherlands
| | - Eric R E van Thiel
- Department of Pulmonology, Albert Schweitzer Hospital, Dordrecht, Zuid-Holland, The Netherlands
| | - Peter E Westerweel
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, Zuid-Holland, The Netherlands
| | - Marije Ten Wolde
- Department of Internal Medicine, Flevo Hospital, Almere, Flevoland, The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, South-Holland, The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, South-Holland, The Netherlands
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