Acute pulmonary embolism in patients presenting pulmonary deterioration after hospitalisation for non-critical COVID-19

Clinical Characteristics of SARS-CoV-2 Acute Pulmonary Embolism and Adjusted D-dimer for Emergency Department Patients

Introduction

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and acute pulmonary embolism (APE) present a diagnostic challenge in the emergency department (ED) setting. We aimed to identify key clinical characteristics and D-dimer thresholds associated with APE in SARS-CoV-2 positive ED patients.

Methods

We performed a multicenter, retrospective cohort study for adult patients who were diagnosed with coronavirus 2019 (COVID-19) and had computed tomography pulmonary angiogram (CTPA) performed between March 17, 2020-January 31, 2021. We performed univariate analysis to determine numeric medians, chi-square values for association between clinical characteristic and positive CTPA. Logistic regression was used to determine the odds of a clinical characteristic being associated with a diagnosis of APE.

Results

Of 408 patients who underwent CTPA, 29 (7.1%) were ultimately found to have APE. In multivariable analysis, patients with a body mass index greater than 32 (odds ratio [OR] 4.4, 95% confidence interval [CI] 1.0 -19.3), a heart rate greater than 90 beats per minute (bpm) (OR 5.0, 95% CI 1.0-24.9), and a D-dimer greater than 1,500 micrograms per liter (μg/L) (OR 5.6, 95% CI 1.6-20.2) were significantly associated with pulmonary embolism. In our population that received a D-dimer and was SARS-CoV-2 positive, limiting CTPA to patients with a heart rate over 90 or a D-dimer value over 1500 μg/L would reduce testing 27.2% and not miss APE.

Conclusion

In patients with acute COVID-19 infections, D-dimer at standard cutoffs was not usable. Limiting CTPA using a combination of heart rate greater than 90 bpm or D-dimer greater than 1,500 μg/L would significantly decrease imaging in this population.

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.

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.

PECULIARITIES OF THE COURSE OF PULMONARY EMBOLISM DURING THE COVID-19 PANDEMIC

OBJECTIVE

The aim: A comparative analysis of the course of pulmonary embolism during the COVID-19 pandemic and the era before pandemia.

PATIENTS AND METHODS

Materials and methods: 294 patients with pulmonary embolism (PE) , 1 group - 188 with PE before the pandemic, 2 group -106 during the pandemic. Two subgroups were distinguished in 2 group : 1- with laboratory-excluded coronavirus (acute and in anamnesis) and 2 - with a history of COVID-19. The diagnosis of PE was confirmed by CT. Echocardiography and ultrasound Doppler imaging of the veins of the lower extremities were performed.

RESULTS

Results: In 1 group there was a more significant increase in pulmonary artery pressure (44.29 ± 17.04 vs 36.91 ± 16.6, p 0.0023) and a decrease in the E/A ratio of the right ventricle (0.80 ± 0,21 vs 1.28 ± 1.42, p 0.0202). In 2 subgroup of patients with COVID-19 had a significantly higher incidence of Diabetes mellitus (73.7% vs 13.3%, p 0.00001) and significantly lower signs of superficial venous thrombosis of the lower extremities (5.3% vs 33,3%, p 0,0175) and signs of proximal deep vein thrombosis (0% vs 56.7%, p 0.00001) and 3 times less often there was a high risk of adverse disease, right ventricular dysfunction were more pronounced (ratio E/A 0.87 ± 0.25 vs 1.13 ± 0.28, p 0.022).

CONCLUSION

Conclusions: In patients with coronavirus infection, PE was significantly more common in the presence of diabetes mellitus , right ventricular diastole disorders were more common, and superficial and proximal deep vein thrombosis of the lower extremities were less common.

[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.

COVID-19 patients with acute pulmonary embolism have a higher mortality risk: systematic review and meta-analysis based on Italian cohorts

BACKGROUND

Acute pulmonary embolism has been recognized as a frequent complication of COVID-19 infection influencing the clinical course and outcomes of these patients.

OBJECTIVES

We performed a systematic review and meta-analysis to evaluate the mortality risk in COVID-19 Italian patients complicated by acute pulmonary embolism in the short-term period.

METHODS

The study was performed in accordance with the Preferred Report Items for Systematic Reviews and Meta-analyses guidelines. PubMed-MEDLINE and Scopus databases were systematically searched for articles, published in the English language and enrolling Italian cohorts with confirmed COVID-19 infection from inception through 20 October 2021. Mortality risk data were pooled using the Mantel-Haenszel random effects models with odds ratio as the effect measure with 95% confidence interval. Heterogeneity among studies was assessed using Higgins and Thomson I2 statistic.

RESULTS

Eight investigations enrolling 1.681 patients (mean age 64.9 years, 1125 males) met the inclusion criteria and were considered for the analysis. A random-effect model showed that acute pulmonary embolism was present in 19.0% of Italian patients with COVID-19 infection. Moreover, these patients were at higher mortality risk compared with those without (odds ratio: 1.76, 95% confidence interval: 1.26-2.47, P  = 0.001, I2  = 0%). Sensitivity analysis confirmed yielded results.

CONCLUSION

In Italian patients with COVID-19 infection, acute pulmonary embolism was present in about one out of five and significantly associated with a higher mortality risk in the short-term period. The identification of acute pulmonary embolism in these patients remains critical to promptly identify vulnerable populations who would require prioritization in treatment and prevention and close monitoring.

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.

Predictive scores for the diagnosis of Pulmonary Embolism in COVID-19: A systematic review

Objectives

During the COVID-19 pandemic, several studies described an increased chance of developing pulmonary embolism (PE). Several scores have been used to predict the occurrence of PE. This systematic review summarizes the literature on predicting rules for PE in hospitalized COVID-19 patients (HCPs).

Methods

PUBMED and EMBASE databases were searched to identify articles (1 January 2020-28 April 2021) presenting data pertaining to the use of a prediction rule to assess the risk for PE in adult HCPs. The investigated outcome was the diagnosis of PE. Studies presenting data using a single laboratory assay for PE prediction were excluded. Included studies were appraised for methodological quality using the Newcastle - Ottawa Quality Assessment Scale for Cohort Studies (NOS).

Results

We obtained a refined pool of twelve studies for five scoring systems (Wells score, Geneva score, CHADS2/CHA2DS2VASc/M-CHA2DS2VASc, CHOD score, Padua Prediction Score), and 4,526 patients. Only one score was designed explicitly for HCPs. Three and nine included studies were prospective and retrospective cohort studies, respectively. Among the examined scores, the CHOD score seems promising for predictive ability.

Conclusion

New prediction rules, specifically developed and validated for estimating the risk of PE in HCP, differentiating ICU from non-ICU patients, and taking into account anticoagulation prophylaxis, comorbidities, and the time from COVID-19 diagnosis are needed.