Pulmonary embolism and COVID-19: A comparative analysis of different diagnostic models performance

Pulmonary Embolism Rule-out Criteria: Diagnostic Accuracy and Impact of COVID-19

BACKGROUND

The Pulmonary Embolism Rule-Out Criteria (PERC), developed to minimize unnecessary testing in low-risk pulmonary embolism (PE) cases, lacks clear validation in the context of COVID-19.

OBJECTIVES

To assess the validity of the PERC in emergency department patients having undergone computed tomography pulmonary angiography (CTPA) during the COVID-19 pandemic.

METHODS

We conducted a retrospective analysis of emergency department patients who underwent CTPA for suspected PE. COVID-19 status was based on the results of a reverse transcription-polymerase chain reaction (RT-PCR) test performed in the emergency department, or within 30 days prior to visiting the emergency department. We collected data on demographics, symptoms, d-dimer levels, and medical history relevant to thrombosis and conducted the PERC test using the criteria including age, oxygen saturation, heart rate, and the absence of hemoptysis or recent trauma. We categorized outcomes based on the concordance between the PERC results and CTPA findings, with specific definitions for true positive and negative, as well as false positive and negative results. We also evaluated the impact of COVID-19 status on the diagnostic performance of the PERC by analyzing the prevalence of PE in patients testing positive and negative for COVID-19.

RESULTS

Among the 2.430 participants, 45.1% tested negative for COVID-19, 43.4% tested positive, and 11.5% were untested. The PERC identified 91.2% of the cases as positive, 6.9% of which were confirmed to have PE. Overall, 84.9% of cases (n = 2.062) showed a discordant result between the PERC and CTPA findings. The lack of significant correspondence between the PERC positivity and actual PE presence (p = 0.001; p < 0.01) indicated low diagnostic concordance. In patients with a positive COVID-19 test result, the PERC demonstrated a sensitivity of 95.3% (95% CI: 86.91-99.02), a specificity of 9.1% (95% CI: 7.46-11.15), a positive predictive value of 6.3% (95% CI: 6.01-6.70), a negative predictive value of 96.8% (95% CI: 90.81-98.94), and an accuracy of 14.4% (95% CI: 12.34-16.67). In patients who tested negative for COVID-19, the sensitivity was 95.4% (95% CI: 88.64-98.73), the specificity was 7.8% (95% CI: 6.25-9.66), the positive predictive value was 8.1% (95% CI: 7.83-8.57), the negative predictive value was 95.1% (95% CI: 88.11-98.14), and the accuracy was 14.7% (95% CI: 12.73-17.02).

CONCLUSION

The study demonstrates that the sensitivity and negative predictive value of the PERC are comparable in COVID-19 positive and negative patients. Furthermore, the incidence of PE among patients presenting to the emergency department did not significantly differ based on COVID-19 status. While this study highlights the relevance of the PERC in clinical decision-making, caution is advised as the PERC may not always provide reliable results when used as the sole diagnostic test.

A systematic review of thromboembolic complications and outcomes in hospitalised COVID-19 patients

Thromboembolic (TE) complications [myocardial infarction (MI), stroke, deep vein thrombosis (DVT), and pulmonary embolism (PE)] are common causes of mortality in hospitalised COVID-19 patients. Therefore, this review was undertaken to explore the incidence of TE complications and mortality associated with TE complications in hospitalised COVID-19 patients from different studies. A literature search was performed using ScienceDirect and PubMed databases using the MeSH term search strategy of "COVID-19", "thromboembolic complication", "venous thromboembolism", "arterial thromboembolism", "deep vein thrombosis", "pulmonary embolism", "myocardial infarction", "stroke", and "mortality". There were 33 studies included in this review. Studies have revealed that COVID-19 patients tend to develop venous thromboembolism (PE:1.0-40.0% and DVT:0.4-84%) compared to arterial thromboembolism (stroke:0.5-15.2% and MI:0.8-8.7%). Lastly, the all-cause mortality of COVID-19 patients ranged from 4.8 to 63%, whereas the incidence of mortality associated with TE complications was between 5% and 48%. A wide range of incidences of TE complications and mortality associated with TE complications can be seen among hospitalized COVID-19 patients. Therefore, every patient should be assessed for the risk of thromboembolic complications and provided with an appropriate thromboprophylaxis management plan tailored to their individual needs.

Predictors of pulmonary embolism in hospitalized patients with COVID-19

BACKGROUND

High venous thromboembolism (VTE) rates have been described in critically ill patients with COVID-19. We hypothesized that specific clinical characteristics may help differentiate hypoxic COVID-19 patients with and without a diagnosed pulmonary embolism (PE).

METHODS

We performed a retrospective observational case-control study of 158 consecutive patients hospitalized in one of four Mount Sinai Hospitals with COVID-19 between March 1 and May 8, 2020, who received a Chest CT Pulmonary Angiogram (CTA) to diagnose a PE. We analyzed demographic, clinical, laboratory, radiological, treatment characteristics, and outcomes in COVID-19 patients with and without PE.

RESULTS

92 patients were negative (CTA-), and 66 patients were positive for PE (CTA+). CTA + had a longer time from symptom onset to admission (7 days vs. 4 days, p = 0.05), higher admission biomarkers, notably D-dimer (6.87 vs. 1.59, p < 0.0001), troponin (0.015 vs. 0.01, p = 0.01), and peak D-dimer (9.26 vs. 3.8, p = 0.0008). Predictors of PE included time from symptom onset to admission (OR = 1.11, 95% CI 1.03-1.20, p = 0.008), and PESI score at the time of CTA (OR = 1.02, 95% CI 1.01-1.04, p = 0.008). Predictors of mortality included age (HR 1.13, 95% CI 1.04-1.22, p = 0.006), chronic anticoagulation (13.81, 95% CI 1.24-154, p = 0.03), and admission ferritin (1.001, 95% CI 1-1.001, p = 0.01).

CONCLUSIONS

In 158 hospitalized COVID-19 patients with respiratory failure evaluated for suspected PE, 40.8% patients had a positive CTA. We identified clinical predictors of PE and mortality from PE, which may help with early identification and reduction of PE-related mortality in patients with COVID-19.

Literature Review-Transthoracic Echocardiography, Computed Tomography Angiography, and Their Value in Clinical Decision Making and Outcome Predictions in Patients with COVID-19 Associated Cardiovascular Complications

The sudden outbreak of the COVID-19 pandemic posed a great threat to the world's healthcare systems. It resulted in the development of new methods and algorithms for the diagnosis and treatment of both COVID-19 and its complications. Diagnostic imaging played a crucial role in both cases. Among the most widely used examinations are transthoracic echocardiography (TTE) and computed tomography angiography (CTA). Cardiovascular complications in COVID-19 are frequently associated with a severe inflammatory response, which results in acute respiratory failure, further leading to severe complications of the cardiovascular system. Our review aims to discuss the value of TTE and CTA in clinical decision making and outcome prediction in patients with COVID-19-associated cardiovascular complications. Our review revealed the high clinical value of various TTE findings and their association with mortality and the prediction of patients' clinical outcomes, especially when used with other laboratory parameters. The strongest association between increased mortality and findings in TTE was observed for tachycardia and decreased left ventricular ejection fraction (odds ratio (OR) 24.06) and tricuspid annular plane systolic excursion/pulmonary artery systolic pressure ratio (TAPSE/PASP ratio) < 0.31 mm/mmHg (OR 17.80). CTA is a valuable tool in diagnosing COVID-19-associated pulmonary embolism, but its association with mortality and its predictive role should always be combined with laboratory findings and patients' medical history. D-dimers > 3000 ng/mL were found as the strongest predictors of pulmonary embolism (PE) (OR 7.494). Our review indicates the necessity for an active search for cardiovascular complications in patients with severe COVID-19, as they are linked with an increased probability of fatal outcomes.

Point of care ultrasound findings in critically ill SARS-COV2 patients in an HIV endemic, resourced constrained setting

Objectives

To describe the incidence of venous thromboembolism (VTE) in mechanically ventilated COVID-19 patients in an HIV endemic, resourced constrained setting. To describe the incidence of VTE in relation to HIV status and anticoagulant therapy, and to evaluate VTE-associated cardio-respiratory changes. To establish the contribution of HIV, anticoagulation therapy and other risk factors to mortality.

Design

Prospective descriptive study.

Setting

Single-center tertiary teaching hospital.

Participants

One hundred and one consecutively admitted critically ill adult patients with COVID-19 acute respiratory distress syndrome.

Interventions

Point of care ultrasound (POCUS) assessment of the lower limbs and the cardio-respiratory system was performed on intensive care unit (ICU) admission and repeated if clinically indicated.

Measurements and main results

DVT was diagnosed by POCUS, whilst pulmonary embolism was diagnosed using a combination of clinical criteria and POCUS (echocardiography and chest wall ultrasound). VTE was diagnosed in 16/101 (16%) patients, despite 14/16 (88%) receiving prior therapeutic dosage of low molecular weight heparin. Clinically significant PE was diagnosed in 5/16 (31%) with 11/16 (69%) having DVT only. The majority of VTE patients, 12/16 (75%), demised 16/101 (16%) patients had HIV co-infection, and 4/16 (25%) with HIV had VTE. Valvular abnormalities were the most common cardiac abnormality with marked tricuspid regurgitation detected in 51/101 (51%). The absence of right atrial enlargement had a 93% negative predictive value for the absence of VTE. Univariate analysis did not demonstrate statistically significant individual risk factors for mortality.

Conclusions

Mechanically ventilated COVID- 19 patients at ICU admission had a low incidence of VTE (16%). Therapeutic dose anticoagulation did not reduce mortality compared to prophylactic dosage. In contrast to findings from other studies, no individual risk factor contributed significantly to mortality, likely due to small sample size. POCUS is an ideal screening tool to aid in the assessment of critically ill patients.

Clinical prediction model for pulmonary thrombosis diagnosis in hospitalized patients with SARS-CoV-2 infection

Background and Aim

We aimed to develop a clinical prediction model for pulmonary thrombosis (PT) diagnosis in hospitalized COVID-19 patients.

Methods

Non-intensive care unit hospitalized COVID-19 patients who underwent a computed tomography pulmonary angiogram (CTPA) for suspected PT were included in the study. Demographic, clinical, analytical, and radiological variables as potential factors associated with the presence of PT were selected. Multivariable Cox regression analysis to develop a score for estimating the pre-test probability of PT was performed. The score was internally validated by bootstrap analysis.

Results

Among the 271 patients who underwent a CTPA, 132 patients (48.7%) had PT. Heart rate >100 bpm (OR = 4.63 [95% CI: 2.30-9.34]; P < 0.001), respiratory rate >22 bpm (OR = 5.21 [95% CI: 2.00-13.54]; P < 0.001), RALE score ≥4 (OR = 3.24 [95% CI: 1.66-6.32]; P < 0.001), C-reactive protein (CRP) >100 mg/L (OR = 2.10 [95% CI: 0.95-4.63]; P = 0.067), and D-dimer >3.000 ng/mL (OR = 6.86 [95% CI: 3.54-13.28]; P < 0.001) at the time of suspected PT were independent predictors of thrombosis. Using these variables, we constructed a nomogram (CRP, Heart rate, D-dimer, RALE score, and respiratory rate [CHEDDAR score]) for estimating the pre-test probability of PT. The score showed a high predictive accuracy (area under the receiver-operating characteristics curve = 0.877; 95% CI: 0.83-0.92). A score lower than 182 points on the nomogram confers a low probability for PT with a negative predictive value of 92%.

Conclusions

CHEDDAR score can be used to estimate the pre-test probability of PT in hospitalized COVID-19 patients outside the intensive care unit.

Relevance for Patients

Developing a new clinical prediction model for PT diagnosis in COVID-19 may help in the triage of patients, and limit unnecessary exposure to radiation and the risk of nephrotoxicity due to iodinated contrast.

Patient Characteristics and Predictors of Pulmonary Embolism in Patients Infected with COVID – 19 in Upper Egypt

Background

A little is known about the risk factors and predictors of pulmonary embolism (PE) in Coronavirus disease 2019 (Covid-19) infected patients. Therefore, we directed this study to investigate the predictors of PE in patients infected with Covid - 19 in Upper Egypt.

Methods

We conducted a retrospective cohort study on 297 patients infected with COVID-19, aged ≥ 18 years old. Suspicion of COVID-19 infection was based on the World Health Organization (WHO) criteria and confirmed by nasal and pharyngeal swab for real-time reverse transcriptase-polymerase chain reaction (RT-PCR) analysis. The patient was also determined to have COVID-19 when CT results that were thought to be typical for COVID-19 and clinical data that were compatible were present.

Results

PE was diagnosed in 18.2% of patients. We found that the incidence of PE was significantly higher in older patients, females, those with higher BMI, hypertensive patients, diabetics, and patients with co-morbidities. Also, PE was significantly higher in patients presented with dyspnea, chest pain, longer duration of symptoms at hospital admission, and lower oxygen concentration. The mean serum Hb level, platelet count, TLC and absolute lymphocytic count were markedly reduced in those who had PE. All the patients who developed PE had a CO-RADS scale five on their CT chest scan. Age > 65, BMI > 25, DM, and associated co-morbidities were the independent patients' characteristics associated with the development of PE after the multivariate regression analysis.

Conclusion

PE is a common complication of Covid 19 infection. PE is associated with a variety of clinical and laboratory parameters in univariate analysis, but age > 65, BMI > 25, DM, and associated co-morbidities were the independent patients' characteristics associated with the development of PE in those infected with Covid-19.

Utility of probability scores for the diagnosis of pulmonary embolism in patients with SARS-CoV-2 infection: A systematic review

BACKGROUND AND OBJECTIVE

Clinical prediction models determine the pre-test probability of pulmonary embolism (PE) and assess the need for tests for these patients. Coronavirus infection is associated with a greater risk of PE, increasing its severity and conferring a worse prognosis. The pathogenesis of PE appears to be different in patients with and without SARS-CoV-2 infection. This systematic review aims to discover the utility of probability models developed for PE in patients with COVID-19 by reviewing the available literature.

METHODS

A literature search on the PubMed, Scopus, and EMBASE databases was carried out. All studies that reported data on the use of clinical prediction models for PE in patients with COVID-19 were included. Study quality was assessed using the Newcastle-Ottawa scale for non-randomized studies.

RESULTS

Thirteen studies that evaluated five prediction models (Wells score, Geneva score, YEARS algorithm, and PERC and PEGeD clinical decision rules) were included. The different scales were used in 1,187 patients with COVID-19. Overall, the models showed limited predictive ability. The two-level Wells score with low (or unlikely) clinical probability in combination with a D-dimer level <3000ng/mL or a normal bedside lung ultrasound showed an adequate correlation for ruling out PE.

CONCLUSIONS

Our systematic review suggests that the clinical prediction models available for PE that were developed in the general population are not applicable to patients with COVID-19. Therefore, their use is in clinical practice as the only diagnostic screening tool is not recommended. New clinical probability models for PE that are validated in these patients are needed.

CT-Angiographic Aspects of Pulmonary Embolism on SARS COV-2

Objectives

To study pulmonary embolism during COVID-19 pneumonia.

Patients and Methods

This was a one-year retrospective and descriptive study of all patients from three imaging sites with SARS-CoV2 infection.

Results

Two hundred and thirty-nine patients were included. The prevalence of pulmonary embolism was 18.4%. The average age was 55 years old. The sex ratio was 1.65. Dyspnea (58.6%), cough (56.1%), and chest pain (40.2%) were the most common reasons for consultation. In 151 patients (63.2%), chest computed tomography (CT) angiography was performed without checking level of D-dimer. The level of D-dimers was elevated in 47.8%. Grade 5 of CO-RADS accounted for 62.3%. In 70.5% of cases, the pulmonary embolism was bilateral with subsegmental involvement in 47.7%.

Condensation in ‘ground glass’ with ‘crazy paving’ were the predominant typical parenchymal lesions with a frequency of 93.7% and 59.4%. In univariate analysis, D-dimers were significantly associated with the occurrence of pulmonary embolism (p < 0.001). Male sex was associated with a non-significantly higher Risk of having a pulmonary embolism (1.18 95% CI: 0.61–2.31, p = 0.622). The critical level increased the risk of pulmonary embolism in a non-significant way. Only the high level of D-dimers was and this, in a significant way.

Conclusion

Pulmonary embolism was increased in the context of SARS-CoV2. The chest CT-angiography associated with the dosage of D-dimers constitutes a good diagnostic arsenal.

[Utility of probability scores for the diagnosis of pulmonary embolism in patients with SARS-CoV-2 infection: A systematic review]

Background and objective

Clinical prediction models determine the pre-test probability of pulmonary embolism (PE) and assess the need for tests for these patients. Coronavirus infection is associated with a greater risk of PE, increasing its severity and conferring a worse prognosis. The pathogenesis of PE appears to be different in patients with and without SARS-CoV-2 infection. This systematic review aims to discover the utility of probability models developed for PE in patients with COVID-19 by reviewing the available literature.

Methods

A literature search on the PubMed, Scopus, and EMBASE databases was carried out. All studies that reported data on the use of clinical prediction models for PE in patients with COVID-19 were included. Study quality was assessed using the Newcastle-Ottawa scale for non-randomized studies.

Results

Thirteen studies that evaluated five prediction models (Wells score, Geneva score, YEARS algorithm, and PERC and PEGeD clinical decision rules) were included. The different scales were used in 1,187 patients with COVID-19. Overall, the models showed limited predictive ability. The two-level Wells score with low (or unlikely) clinical probability in combination with a D-dimer level < 3000 ng/mL or a normal bedside lung ultrasound showed an adequate correlation for ruling out PE.

Conclusions

Our systematic review suggests that the clinical prediction models available for PE that were developed in the general population are not applicable to patients with COVID-19. Therefore, their use is in clinical practice as the only diagnostic screening tool is not recommended. New clinical probability models for PE that are validated in these patients are needed.

Risk factors and mortality of pulmonary embolism in COVID-19 patients: Evidence based on fifty observational studies

BACKGROUND

At present, many studies have described acute pulmonary embolism (PE) as a frequent and prognostically relevant complication of coronavirus disease 2019 (COVID-19) infection. Thus we performed the present analysis of 50 studies to evaluate the risk factors and mortality of PE in COVID-19 patients.

METHOD

Databases including PubMed, Embase, Cochrane Library and Web of Science were searched to October, 2021. Odds ratio (OR), mean difference (MD) or standard MD was used to evaluate the outcomes. The primary outcomes were the difference of mortality between PE and non-PE COVID-19 patients as well as relevant risk factors of PE in COVID-19 patients. All statistical analyses were performed using the standard statistical procedures provided in Review Manager 5.2.

RESULT

A total of 50 studies including 10053 patients were included in this meta-analysis. Our results indicated that COVID-19 patients with PE experienced significantly higher mortality than non-PE patients (21.9% vs. 10.7%), with a pooled OR of 2.21 (95% CI 1.30 - 3.76; P = .003). In addition, COVID-19 patients with PE also experienced more mechanical ventilation (MV) (OR 2.21; 95% CI 1.30 - 3.75; P = .003) and invasive mechanical ventilation (IMV) (OR 3.58; 95% CI 2.47 - 5.20; P < .0001) respectively. Univariate analysis (UVA) results indicated the Sequential Organ Failure Assessment (SOFA) score, time to deep venous thrombosis (DVT), nonintensive care unit (non-ICU) patients and no anticoagulation as risk factors of PE for COVID-19 patients. In addition, multivariate analysis also found that SOFA score, D-dimer, BMI > 30 kg/m2 and history of PE were risk factors of PE for COVID-19 patients.

CONCLUSION

The present analysis indicated that PE increased the mortality of COVID-19 patients. Mechanical ventilation, especially invasive mechanical ventilation, is correlated with an increased incidence of PE in patients with COVID-19. The incidence of PE for COVID-19 patients may be multifactorial and further researches focused on risk factors were needed in the future.

Predictors of venous thromboembolism in COVID-19 patients: results of the COVID-19 Brazilian Registry

Previous studies that assessed risk factors for venous thromboembolism (VTE) in COVID-19 patients have shown inconsistent results. Our aim was to investigate VTE predictors by both logistic regression (LR) and machine learning (ML) approaches, due to their potential complementarity. This cohort study of a large Brazilian COVID-19 Registry included 4120 COVID-19 adult patients from 16 hospitals. Symptomatic VTE was confirmed by objective imaging. LR analysis, tree-based boosting, and bagging were used to investigate the association of variables upon hospital presentation with VTE. Among 4,120 patients (55.5% men, 39.3% critical patients), VTE was confirmed in 6.7%. In multivariate LR analysis, obesity (OR 1.50, 95% CI 1.11-2.02); being an ex-smoker (OR 1.44, 95% CI 1.03-2.01); surgery ≤ 90 days (OR 2.20, 95% CI 1.14-4.23); axillary temperature (OR 1.41, 95% CI 1.22-1.63); D-dimer ≥ 4 times above the upper limit of reference value (OR 2.16, 95% CI 1.26-3.67), lactate (OR 1.10, 95% CI 1.02-1.19), C-reactive protein levels (CRP, OR 1.09, 95% CI 1.01-1.18); and neutrophil count (OR 1.04, 95% CI 1.005-1.075) were independent predictors of VTE. Atrial fibrillation, peripheral oxygen saturation/inspired oxygen fraction (SF) ratio and prophylactic use of anticoagulants were protective. Temperature at admission, SF ratio, neutrophil count, D-dimer, CRP and lactate levels were also identified as predictors by ML methods. By using ML and LR analyses, we showed that D-dimer, axillary temperature, neutrophil count, CRP and lactate levels are risk factors for VTE in COVID-19 patients.

Examining D-dimer and Empiric Anti-coagulation in COVID-19-Related Thrombosis

Objective

Thrombosis is thought to occur frequently in the setting of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We aimed to elucidate the relationship between macro/microvascular thrombosis, D-dimer levels, and empiric anticoagulation in coronavirus disease 2019 (COVID-19).

Methods

This was an exploratory prospective, single-site, observational study. Adult emergency department patients with COVID-19 requiring hospitalization received a point-of-care lower extremity venous duplex ultrasound. The primary endpoint was thromboembolism and associated D-dimer level. Secondary endpoints included rates of micro and macro thrombotic complications as well as empiric anticoagulant use.

Results

Between January 13^th and April 12^th 2021, 52 patients were enrolled. Median D-dimer at presentation was 650 ng/mL (range 250-10,000 ng/mL) among patients with negative duplex studies. During hospitalization, 18 patients underwent 20 additional studies assessing for venous thromboembolism (VTE). These studies yielded one deep vein thrombosis (DVT) diagnosis. Among patients with negative studies median D-dimer was 1,246 ng/mL (range 329-10,000 ng/mL). Two patients experienced microvascular complications. Seven patients were started on empiric full dose anticoagulation.

Conclusion

While VTE remains a major concern amongst patients with COVID-19, the normal D-dimer cut off of >500 ng/mL likely should not be used to initiate further VTE workup. Additionally, moderately elevated D-dimer did not correlate strongly with microvascular complications and may not be relevant in the decision to initiate empiric anticoagulation.

Lower Risk of Cardiovascular Events in Adult Patients with Chronic Hypoparathyroidism Treated with rhPTH(1-84): A Retrospective Cohort Study

Introduction

Patients with chronic hypoparathyroidism are at increased risk of cardiovascular disease. This study evaluated the risk of developing cardiovascular conditions over a period of 5 years in adult patients with chronic hypoparathyroidism treated with recombinant human parathyroid hormone (1–84), rhPTH(1–84), compared with a historical control cohort of patients not treated with rhPTH(1–84).

Methods

This retrospective cohort study comprised patients with chronic hypoparathyroidism treated with rhPTH(1–84) in the REPLACE (NCT00732615), RELAY (NCT01268098), and RACE (NCT01297309) clinical trials, and controls selected from the IBM^® Explorys electronic medical record database (January 2007–August 2019) who did not receive parathyroid hormone but who had enrollment criteria similar to those for the clinical trials. Cardiovascular outcomes were the first diagnosis of cerebrovascular, coronary artery, peripheral vascular disease, or heart failure during the study period.

Results

We evaluated 113 adult patients with chronic hypoparathyroidism treated with rhPTH(1–84) and 618 control patients who did not receive rhPTH(1–84). Over the 5-year follow-up period, 3.5% of patients (n = 4) in the rhPTH(1–84) cohort had a cardiovascular event compared with 16.3% (n = 101) in the control cohort. Kaplan–Meier analysis demonstrated that patients in the rhPTH(1–84) cohort had lower risk of experiencing a cardiovascular event compared with patients in the control cohort (P = 0.005). Multivariable analyses adjusted for baseline variables showed that patients in the rhPTH(1–84) cohort had 75% lower risk for a cardiovascular event compared with patients in the control cohort (adjusted hazard ratio, 0.25 [95% CI 0.08–0.81]; P = 0.020).

Conclusion

Long-term treatment with rhPTH(1–84) was associated with a lower risk of incident cardiovascular conditions compared with conventional therapy in patients with chronic hypoparathyroidism. Previous studies demonstrated that mineral homeostasis was maintained with lower use of calcium and active vitamin D when rhPTH(1–84) was added to conventional therapy. Future studies are needed to understand whether improved regulation of mineral homeostasis conferred by rhPTH(1–84) may provide long-term cardiovascular benefits to patients with chronic hypoparathyroidism.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-022-02198-y.

Diagnostic Management of Acute Pulmonary Embolism in COVID-19 and Other Special Patient Populations

Venous thromboembolism (VTE), in particular acute pulmonary embolism (PE), has been shown to be a frequent and potentially fatal complication of coronavirus disease 2019 (COVID-19). In response to the observed thrombotic complications, a large number of studies has been devoted to the understanding and management of COVID-19-associated coagulopathy. Notably, only a limited number of mostly retrospective studies has focused on the optimal diagnostic strategy for suspected PE in COVID-19 patients. As in other special populations, the accuracy of diagnostic algorithms for PE-exclusion has been debated in this specific patient subgroup as the specificity of D-dimer assays and clinical decision rules (CDRs) may be lower than normal. From this viewpoint, we discuss the current state-of-the-art diagnostic algorithms for acute PE with a focus on patients with COVID-19 in the perspective of other special patient populations. Furthermore, we summarize current knowledge regarding the natural history of PE resolution with anticoagulant treatment in patients with COVID-19.

Performances diagnostiques des D-dimères pour exclure l’EP des patients aux urgences ayant la COVID-19

Introduction & Objectifs

L’infection à la COVID-19 est associée à une hausse de l’incidence d’embolies pulmonaires (EP) chez les patients hospitalisés qui n’est pas retrouvée chez les patients venant aux urgences, souvent à un stade précoce de la maladie. La stratégie diagnostique de l’EP repose sur le calcul de scores de probabilité clinique avec le dosage des D-dimères, suivi d’un angioscanner thoracique si nécessaire.

Dans l’infection au COVID-19, il a été observé des concentrations élevées de D-dimères même en l’absence d’EP objectivée.

Objectif de l’étude

Évaluer les performances diagnostiques de différents seuils de D-dimères afin d’exclure l’EP chez les patients ayant une pneumopathie COVID-19 et se présentant aux urgences.

Méthodologie

Étude rétrospective monocentrique incluant tous les patients majeurs consultant aux urgences du CHU Grenoble-Alpes du 15/10/2020 au 31/01/2021 avec :

– un test PCR positif au COVID-19 < 30 jours ;

– un angioscanner thoracique pour suspicion d’EP ;

– un dosage des D-dimères.

Analyses uni- et multivariée des facteurs de risque de l’EP.

Évaluation des performances diagnostiques de différents seuils de D-dimères via la courbe ROC pour chercher le seuil permettant d’exclure avec sûreté l’EP.

Résultats

Au total, 286 patients inclus : 22 EP+ soit 7,7 %, 264 EP−.

Différences statistiquement significatives sur l’âge (81,5 ans EP+ vs 68 ans EP−, p 0,02), l’antécédent de maladie thromboembolique veineuse et la concentration de D-dimères (5550 μg/L groupe EP+ vs 1285 μg/L groupe EP−, p < 0,001).

Après ajustement, seule la concentration de D-dimères montrait une différence significative.

Valeur minimale de D-dimères dans le groupe EP+ : 1850 μg/L, correspondant au meilleur seuil sur la courbe ROC avec une sensibilité 100 % ; VPN 100 % ; RVN 0.

Patients comparables sur le sexe, les comorbidités, les lésions infectieuses pulmonaires au scanner, la biologie.

Discussion

Données concordantes avec la littérature : proportion d’EP similaire, facteurs de risque habituels de l’EP non retrouvés, concentration de D-Dimères élevées similaires [1].

Risque de faux négatifs en cas d’utilisation d’un seuil plus élevé des D-dimères [2].

Plusieurs limites : caractère rétrospectif, monocentrique, faible effectif, interprétation difficile des EP sous-segmentaires.

Conclusion

Au stade initial de l’infection COVID-19, l’utilisation d’un seuil de D-dimères plus élevé que le seuil conventionnel pourrait avoir une meilleure performance diagnostique afin d’exclure l’EP. Cependant, dans l’attente d’études prospectives multicentriques, la prudence s’impose.

Automated Quantitative Lung CT Improves Prognostication in Non-ICU COVID-19 Patients beyond Conventional Biomarkers of Disease

(1) Background: COVID-19 continues to represent a worrying pandemic. Despite the high percentage of non-severe illness, a wide clinical variability is often reported in real-world practice. Accurate predictors of disease aggressiveness, however, are still lacking. The purpose of our study was to evaluate the impact of quantitative analysis of lung computed tomography (CT) on non-intensive care unit (ICU) COVID-19 patients' prognostication; (2) Methods: Our historical prospective study included fifty-five COVID-19 patients consecutively submitted to unenhanced lung CT. Primary outcomes were recorded during hospitalization, including composite ICU admission for the need of mechanical ventilation and/or death occurrence. CT examinations were retrospectively evaluated to automatically calculate differently aerated lung tissues (i.e., overinflated, well-aerated, poorly aerated, and non-aerated tissue). Scores based on the percentage of lung weight and volume were also calculated; (3) Results: Patients who reported disease progression showed lower total lung volume. Inflammatory indices correlated with indices of respiratory failure and high-density areas. Moreover, non-aerated and poorly aerated lung tissue resulted significantly higher in patients with disease progression. Notably, non-aerated lung tissue was independently associated with disease progression (HR: 1.02; p-value: 0.046). When different predictive models including clinical, laboratoristic, and CT findings were analyzed, the best predictive validity was reached by the model that included non-aerated tissue (C-index: 0.97; p-value: 0.0001); (4) Conclusions: Quantitative lung CT offers wide advantages in COVID-19 disease stratification. Non-aerated lung tissue is more likely to occur with severe inflammation status, turning out to be a strong predictor for disease aggressiveness; therefore, it should be included in the predictive model of COVID-19 patients.