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Artaud-Macari E, Le Bouar G, Maris J, Dantoing E, Vatignez T, Girault C. [Ventilatory management of SARS-CoV-2 acute respiratory failure]. Rev Mal Respir 2023; 40:751-767. [PMID: 37865564 DOI: 10.1016/j.rmr.2023.09.005] [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: 04/16/2023] [Accepted: 09/19/2023] [Indexed: 10/23/2023]
Abstract
COVID-19 pneumonia presents several particularities in its clinical presentation (cytokine storm, silent hypoxemia, thrombo-embolic risk) and may lead to a number of acute respiratory distress syndrome (ARDS) phenotypes. While the optimal oxygenation strategy in cases of hypoxemic acute respiratory failure (ARF) is still under debate, ventilatory management of COVID-19-related ARF has confirmed the efficacy of high-flow oxygen therapy and restored interest in other ventilatory approaches such as continuous positive airway pressure (CPAP) and noninvasive ventilation involving a helmet, which due to patient overflow are sometimes implemented outside of critical care units. However, further studies are still needed to determine which patients should be given which oxygenation technique, and under which conditions they require invasive mechanical ventilation, given that delayed initiation potentially burdens prognosis. During invasive mechanical ventilation, ventral decubitus and extracorporeal membrane oxygenation have become increasingly prevalent. While innovative therapies such as awake prone position or lung transplantation have likewise been developed, their indications, modalities and efficacy remain to be determined.
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Affiliation(s)
- E Artaud-Macari
- Service de pneumologie, oncologie thoracique et soins intensifs respiratoires, CHU de Rouen, 76000 Rouen, France; UNIROUEN, UR-3830, Normandie université, CHU de Rouen, 76000 Rouen, France.
| | - G Le Bouar
- Service de pneumologie, oncologie thoracique et soins intensifs respiratoires, CHU de Rouen, 76000 Rouen, France
| | - J Maris
- Service de pneumologie, oncologie thoracique et soins intensifs respiratoires, CHU de Rouen, 76000 Rouen, France
| | - E Dantoing
- Service de pneumologie, oncologie thoracique et soins intensifs respiratoires, CHU de Rouen, 76000 Rouen, France
| | - T Vatignez
- Service de médecine intensive et réanimation, CHU de Rouen, 76000 Rouen, France
| | - C Girault
- UNIROUEN, UR-3830, Normandie université, CHU de Rouen, 76000 Rouen, France; Service de médecine intensive et réanimation, CHU de Rouen, 76000 Rouen, France
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2
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Buso G, Mazzolai L, Rueda-Camino JA, Fernández-Capitán C, Jiménez D, Bikdeli B, Lobo JL, Fernández-Reyes JL, Ciammaichella M, Monreal M. Pulmonary Embolism in Patients with COVID-19: Comparison between Different Care Settings. Semin Thromb Hemost 2023; 49:34-46. [PMID: 34902865 DOI: 10.1055/s-0041-1740152] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The clinical characteristics and outcomes of patients with coronavirus disease 2019 (COVID-19) who develop pulmonary embolism (PE) in the full spectrum of patient care settings need to be elucidated. The aim of this study was to compare the clinical characteristics, treatment, and 90-day outcomes in patients diagnosed with PE while recovering from COVID-19 in the outpatient setting versus those who were diagnosed with PE while being hospitalized with COVID-19. Data from the international Registro Informatizado de Enfermedad TromboEmbólica (RIETE) registry were used. The major study outcomes were all-cause death, major bleeding, and venous thromboembolism (VTE) recurrences during the first 90 days after PE. From March 2020 to March 2021, 737 patients with COVID-19 experienced acute PE. Of these, 340 (46%) were recovering from COVID-19 as outpatients (267 patients who had been treated at home for COVID-19 and 73 discharged after being hospitalized with COVID-19). Compared with inpatients with COVID-19, those recovering in the outpatient setting upon PE were less likely to be men (odds ratio [OR]: 0.54; 95% confidence interval [CI]: 0.40-0.72) and less likely to have hypertension (OR: 0.55; 95% CI: 0.41-0.74) or diabetes (OR: 0.51; 95% CI: 0.33-0.76). At 90-day follow-up, eight patients (none recovering from COVID-19 as outpatient vs. 2.4% of inpatients with COVID-19) developed recurrent VTE, 34 (1.9 vs. 7.9%) had major bleeding, and 128 (10 vs. 24%) died. On multivariable analysis, inpatients with COVID-19 were at a higher risk of major bleeding (adjusted hazard ratio [HR]: 6.80; 95% CI: 1.52-30.4) or death (adjusted HR: 2.24; 95% CI: 1.40-3.58). In conclusion, using a large multinational registry of patients with COVID-19 who experienced PE, thromboembolic episodes occurring in those recovering from COVID-19 as outpatients were associated with less ominous outcomes than inpatients with COVID-19.
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Affiliation(s)
- Giacomo Buso
- Angiology Division, Heart and Vessels Department, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Lucia Mazzolai
- Angiology Division, Heart and Vessels Department, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | | | | | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain.,Medicine Department, Universidad de Alcala, Madrid, Spain
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Yale/YNHH Center for Outcomes Research & Evaluation (CORE), New Haven, Connecticut.,Cardiovascular Research Foundation (CRF), New York, New York
| | - José Luis Lobo
- Department of Pneumonology, Hospital Universitario Araba, Álava, Spain
| | | | | | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol. Badalona, Barcelona, Spain.,Chair for the Study of Thromboembolic Disease, Faculty of Health Sciences, UCAM - Universidad Católica San Antonio de Murcia, Spain
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3
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Luu IHY, Frijns T, Buijs J, Krdzalic J, de Kruif MD, Mostard GJM, Ten Cate H, Martens RJH, Mostard RLM, Leers MPG, van Twist DJL. Systematic screening versus clinical gestalt in the diagnosis of pulmonary embolism in COVID-19 patients in the emergency department. PLoS One 2023; 18:e0283459. [PMID: 36952456 PMCID: PMC10035852 DOI: 10.1371/journal.pone.0283459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 03/03/2023] [Indexed: 03/25/2023] Open
Abstract
BACKGROUND Diagnosing concomitant pulmonary embolism (PE) in COVID-19 patients remains challenging. As such, PE may be overlooked. We compared the diagnostic yield of systematic PE-screening based on the YEARS-algorithm to PE-screening based on clinical gestalt in emergency department (ED) patients with COVID-19. METHODS We included all ED patients who were admitted because of COVID-19 between March 2020 and February 2021. Patients already receiving anticoagulant treatment were excluded. Up to April 7, 2020, the decision to perform CT-pulmonary angiography (CTPA) was based on physician's clinical gestalt (clinical gestalt cohort). From April 7 onwards, systematic PE-screening was performed by CTPA if D-dimer level was ≥1000 ug/L, or ≥500 ug/L in case of ≥1 YEARS-item (systematic screening cohort). RESULTS 1095 ED patients with COVID-19 were admitted. After applying exclusion criteria, 289 were included in the clinical gestalt and 574 in the systematic screening cohort. The number of PE diagnoses was significantly higher in the systematic screening cohort compared to the clinical gestalt cohort: 8.2% vs. 1.0% (3/289 vs. 47/574; p<0.001), even after adjustment for differences in patient characteristics (adjusted OR 8.45 (95%CI 2.61-27.42, p<0.001) for PE diagnosis). In multivariate analysis, D-dimer (OR 1.09 per 1000 μg/L increase, 95%CI 1.06-1.13, p<0.001) and CRP >100 mg/L (OR 2.78, 95%CI 1.37-5.66, p = 0.005) were independently associated with PE. CONCLUSION In ED patients with COVID-19, the number of PE diagnosis was significantly higher in the cohort that underwent systematic PE screening based on the YEARS-algorithm in comparison with the clinical gestalt cohort, with a number needed to test of 7.1 CTPAs to detect one PE.
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Affiliation(s)
- Inge H Y Luu
- Department of Internal Medicine, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Tim Frijns
- Department of Internal Medicine, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Jacqueline Buijs
- Department of Internal Medicine, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Jasenko Krdzalic
- Department of Radiology, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Martijn D de Kruif
- Department of Pulmonology, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Guy J M Mostard
- Department of Internal Medicine, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Hugo Ten Cate
- Department of Internal Medicine and Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Remy J H Martens
- Department of Clinical Chemistry and Haematology, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Remy L M Mostard
- Department of Pulmonology, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Math P G Leers
- Department of Clinical Chemistry and Haematology, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Daan J L van Twist
- Department of Internal Medicine, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
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Kobusiak-Prokopowicz M, Fułek K, Fułek M, Kaaz K, Mysiak A, Kurpas D, Beszłej JA, Brzecka A, Leszek J. Cardiovascular, Pulmonary, and Neuropsychiatric Short- and Long-Term Complications of COVID-19. Cells 2022; 11:cells11233882. [PMID: 36497138 PMCID: PMC9735460 DOI: 10.3390/cells11233882] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 12/05/2022] Open
Abstract
Beginning with the various strategies of the SARS-CoV-2 virus to invade our bodies and manifest infection, and ending with the recent long COVID, we are witnessing the evolving course of the disease in addition to the pandemic. Given the partially controlled course of the COVID-19 pandemic, the greatest challenge currently lies in managing the short- and long-term complications of COVID-19. We have assembled current knowledge of the broad spectrum of cardiovascular, pulmonary, and neuropsychiatric sequelae following SARS-CoV-2 infection to understand how these clinical manifestations collectively lead to a severe form of the disease. The ultimate goal would be to better understand these complications and find ways to prevent clinical deterioration.
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Affiliation(s)
| | - Katarzyna Fułek
- Lower Silesian Oncology, Pulmonology and Hematology Center, 53-413 Wroclaw, Poland
| | - Michał Fułek
- Department and Clinic of Internal Medicine, Occupational Diseases, Hypertension and Clinical Oncology, Wroclaw Medical University, 50-556 Wroclaw, Poland
- Correspondence: (M.F.); (J.L.)
| | - Konrad Kaaz
- Department of Cardiology, Institute of Heart Diseases, Wroclaw Medical University, 50-556 Wroclaw, Poland
| | - Andrzej Mysiak
- Department of Cardiology, Institute of Heart Diseases, Wroclaw Medical University, 50-556 Wroclaw, Poland
| | - Donata Kurpas
- Department and Clinic of Family Medicine, Wroclaw Medical University, 51-141 Wroclaw, Poland
| | | | - Anna Brzecka
- Department of Pulmonology and Lung Oncology, Wroclaw Medical University, 53-439 Wroclaw, Poland
| | - Jerzy Leszek
- Department and Clinic of Psychiatry, Wroclaw Medical University, 50-367 Wroclaw, Poland
- Correspondence: (M.F.); (J.L.)
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5
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Charles J, Ploplis VA. COVID-19 Induces Cytokine Storm and Dysfunctional Hemostasis. Curr Drug Targets 2022; 23:1603-1610. [PMID: 36284376 DOI: 10.2174/1389450124666221025102929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 10/05/2022] [Accepted: 10/12/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Infection with SARS-CoV-2 leads to COVID-19 which can manifest in various ways from asymptomatic or mild disease to acute respiratory distress syndrome. The occurrence of dysregulated inflammatory responses in the form of a cytokine storm has been reported in patients with severe COVID-19. Infection can also lead to dysfunctional hemostasis reflected in elevated circulating D-dimer and fibrin degradation products. Components of hemostasis and the immune system during infection can result in a procoagulation and/or proinflammatory state. The interplay between coagulation and inflammation has been elucidated in a number of diseases. OBJECTIVE In this article, we discuss the occurrence of cytokine storms and dysfunctional hemostasis induced in COVID-19. METHODS This review was written using literature from the past two to three years investigating coagulation and inflammation in COVID-19. Additional literature, both clinical and basic research, related to pathogen infection and host responses were also considered in this review. RESULTS/CONCLUSIONS Infection with SARS-CoV-2 can lead to dysregulated inflammatory responses that may be detrimental to the host. The increased expression of various inflammatory factors can ultimately create an environment that promotes thrombosis.
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Affiliation(s)
- Jermilia Charles
- W.M. Keck Center for Transgene Research, University of Notre Dame, Notre Dame, IN 46556, USA
| | - Victoria A Ploplis
- W.M. Keck Center for Transgene Research, University of Notre Dame, Notre Dame, IN 46556, USA
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6
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SARS-CoV-2 antibody research in patients with unprovoked pulmonary embolism in COVID-19 pandemic period. J Thromb Thrombolysis 2022; 54:587-592. [PMID: 36121538 PMCID: PMC9483878 DOI: 10.1007/s11239-022-02703-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/31/2022] [Indexed: 11/17/2022]
Abstract
Objective Due to the coronavirus disease 2019 (COVID-19) pandemic, a significant increase has been observed in patients diagnosed with pulmonary embolism (PE) in our clinic. In addition to COVID-19-related PE, the increase in the number of patients with unprovoked or idiopathic PE was also noteworthy. Although it is not surprising that PE due to immobilization was observed in elderly patients and patients with comorbidities at risk for PE during the pandemic, it is important to investigate the increase in the number of unprovoked PE. Thus, we aimed to show that a previous COVID-19 infection may be a risk factor in these patients by examining the presence of severe acute respiratory syndrome-causing coronavirus (SARS-CoV-2) antibodies in patients diagnosed with unprovoked PE. Materials and methods The participants of the study consisted of 45 consecutive patients who were diagnosed with PE in our clinic, had no risk factors for PE, were considered unprovoked (idiopathic) PE, and had no history of COVID-19. SARS-CoV-2 antibody titers were measured in the serum samples of the patients for detecting immunity as a result of encountering COVID-19. Results Of the 45 patients diagnosed with PE, 24 (53.3%) patients were diagnosed with computed tomography pulmonary angiogram (CTPA), and 21 (46.7%) patients were diagnosed with perfusion single-photon emission computed tomography (Q-SPECT/CT). Immunity acquired after encountering COVID-19 was checked with the NCP kit, which revealed positive results in 9 (20%) patients. Conclusion It should be kept in mind that some of the patients diagnosed with idiopathic PE during the pandemic may have embolism due to asymptomatic COVID-19. In addition, it is now known that COVID-19 also creates a tendency toward thrombosis in asymptomatic patients. Supplementary Information The online version contains supplementary material available at 10.1007/s11239-022-02703-8.
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Montani D, Certain MC, Weatherald J, Jaïs X, Bulifon S, Noel-Savina E, Nieves A, Renard S, Traclet J, Bouvaist H, Riou M, de Groote P, Moceri P, Bertoletti L, Favrolt N, Guillaumot A, Jutant EM, Beurnier A, Boucly A, Ebstein N, Jevnikar M, Pichon J, Keddache S, Preda M, Roche A, Solinas S, Seferian A, Reynaud-Gaubert M, Cottin V, Savale L, Humbert M, Sitbon O. COVID-19 in Patients with Pulmonary Hypertension: A National Prospective Cohort Study. Am J Respir Crit Care Med 2022; 206:573-583. [PMID: 35549842 PMCID: PMC9716894 DOI: 10.1164/rccm.202112-2761oc] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Rationale: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is associated with pulmonary endothelial dysfunction. There are limited data available on the outcomes of coronavirus disease (COVID-19) in patients with pulmonary hypertension (PH), a disease characterized by pulmonary endothelial dysfunction. Objectives: To describe characteristics and outcomes of patients with precapillary PH and COVID-19. Methods: We prospectively collected characteristics, management, and outcomes of adult patients with precapillary PH in the French PH network who had COVID-19 between February 1, 2020, and April 30, 2021. Clinical, functional, and hemodynamic characteristics of PH before COVID-19 were collected from the French PH registry. Measurements and Main Results: A total of 211 patients with PH (including 123 with pulmonary arterial hypertension, 47 with chronic thromboembolic PH, and 41 with other types of PH) experienced COVID-19, and 40.3% of them were outpatients, 32.2% were hospitalized in a conventional ward, and 27.5% were in an ICU. Among hospitalized patients (n = 126), 54.0% received corticosteroids, 37.3% high-flow oxygen, and 11.1% invasive ventilation. Right ventricular and acute renal failure occurred in 30.2% and 19.8% of patients, respectively. Fifty-two patients (all hospitalized) died from COVID-19. Overall mortality was 24.6% (95% CI [confidence interval], 18.8-30.5) and in-hospital mortality 41.3% (95% CI, 32.7-49.9). Nonsurvivors were significantly older, more frequently male and suffering comorbidities (diabetes, chronic respiratory diseases, systemic hypertension, chronic cardiac diseases, and/or chronic renal failure), and had more severe PH at their most recent evaluation preceding COVID-19 diagnosis (in terms of functional class and 6-minute-walk distance; all P < 0.05). Use of pulmonary arterial hypertension therapy was similar between survivors and nonsurvivors. Conclusions: COVID-19 in patients with precapillary PH was associated with a high in-hospital mortality. The typical risk factors for severe COVID-19 and severity of PH were associated with mortality in this population.
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Affiliation(s)
- David Montani
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France;,Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche _S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France;,Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, and
| | - Marie-Caroline Certain
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France;,Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche _S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France;,Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, and
| | - Jason Weatherald
- Division of Respirology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada;,Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Xavier Jaïs
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France;,Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche _S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France;,Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, and
| | - Sophie Bulifon
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France;,Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche _S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France;,Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, and
| | | | - Ana Nieves
- Service de Pneumologie Centre Hospitalier Universitaire Nord, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Sébastien Renard
- Service de Cardiologie, Centre Régional de Compétences de l'Hypertension Pulmonaire, Hôpital La Timone, Marseille, France
| | - Julie Traclet
- Université Lyon-1, Hospices Civils de Lyon, Centre de Référence des Maladies Pulmonaires Rares, Centre de Compétences de l'Hypertension Pulmonaire, Hôpital Louis Pradel, Lyon, France
| | - Hélène Bouvaist
- Service de Cardiologie, Hôpital Universitaire Grenoble-Alpes, Grenoble, France
| | - Marianne Riou
- Département de Pneumologie, Nouvel Hôpital Civil, Strasbourg, France
| | - Pascal de Groote
- Hôpital Cardiologique de Lille, Centre de Compétences de l'Hypertension Pulmonaire, Lille, France
| | - Pamela Moceri
- Unité de Recherche Clinique Côte d'Azur, Service de Cardiologie, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, Nice, France
| | - Laurent Bertoletti
- Service de Médecine Vasculaire et Thérapeutique, Institut National de la Santé et de la Recherche Médicale Unité 1059 et Centre d'Investigation Clinique 1408, Centre Hospitalier Universitaire de Saint-Etienne, Université Jean-Monnet, Saint-Etienne, France
| | - Nicolas Favrolt
- Service de Pneumologie et Soins Intensifs Respiratoires, Centre Hospitalier Universitaire de Dijon, Dijon, France
| | - Anne Guillaumot
- Université de Lorraine, Centre Hospitalo-Universitaire Nancy, Pôle des Spécialités Médicales, Département de Pneumologie, Vandoeuvre-lès-Nancy, France; and
| | - Etienne-Marie Jutant
- Université de Poitiers, Centre Hospitalo-Universitaire de Poitiers, Service de pneumologie, Institut National de la Santé et de la Recherche Médicale Centre d'Investigation Clinique 1402, Poitiers, France
| | - Antoine Beurnier
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France;,Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche _S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France;,Department of Physiology – Pulmonary Function Testing, Assistance Publique – Hôpitaux de Paris, Hôpital Bicêtre, Département Médico-Universitaire 5 Thorinno, Le Kremlin-Bicêtre, France
| | - Athénaïs Boucly
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France;,Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche _S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France;,Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, and
| | - Nathan Ebstein
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France;,Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche _S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France;,Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, and
| | - Mitja Jevnikar
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France;,Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche _S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France;,Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, and
| | - Jérémie Pichon
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France;,Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche _S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France;,Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, and
| | - Sophia Keddache
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France;,Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche _S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France;,Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, and
| | - Mariana Preda
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France;,Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche _S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France;,Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, and
| | - Anne Roche
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France;,Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche _S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France;,Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, and
| | - Sabina Solinas
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France;,Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche _S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France;,Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, and
| | - Andrei Seferian
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France;,Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche _S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France;,Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, and
| | - Martine Reynaud-Gaubert
- Service de Pneumologie Centre Hospitalier Universitaire Nord, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Vincent Cottin
- Université Lyon-1, Hospices Civils de Lyon, Centre de Référence des Maladies Pulmonaires Rares, Centre de Compétences de l'Hypertension Pulmonaire, Hôpital Louis Pradel, Lyon, France
| | - Laurent Savale
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France;,Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche _S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France;,Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, and
| | - Marc Humbert
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France;,Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche _S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France;,Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, and
| | - Olivier Sitbon
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France;,Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche _S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France;,Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, and
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The potential role of ischaemia-reperfusion injury in chronic, relapsing diseases such as rheumatoid arthritis, Long COVID, and ME/CFS: evidence, mechanisms, and therapeutic implications. Biochem J 2022; 479:1653-1708. [PMID: 36043493 PMCID: PMC9484810 DOI: 10.1042/bcj20220154] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 08/09/2022] [Accepted: 08/10/2022] [Indexed: 02/07/2023]
Abstract
Ischaemia–reperfusion (I–R) injury, initiated via bursts of reactive oxygen species produced during the reoxygenation phase following hypoxia, is well known in a variety of acute circumstances. We argue here that I–R injury also underpins elements of the pathology of a variety of chronic, inflammatory diseases, including rheumatoid arthritis, ME/CFS and, our chief focus and most proximally, Long COVID. Ischaemia may be initiated via fibrin amyloid microclot blockage of capillaries, for instance as exercise is started; reperfusion is a necessary corollary when it finishes. We rehearse the mechanistic evidence for these occurrences here, in terms of their manifestation as oxidative stress, hyperinflammation, mast cell activation, the production of marker metabolites and related activities. Such microclot-based phenomena can explain both the breathlessness/fatigue and the post-exertional malaise that may be observed in these conditions, as well as many other observables. The recognition of these processes implies, mechanistically, that therapeutic benefit is potentially to be had from antioxidants, from anti-inflammatories, from iron chelators, and via suitable, safe fibrinolytics, and/or anti-clotting agents. We review the considerable existing evidence that is consistent with this, and with the biochemical mechanisms involved.
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DEMİRCİOĞLU Ö, KOCAKAYA D, ÇİMŞİT C, SARİNOĞLU RC, ÜLGER N, ÇİMŞİT C. Radiological comparison of the Wuhan and B.1.1.7 variant COVID-19 infection; are there any differences in chest CT scans? JOURNAL OF HEALTH SCIENCES AND MEDICINE 2022. [DOI: 10.32322/jhsm.1114475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Aim: In September 2020, a variant of the SARS-CoV-2 virus was detected in England and it became the dominant type in most of the countries. The clinical behavior of the B.1.1.7 variant COVID-19 infectionis different from the Wuhan type.So we aimed to investigate whether there are any differences in computed tomography (CT) imaging findings of pneumonia caused by COVID-19 variants.
Material and Method: 340 patients who admitted to the emergency departmentwith symptoms of dyspnea and chest pain suspecting COVID-19 pneumonia and pulmonary embolism were included in the study. Oncology (n:12) and pediatric (n:8) patients, patients with negative PCR test (n:56), and patients infected with different variant (n:6) were excluded leaving 258 patients grouped into two (B.1.1.7 and Wuhan type) for evaluation of CT findings such as pleural thickening,pleural and pericardial effusion, consolidation, GGO presence and distribution, upper lobe involvement, pulmonary embolism, tree in bud pattern, centrilobuler nodule, revers halo sign, and hepatosteatosis.
Results: A statistically significant difference was obtained between the two groups in terms of pleural thickening (p=0.020), upper lobe involvement (p=0.037), localization of GGO (p=0.001), presence of pleural effusion (p=0.025), embolism (p=0.011) and presence of consolidation (p=0.042). However, no significant difference was found for the development of hepatosteatosis (p=0.520).
Conclusion: There aredifferences in radiological findings between B.1.1.7 variant and Wuhan type. In our study atypical radiological findings are more common in B.1.1.7 type. In addition, radiological findings that seen in severe COVID-19 pneumonia are more common in B.1.1.7.
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Suarez Castillejo C, Toledo-Pons N, Calvo N, Ramon-Clar L, Martínez J, Hermoso de Mendoza S, Morell-García D, Bauça JM, Berga F, Núñez B, Preda L, Sauleda J, Argente Castillo P, Ballesteros A, Martín L, Sala-Llinas E, Alonso-Fernández A. A Prospective Study Evaluating Cumulative Incidence and a Specific Prediction Rule in Pulmonary Embolism in COVID-19. Front Med (Lausanne) 2022; 9:936816. [PMID: 35847817 PMCID: PMC9283900 DOI: 10.3389/fmed.2022.936816] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 05/25/2022] [Indexed: 01/08/2023] Open
Abstract
Rationale Abnormal values of hypercoagulability biomarkers, such as D-dimer, have been described in Coronavirus Disease 2019 (COVID-19), which has also been associated with disease severity and in-hospital mortality. COVID-19 patients with pneumonia are at greater risk of pulmonary embolism (PE). However, the real incidence of PE is not yet clear, since studies have been limited in size, mostly retrospective, and PE diagnostic procedures were only performed when PE was clinically suspected. Objectives (1) To determine the incidence, clinical, radiological, and biological characteristics, and clinical outcomes of PE among patients hospitalized for COVID-19 pneumonia with D-dimer > 1,000 ng/mL. (2) To develop a prognostic model to predict PE in these patients. Methods Single-center prospective cohort study. Consecutive confirmed cases of COVID-19 pneumonia with D-dimer > 1,000 ng/mL underwent computed tomography pulmonary angiography (CTPA). Demographic and laboratory data, comorbidities, CTPA scores, treatments administered, and clinical outcomes were analyzed and compared between patients with and without PE. A risk score was constructed from all these variables. Results Between 6 April 2020 and 2 February 2021, 179 consecutive patients were included. The overall incidence of PE was 39.7% (71 patients) (CI 95%, 32–47%). In patients with PE, emboli were located mainly in segmental/subsegmental arteries (67%). Patients with PE did not differ from the non-PE group in sex, age, or risk factors for thromboembolic disease. Higher urea, D-Dimer, D-dimer-to-ferritin and D-dimer-to-lactate dehydrogenase (LDH) ratios, platelet distribution width (PDW), and neutrophil-to-lymphocyte ratio (NLR) values were found in patients with PE when compared to patients with non-PE. Besides, lymphocyte counts turned out to be lower in patients with PE. A score for PE prediction was constructed with excellent overall performance [area under the ROC curve-receiver operating characteristic (AUC-ROC) 0.81 (95% CI: 0.73–0.89)]. The PATCOM score stands for Pulmonary Artery Thrombosis in COVID-19 Mallorca and includes platelet count, PDW, urea concentration, and D-dimer-to-ferritin ratio. Conclusion COVID-19 patients with pneumonia and D-dimer values > 1,000 ng/mL were presented with a very high incidence of PE, regardless of clinical suspicion. Significant differences in urea, D-dimer, PDW, NLR, and lymphocyte count were found between patients with PE and non-PE. The PATCOM score is presented in this study as a promising PE prediction rule, although validation in further studies is required.
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Affiliation(s)
- Carla Suarez Castillejo
- Servicio de Neumología, Hospital Universitario Son Espases, Palma de Mallorca, Spain
- Institut d’Investigació Sanitària Illes Balears (IdISBa), Palma, Spain
| | - Nuria Toledo-Pons
- Servicio de Neumología, Hospital Universitario Son Espases, Palma de Mallorca, Spain
- Institut d’Investigació Sanitària Illes Balears (IdISBa), Palma, Spain
| | - Néstor Calvo
- Servicio de Radiodiagnostico, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - Luisa Ramon-Clar
- Servicio de Neumología, Hospital Universitario Son Espases, Palma de Mallorca, Spain
- Institut d’Investigació Sanitària Illes Balears (IdISBa), Palma, Spain
| | - Joaquín Martínez
- Servicio de Neumología, Hospital Universitario Son Espases, Palma de Mallorca, Spain
- Institut d’Investigació Sanitària Illes Balears (IdISBa), Palma, Spain
| | | | - Daniel Morell-García
- Institut d’Investigació Sanitària Illes Balears (IdISBa), Palma, Spain
- Servicio de Análisis Clínicos, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - Josep Miquel Bauça
- Servicio de Análisis Clínicos, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - Francisco Berga
- Servicio de Análisis Clínicos, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - Belén Núñez
- Servicio de Neumología, Hospital Universitario Son Espases, Palma de Mallorca, Spain
- Institut d’Investigació Sanitària Illes Balears (IdISBa), Palma, Spain
| | - Luminita Preda
- Servicio de Radiodiagnostico, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - Jaume Sauleda
- Servicio de Neumología, Hospital Universitario Son Espases, Palma de Mallorca, Spain
- Institut d’Investigació Sanitària Illes Balears (IdISBa), Palma, Spain
- CIBER Enfermedades Respiratorias, Palma de Mallorca, Spain
| | - Paula Argente Castillo
- Servicio de Análisis Clínicos, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - Antonieta Ballesteros
- Servicio de Análisis Clínicos, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - Luisa Martín
- Servicio de Medicina Interna, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - Ernest Sala-Llinas
- Servicio de Neumología, Hospital Universitario Son Espases, Palma de Mallorca, Spain
- Institut d’Investigació Sanitària Illes Balears (IdISBa), Palma, Spain
- CIBER Enfermedades Respiratorias, Palma de Mallorca, Spain
| | - Alberto Alonso-Fernández
- Servicio de Neumología, Hospital Universitario Son Espases, Palma de Mallorca, Spain
- Institut d’Investigació Sanitària Illes Balears (IdISBa), Palma, Spain
- CIBER Enfermedades Respiratorias, Palma de Mallorca, Spain
- *Correspondence: Alberto Alonso-Fernández,
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Bais B, Sozio E, De Silvestri D, Volpetti S, Zannier ME, Filì C, Bassi F, Alcaro L, Cotrufo M, Pagotto A, Giacinta A, Patruno V, Da Porto A, Sbrojavacca R, Curcio F, Tascini C, Sechi LA, Colussi G. Effect of heparin treatment on pulmonary embolism and in-hospital death in unvaccinated COVID-19 patients without overt deep vein thrombosis. Thromb J 2022; 20:34. [PMID: 35725464 PMCID: PMC9207168 DOI: 10.1186/s12959-022-00393-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 06/09/2022] [Indexed: 11/15/2022] Open
Abstract
Background Pulmonary embolism (PE) without overt deep vein thrombosis (DVT) was common in hospitalized coronavirus-induced disease (COVID)-19 patients and represented a diagnostic, prognostic, and therapeutic challenge. The aim of this study was to analyze the prognostic role of PE on mortality and the preventive effect of heparin on PE and mortality in unvaccinated COVID-19 patients without overt DVT. Methods Data from 401 unvaccinated patients (age 68 ± 13 years, 33% females) consecutively admitted to the intensive care unit or the medical ward were included in a retrospective longitudinal study. PE was documented by computed tomography scan and DVT by compressive venous ultrasound. The effect of PE diagnosis and any heparin use on in-hospital death (primary outcome) was analyzed by a classical survival model. The preventive effect of heparin on either PE diagnosis or in-hospital death (secondary outcome) was analyzed by a multi-state model after having reclassified patients who started heparin after PE diagnosis as not treated. Results Median follow-up time was 8 days (range 1–40 days). PE cumulative incidence and in-hospital mortality were 27% and 20%, respectively. PE was predicted by increased D-dimer levels and COVID-19 severity. Independent predictors of in-hospital death were age (hazards ratio (HR) 1.05, 95% confidence interval (CI) 1.03–1.08, p < 0.001), body mass index (HR 0.93, 95% CI 0.89–0.98, p = 0.004), COVID-19 severity (severe versus mild/moderate HR 3.67, 95% CI 1.30–10.4, p = 0.014, critical versus mild/moderate HR 12.1, 95% CI 4.57–32.2, p < 0.001), active neoplasia (HR 2.58, 95% CI 1.48–4.50, p < 0.001), chronic obstructive pulmonary disease (HR 2.47; 95% CI 1.15–5.27, p = 0.020), respiratory rate (HR 1.06, 95% CI 1.02–1.11, p = 0.008), heart rate (HR 1.03, 95% CI 1.01–1.04, p < 0.001), and any heparin treatment (HR 0.35, 95% CI 0.18–0.67, p = 0.001). In the multi-state model, preventive heparin at prophylactic or intermediate/therapeutic dose, compared with no treatment, reduced PE risk and in-hospital death, but it did not influence mortality of patients with a PE diagnosis. Conclusions PE was common during the first waves pandemic in unvaccinated patients, but it was not a negative prognostic factor for in-hospital death. Heparin treatment at any dose prevented mortality independently of PE diagnosis, D-dimer levels, and disease severity.
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Affiliation(s)
- Bruno Bais
- Thrombosis Prevention Unit, Division of Internal Medicine, Academic Hospital of Udine (ASUFC), 33100, Udine, UD, Italy
| | - Emanuela Sozio
- Infectious Diseases Clinic, Department of Medicine, University of Udine, 33100, Udine, Italy
| | - Daniele De Silvestri
- Thrombosis Prevention Unit, Division of Internal Medicine, Academic Hospital of Udine (ASUFC), 33100, Udine, UD, Italy
| | - Stefano Volpetti
- Hematology and Bone Marrow Transplantation, Department of Medicine, University of Udine, 33100, Udine, Italy
| | - Maria Elena Zannier
- Hematology and Bone Marrow Transplantation, Department of Medicine, University of Udine, 33100, Udine, Italy
| | - Carla Filì
- Hematology and Bone Marrow Transplantation, Department of Medicine, University of Udine, 33100, Udine, Italy
| | - Flavio Bassi
- Department of Anesthesia and Intensive Care Medicine, Academic Hospital of Udine (ASUFC), 33100, Udine, Italy
| | - Lucia Alcaro
- Internal Medicine, Department of Medicine, University of Udine, 33100, Udine, Italy
| | - Marco Cotrufo
- Infectious Diseases Clinic, Department of Medicine, University of Udine, 33100, Udine, Italy
| | - Alberto Pagotto
- Infectious Diseases Clinic, Department of Medicine, University of Udine, 33100, Udine, Italy
| | - Alessandro Giacinta
- Infectious Diseases Clinic, Department of Medicine, University of Udine, 33100, Udine, Italy
| | - Vincenzo Patruno
- Division of Pulmonary Medicine, Academic Hospital of Udine (ASUFC), 33100, Udine, Italy
| | - Andrea Da Porto
- Internal Medicine, Department of Medicine, University of Udine, 33100, Udine, Italy
| | - Rodolfo Sbrojavacca
- Infectious Diseases Clinic, Department of Medicine, University of Udine, 33100, Udine, Italy
| | - Francesco Curcio
- Department of Laboratory Medicine, University of Udine, 33100, Udine, Italy
| | - Carlo Tascini
- Infectious Diseases Clinic, Department of Medicine, University of Udine, 33100, Udine, Italy
| | | | - GianLuca Colussi
- Internal Medicine, Department of Medicine, University of Udine, 33100, Udine, Italy.
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12
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Cantarinha A, Bassil C, Savignac A, Devilder M, Maxwell F, Crézé M, Purcell YM, Bellin MF, Meyrignac O, Dillenseger JP. "Triple low" free-breathing CTPA protocol for patients with dyspnoea. Clin Radiol 2022; 77:e628-e635. [PMID: 35688771 DOI: 10.1016/j.crad.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 05/09/2022] [Indexed: 11/03/2022]
Abstract
AIM To assess the performance of a "triple-low" free-breathing protocol for computed tomography pulmonary angiography (CTPA) evaluated on patients with dyspnoea and suspected pulmonary embolism and discuss its application in routine clinical practice for the study of the pulmonary parenchyma and vasculature. MATERIAL AND METHODS This study was conducted on a selected group of dyspnoeic patients referred for CTPA. The protocol was designed using fast free-breathing acquisition and a small, fixed volume (35 ml) of contrast agent in order to achieve a low-exposure dose. For each examination, radiodensity of the pulmonary trunk and ascending aorta, and the dose-length product (DLP) were recorded. A qualitative analysis was performed of pulmonary arterial enhancement and the pulmonary parenchyma. RESULTS This study included 134 patients. Contrast enhancement of the pulmonary arteries (409 ± 159 HU) was systematically >250 HU. The duration of acquisition ranged from 0.9 to 1.3 seconds for free-breathing imaging. The mean DLP was in the range of low-dose chest CT acquisitions (145 ± 73 mGy·cm). The analysis was deemed optimal in 90% (120/134) of cases for the pulmonary parenchyma. Sixty-nine per cent (92/134) of cases demonstrated homogeneous enhancement of the pulmonary arteries to the subsegmental level. Only 6% (8/134) of examinations were considered uninterpretable. CONCLUSION The present "triple-low" CTPA protocol allows convenient analysis of the pulmonary parenchyma and arteries without hindrance by respiratory motion artefacts in dyspnoeic patients.
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Affiliation(s)
- A Cantarinha
- Service de Radiologie Générale Adulte, Hôpital Bicêtre, Hôpitaux Universitaires Paris-Sud, Département Médico Universitaire Smart Imaging, Assistance Publique des Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - C Bassil
- Service de Radiologie Générale Adulte, Hôpital Bicêtre, Hôpitaux Universitaires Paris-Sud, Département Médico Universitaire Smart Imaging, Assistance Publique des Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - A Savignac
- Service de Radiologie Générale Adulte, Hôpital Bicêtre, Hôpitaux Universitaires Paris-Sud, Département Médico Universitaire Smart Imaging, Assistance Publique des Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - M Devilder
- Service de Radiologie Générale Adulte, Hôpital Bicêtre, Hôpitaux Universitaires Paris-Sud, Département Médico Universitaire Smart Imaging, Assistance Publique des Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - F Maxwell
- Service de Radiologie Générale Adulte, Hôpital Bicêtre, Hôpitaux Universitaires Paris-Sud, Département Médico Universitaire Smart Imaging, Assistance Publique des Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - M Crézé
- Service de Radiologie Générale Adulte, Hôpital Bicêtre, Hôpitaux Universitaires Paris-Sud, Département Médico Universitaire Smart Imaging, Assistance Publique des Hôpitaux de Paris, Le Kremlin-Bicêtre, France; BioMaps, Université Paris-Saclay, Hôpital Kremlin-Bicêtre, Le Kremlin-Bicêtre, France
| | - Y M Purcell
- Hôpital Fondation Adolphe de Rothschild, Paris, France
| | - M-F Bellin
- Service de Radiologie Générale Adulte, Hôpital Bicêtre, Hôpitaux Universitaires Paris-Sud, Département Médico Universitaire Smart Imaging, Assistance Publique des Hôpitaux de Paris, Le Kremlin-Bicêtre, France; BioMaps, Université Paris-Saclay, Hôpital Kremlin-Bicêtre, Le Kremlin-Bicêtre, France
| | - O Meyrignac
- Service de Radiologie Générale Adulte, Hôpital Bicêtre, Hôpitaux Universitaires Paris-Sud, Département Médico Universitaire Smart Imaging, Assistance Publique des Hôpitaux de Paris, Le Kremlin-Bicêtre, France; BioMaps, Université Paris-Saclay, Hôpital Kremlin-Bicêtre, Le Kremlin-Bicêtre, France
| | - J-P Dillenseger
- Faculté de Médecine, Maïeutique, et Sciences de la Santé, Université de Strasbourg, Strasbourg, France; ICube-UMR 7357, CNRS, Université de Strasbourg, Strasbourg, France.
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13
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Blondon M, Cereghetti S, Pugin J, Marti C, Darbellay Farhoumand P, Reny J, Calmy A, Combescure C, Mazzolai L, Pantet O, Ltaief Z, Méan M, Manzocchi Besson S, Jeanneret S, Stricker H, Robert‐Ebadi H, Fontana P, Righini M, Casini A. Therapeutic anticoagulation to prevent thrombosis, coagulopathy, and mortality in severe COVID‐19: The Swiss COVID‐HEP randomized clinical trial. Res Pract Thromb Haemost 2022; 6:e12712. [PMID: 35599701 PMCID: PMC9116142 DOI: 10.1002/rth2.12712] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/28/2022] [Accepted: 04/05/2022] [Indexed: 12/18/2022] Open
Abstract
Background Hospitalized patients with COVID‐19 suffered initially from high rates of venous thromboembolism (VTE), with possible associations between therapeutic anticoagulation and better clinical outcomes in observational studies. Objective To test whether therapeutic anticoagulation improves clinical outcomes in severe COVID‐19. Patients/Methods In this multicenter, open‐label, randomized controlled trial, we recruited acutely ill medical COVID‐19 patients with D‐dimer >1000 ng/ml or critically ill COVID‐19 patients in four Swiss hospitals, from April 2020 until June 2021, with a 30‐day follow‐up. Participants were randomized to in‐hospital therapeutic anticoagulation versus low‐dose anticoagulation in acutely ill participants/intermediate‐dose anticoagulation in critically ill participants, with enoxaparin or unfractionated heparins. The primary outcome was a centrally adjudicated composite of 30‐day all‐cause mortality, VTE, arterial thrombosis, and disseminated intravascular coagulopathy (DIC), with screening for proximal deep vein thrombosis. Results Among 159 participants, 55.3% were critically ill and 94.3% received corticosteroids. Before study inclusion, pulmonary embolism had been excluded in 71.7%. The primary outcome occurred in 4/79 participants randomized to therapeutic anticoagulation and 4/80 to low/intermediate anticoagulation (5.4% vs. 5.0%; risk difference +0.4%; adjusted hazard ratio 0.76, 95% confidence interval 0.18–3.21), including three deaths in each group. All primary outcomes and major bleeding (n = 3) occurred in critically ill participants. There was no asymptomatic proximal deep vein thrombosis and no difference in major bleeding. Conclusions Among patients with severe COVID‐19 treated with corticosteroids and with exclusion of pulmonary embolism at hospital admission for most, risks of mortality, thrombotic outcomes, and DIC were low at 30 days. The lack of benefit of therapeutic anticoagulation was too imprecise for definite conclusions.
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Affiliation(s)
- Marc Blondon
- Division of Angiology and Hemostasis Geneva University Hospitals and Faculty of Medicine Geneva Switzerland
| | - Sara Cereghetti
- Division of Intensive Care Geneva University Hospitals and Faculty of Medicine Geneva Switzerland
| | - Jérôme Pugin
- Division of Intensive Care Geneva University Hospitals and Faculty of Medicine Geneva Switzerland
| | - Christophe Marti
- Division of General Internal Medicine Geneva University Hospitals and Faculty of Medicine Geneva Switzerland
| | | | - Jean‐Luc Reny
- Division of General Internal Medicine Geneva University Hospitals and Faculty of Medicine Geneva Switzerland
| | - Alexandra Calmy
- HIV/AIDS Unit Division of Infectious Disease Geneva University Hospitals and Faculty of Medicine Geneva Switzerland
| | - Christophe Combescure
- Clinical Research Center Geneva University Hospitals and Faculty of Medicine Geneva Switzerland
| | - Lucia Mazzolai
- Division of Angiology Centre Hospitalier Universitaire Vaudois Lausanne Switzerland
| | - Olivier Pantet
- Division of Intensive Care Centre Hospitalier Universitaire Vaudois Lausanne Switzerland
| | - Zied Ltaief
- Division of Intensive Care Centre Hospitalier Universitaire Vaudois Lausanne Switzerland
| | - Marie Méan
- Division of Internal Medicine Centre Hospitalier Universitaire Vaudois Lausanne Switzerland
| | | | | | - Hans Stricker
- Division of Angiology Locarno Regional Hospital Locarno Switzerland
| | - Helia Robert‐Ebadi
- Division of Angiology and Hemostasis Geneva University Hospitals and Faculty of Medicine Geneva Switzerland
| | - Pierre Fontana
- Division of Angiology and Hemostasis Geneva University Hospitals and Faculty of Medicine Geneva Switzerland
| | - Marc Righini
- Division of Angiology and Hemostasis Geneva University Hospitals and Faculty of Medicine Geneva Switzerland
| | - Alessandro Casini
- Division of Angiology and Hemostasis Geneva University Hospitals and Faculty of Medicine Geneva Switzerland
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14
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Montani D, Savale L, Noel N, Meyrignac O, Colle R, Gasnier M, Corruble E, Beurnier A, Jutant EM, Pham T, Lecoq AL, Papon JF, Figueiredo S, Harrois A, Humbert M, Monnet X. Post-acute COVID-19 syndrome. Eur Respir Rev 2022; 31:31/163/210185. [PMID: 35264409 PMCID: PMC8924706 DOI: 10.1183/16000617.0185-2021] [Citation(s) in RCA: 96] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 11/27/2021] [Indexed: 01/08/2023] Open
Abstract
Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for the coronavirus disease 2019 (COVID-19) pandemic that has resulted in millions of deaths and a major strain on health systems worldwide. Medical treatments for COVID-19 (anticoagulants, corticosteroids, anti-inflammatory drugs, oxygenation therapy and ventilation) and vaccination have improved patient outcomes. The majority of patients will recover spontaneously or after acute-phase management, but clinicians are now faced with long-term complications of COVID-19 including a large variety of symptoms, defined as "post-acute COVID-19 syndrome". Most studies have focused on patients hospitalised for severe COVID-19, but acute COVID-19 syndrome is not restricted to these patients and exists in outpatients. Given the diversity of symptoms and the high prevalence of persistent symptoms, the management of these patients requires a multidisciplinary team approach, which will result in the consumption of large amounts of health resources in the coming months. In this review, we discuss the presentation, prevalence, pathophysiology and evolution of respiratory complications and other organ-related injuries associated with post-acute COVID-19 syndrome.
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Affiliation(s)
- David Montani
- Université Paris-Saclay, AP-HP, Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital de Bicêtre, DMU 5 Thorinno, Inserm UMR_S999, Le Kremlin-Bicêtre, France
| | - Laurent Savale
- Université Paris-Saclay, AP-HP, Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital de Bicêtre, DMU 5 Thorinno, Inserm UMR_S999, Le Kremlin-Bicêtre, France
| | - Nicolas Noel
- Université Paris-Saclay, AP-HP, Service de Médecine Interne et Immunologie Clinique, Hôpital de Bicêtre, DMU 7 Endocrinologie-Immunités-Inflammations-Cancer-Urgences, Le Kremlin-Bicêtre, France
| | - Olivier Meyrignac
- Université Paris-Saclay, AP-HP, Service de Radiologie Diagnostique et Interventionnelle, Hôpital de Bicêtre, DMU 14 Smart Imaging, BioMaps, Le Kremlin-Bicêtre, France
| | - Romain Colle
- Université Paris-Saclay, AP-HP, Service de Psychiatrie, Hôpital de Bicêtre, DMU 11 Psychiatrie, Santé Mentale, Addictologie et Nutrition, Équipe MOODS, Inserm U1178, CESP (Centre de Recherche en Epidémiologie et Santé des Populations), Le Kremlin-Bicêtre, France
| | - Matthieu Gasnier
- Université Paris-Saclay, AP-HP, Service de Psychiatrie, Hôpital de Bicêtre, DMU 11 Psychiatrie, Santé Mentale, Addictologie et Nutrition, Équipe MOODS, Inserm U1178, CESP (Centre de Recherche en Epidémiologie et Santé des Populations), Le Kremlin-Bicêtre, France
| | - Emmanuelle Corruble
- Université Paris-Saclay, AP-HP, Service de Psychiatrie, Hôpital de Bicêtre, DMU 11 Psychiatrie, Santé Mentale, Addictologie et Nutrition, Équipe MOODS, Inserm U1178, CESP (Centre de Recherche en Epidémiologie et Santé des Populations), Le Kremlin-Bicêtre, France
| | - Antoine Beurnier
- Université Paris-Saclay, AP-HP, Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital de Bicêtre, DMU 5 Thorinno, Inserm UMR_S999, Le Kremlin-Bicêtre, France
| | - Etienne-Marie Jutant
- Université Paris-Saclay, AP-HP, Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital de Bicêtre, DMU 5 Thorinno, Inserm UMR_S999, Le Kremlin-Bicêtre, France.,Université de Poitiers, CHU de Poitiers, Service de Pneumologie, Inserm CIC 1402, Poitiers, France
| | - Tài Pham
- Université Paris-Saclay, AP-HP, Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, DMU 4 CORREVE Maladies du Dœur et des Vaisseaux, Inserm UMR_S999, FHU Sepsis, CARMAS, Le Kremlin-Bicêtre, France
| | - Anne-Lise Lecoq
- Université Paris-Saclay, AP-HP, Centre de Recherche Clinique Paris-Saclay, DMU 13 Santé Publique, Information Médicale, Appui à la Recherche Clinique, Le Kremlin-Bicêtre, France
| | - Jean-François Papon
- Université Paris-Saclay, AP-HP, Service d'ORL et de Chirurgie Cervico-faciale, DMU 9 Neurosciences, Inserm U955, E13, CNRS ERL7000, Le Kremlin-Bicêtre, France
| | - Samy Figueiredo
- Université Paris-Saclay, AP-HP, Service d'Anesthésie-Réanimation et Médecine Périopératoire, Hôpital de Bicêtre, DMU 12 Anesthésie, Réanimation, Douleur, Le Kremlin-Bicêtre, France
| | - Anatole Harrois
- Université Paris-Saclay, AP-HP, Service d'Anesthésie-Réanimation et Médecine Périopératoire, Hôpital de Bicêtre, DMU 12 Anesthésie, Réanimation, Douleur, Le Kremlin-Bicêtre, France
| | - Marc Humbert
- Université Paris-Saclay, AP-HP, Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital de Bicêtre, DMU 5 Thorinno, Inserm UMR_S999, Le Kremlin-Bicêtre, France
| | - Xavier Monnet
- Université Paris-Saclay, AP-HP, Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, DMU 4 CORREVE Maladies du Dœur et des Vaisseaux, Inserm UMR_S999, FHU Sepsis, CARMAS, Le Kremlin-Bicêtre, France
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15
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Gabet A, Grave C, Tuppin P, Olié V, Emmerich J. One Year Prevalence of Venous Thromboembolism in Hospitalized COVID-19 Patients in France: Patients' Characteristics, Time Trends, and Outcomes. Thromb Haemost 2022; 122:1532-1541. [PMID: 35288889 DOI: 10.1055/s-0042-1743475] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Patients hospitalized with coronavirus disease-2019 (COVID-19) are at high risk of deep venous thrombosis (DVT) and pulmonary embolism (PE). OBJECTIVES The aims were to provide time trends in the 2020 nation-wide prevalence of venous thromboembolism (VTE) in patients hospitalized with a COVID-19 diagnosis in France, and to describe in-hospital and up to 30-day postdischarge death. METHODS All patients hospitalized in France with a COVID-19 diagnosis in 2020 were selected. Crude and age-adjusted prevalence of VTE and PE was computed by 4-week intervals and for the overall study period using Poisson regression. Time trends in in-hospital and 30-day postdischarge case-fatality rates were evaluated by comparing each 4-week intervals to weeks 10 to 14 corresponding to the first part of the first lockdown using logistic regression models. RESULTS Among the 287,638 patients hospitalized with a COVID-19 diagnosis in 2020 in France, 14,985 (5.2%) had a concomitant VTE, with 10,453 (3.6%) having PE and 4,532 (1.6%) having DVT. In patients admitted to intensive care units, the crude prevalence of VTE and PE reached 16.1 and 11.0% respectively during the first lockdown. After adjustment, the prevalence of VTE and PE decreased during the year 2020 but a rebound was observed during the second lockdown. In-hospital case-fatality rates among hospitalized COVID-19 patients with PE globally decreased between the first and the second epidemic waves. CONCLUSION Our study showed a decrease in the incidence of symptomatic VTE and PE in hospitalized COVID-19 patients, and a decreased time trend of outcomes during the second wave compared with the first one.
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Affiliation(s)
- Amélie Gabet
- Cardiovascular Division, Department of Non-Communicable Diseases, Santé Publique France, Saint-Maurice (94), France
| | - Clémence Grave
- Cardiovascular Division, Department of Non-Communicable Diseases, Santé Publique France, Saint-Maurice (94), France
| | - Philippe Tuppin
- Department of Studies Strategy and Statistics, Caisse Nationale d'Assurance Maladie, Paris, France
| | - Valérie Olié
- Cardiovascular Division, Department of Non-Communicable Diseases, Santé Publique France, Saint-Maurice (94), France
| | - Joseph Emmerich
- Department of Vascular Medicine, Groupe Hospitalier Paris Saint-Joseph, Université de Paris, INSERM CRESS 1153, Paris, France
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16
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Perico L, Morigi M, Galbusera M, Pezzotta A, Gastoldi S, Imberti B, Perna A, Ruggenenti P, Donadelli R, Benigni A, Remuzzi G. SARS-CoV-2 Spike Protein 1 Activates Microvascular Endothelial Cells and Complement System Leading to Platelet Aggregation. Front Immunol 2022; 13:827146. [PMID: 35320941 PMCID: PMC8936079 DOI: 10.3389/fimmu.2022.827146] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 02/08/2022] [Indexed: 12/12/2022] Open
Abstract
Microvascular thrombosis is associated with multiorgan failure and mortality in coronavirus disease 2019 (COVID-19). Although thrombotic complications may be ascribed to the ability of SARS-CoV-2 to infect and replicate in endothelial cells, it has been poorly investigated whether, in the complexity of viral infection in the human host, specific viral elements alone can induce endothelial damage. Detection of circulating spike protein in the sera of severe COVID-19 patients was evaluated by ELISA. In vitro experiments were performed on human microvascular endothelial cells from the derma and lung exposed to SARS-CoV-2-derived spike protein 1 (S1). The expression of adhesive molecules was studied by immunofluorescence and leukocyte adhesion and platelet aggregation were assessed under flow conditions. Angiotensin converting enzyme 2 (ACE2) and AMPK expression were investigated by Western Blot analysis. In addition, S1-treated endothelial cells were incubated with anti-ACE2 blocking antibody, AMPK agonist, or complement inhibitors. Our results show that significant levels of spike protein were found in the 30.4% of severe COVID-19 patients. In vitro, the activation of endothelial cells with S1 protein, via ACE2, impaired AMPK signalling, leading to robust leukocyte recruitment due to increased adhesive molecule expression and thrombomodulin loss. This S1-induced pro-inflammatory phenotype led to exuberant C3 and C5b-9 deposition on endothelial cells, along with C3a and C5a generation that further amplified S1-induced complement activation. Functional blockade of ACE2 or complement inhibition halted S1-induced platelet aggregates by limiting von Willebrand factor and P-selectin exocytosis and expression on endothelial cells. Overall, we demonstrate that SARS-CoV-2-derived S1 is sufficient in itself to propagate inflammatory and thrombogenic processes in the microvasculature, amplified by the complement system, recapitulating the thromboembolic complications of COVID-19.
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Affiliation(s)
- Luca Perico
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Marina Morigi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Miriam Galbusera
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Anna Pezzotta
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Sara Gastoldi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Barbara Imberti
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Annalisa Perna
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Piero Ruggenenti
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
- Unit of Nephrology and Dialysis, Azienda Socio Sanitaria Territoriale (ASST) Papa Giovanni XXIII, Bergamo, Italy
| | - Roberta Donadelli
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Ariela Benigni
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
- *Correspondence: Ariela Benigni,
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
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17
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Ward A, Sarraju A, Lee D, Bhasin K, Gad S, Beetel R, Chang S, Bonafede M, Rodriguez F, Dash R. COVID-19 is associated with higher risk of venous thrombosis, but not arterial thrombosis, compared with influenza: Insights from a large US cohort. PLoS One 2022; 17:e0261786. [PMID: 35020742 PMCID: PMC8754296 DOI: 10.1371/journal.pone.0261786] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 12/09/2021] [Indexed: 12/23/2022] Open
Abstract
Introduction Infection with SARS-CoV-2 is typically compared with influenza to contextualize its health risks. SARS-CoV-2 has been linked with coagulation disturbances including arterial thrombosis, leading to considerable interest in antithrombotic therapy for Coronavirus Disease 2019 (COVID-19). However, the independent thromboembolic risk of SARS-CoV-2 infection compared with influenza remains incompletely understood. We evaluated the adjusted risks of thromboembolic events after a diagnosis of COVID-19 compared with influenza in a large retrospective cohort. Methods We used a US-based electronic health record (EHR) dataset linked with insurance claims to identify adults diagnosed with COVID-19 between April 1, 2020 and October 31, 2020. We identified influenza patients diagnosed between October 1, 2018 and April 31, 2019. Primary outcomes [venous composite of pulmonary embolism (PE) and acute deep vein thrombosis (DVT); arterial composite of ischemic stroke and myocardial infarction (MI)] and secondary outcomes were assessed 90 days post-diagnosis. Propensity scores (PS) were calculated using demographic, clinical, and medication variables. PS-adjusted hazard ratios (HRs) were calculated using Cox proportional hazards regression. Results There were 417,975 COVID-19 patients (median age 57y, 61% women), and 345,934 influenza patients (median age 47y, 66% women). Compared with influenza, patients with COVID-19 had higher venous thromboembolic risk (HR 1.53, 95% CI 1.38–1.70), but not arterial thromboembolic risk (HR 1.02, 95% CI 0.95–1.10). Secondary analyses demonstrated similar risk for ischemic stroke (HR 1.11, 95% CI 0.98–1.25) and MI (HR 0.93, 95% CI 0.85–1.03) and higher risk for DVT (HR 1.36, 95% CI 1.19–1.56) and PE (HR 1.82, 95% CI 1.57–2.10) in patients with COVID-19. Conclusion In a large retrospective US cohort, COVID-19 was independently associated with higher 90-day risk for venous thrombosis, but not arterial thrombosis, as compared with influenza. These findings may inform crucial knowledge gaps regarding the specific thromboembolic risks of COVID-19.
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Affiliation(s)
- Andrew Ward
- HealthPals Inc., Redwood City, California, United States of America
| | - Ashish Sarraju
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University, Stanford, California, United States of America
- * E-mail:
| | - Donghyun Lee
- HealthPals Inc., Redwood City, California, United States of America
| | - Kanchan Bhasin
- HealthPals Inc., Redwood City, California, United States of America
| | - Sanchit Gad
- HealthPals Inc., Redwood City, California, United States of America
| | - Rob Beetel
- HealthPals Inc., Redwood City, California, United States of America
| | - Stella Chang
- Veradigm, Chicago, Illinois, United States of America
| | - Mac Bonafede
- Veradigm, Chicago, Illinois, United States of America
| | - Fatima Rodriguez
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University, Stanford, California, United States of America
| | - Rajesh Dash
- HealthPals Inc., Redwood City, California, United States of America
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University, Stanford, California, United States of America
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18
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Revel MP, Beeker N, Porcher R, Jilet L, Fournier L, Rance B, Chassagnon G, Fontenay M, Sanchez O. What level of D-dimers can safely exclude pulmonary embolism in COVID-19 patients presenting to the emergency department? Eur Radiol 2022; 32:2704-2712. [PMID: 34994845 PMCID: PMC8739682 DOI: 10.1007/s00330-021-08377-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/14/2021] [Accepted: 09/30/2021] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To identify which level of D-dimer would allow the safe exclusion of pulmonary embolism (PE) in COVID-19 patients presenting to the emergency department (ED). METHODS This retrospective study was conducted on the COVID database of Assistance Publique - Hôpitaux de Paris (AP-HP). COVID-19 patients who presented at the ED of AP-HP hospitals between March 1 and May 15, 2020, and had CTPA following D-dimer dosage within 48h of presentation were included. The D-dimer sensitivity, specificity, and positive and negative predictive values were calculated for different D-dimer thresholds, as well as the false-negative and failure rates, and the number of CTPAs potentially avoided. RESULTS A total of 781 patients (mean age 62.0 years, 53.8% men) with positive RT-PCR for SARS-Cov-2 were included and 60 of them (7.7%) had CTPA-confirmed PE. Their median D-dimer level was significantly higher than that of patients without PE (4,013 vs 1,198 ng·mL-1, p < 0.001). Using 500 ng·mL-1, or an age-adjusted cut-off for patients > 50 years, the sensitivity and the NPV were above 90%. With these thresholds, 17.1% and 31.5% of CTPAs could have been avoided, respectively. Four of the 178 patients who had a D-dimer below the age-adjusted cutoff had PE, leading to an acceptable failure rate of 2.2%. Using higher D-dimer cut-offs could have avoided more CTPAs, but would have lowered the sensitivity and increased the failure rate. CONCLUSION The same D-Dimer thresholds as those validated in non-COVID outpatients should be used to safely rule out PE. KEY POINTS • The median D-dimer level was significantly higher in COVID-19 patients with PE as compared to those without PE (4,013 ng·mL-1 vs 1,198 ng·mL-1 respectively, p < 0.001). • Using 500 ng·mL-1, or an age-adjusted D-dimer cut-off to exclude pulmonary embolism, the sensitivity and negative predictive value were above 90%. • Higher cut-offs would lead to a reduction in the sensitivity below 85% and an increase in the failure rate, especially for patients under 50 years.
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Affiliation(s)
- Marie-Pierre Revel
- Université de Paris, 75006, Paris, France. .,Radiology Department, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Cochin, Service de Radiologie27 rue du Faubourg Saint Jacques, 75014, Paris, France.
| | - Nathanael Beeker
- Université de Paris, 75006, Paris, France.,Assistance Publique-Hôpitaux de Paris (AP-HP), Unité de Recherche Clinique, Hôpital Cochin, Paris, France
| | - Raphael Porcher
- Université de Paris, 75006, Paris, France.,Assistance Publique-Hôpitaux de Paris (AP-HP), Centre d'épidémiologie clinique, Hôtel-Dieu, Paris, France
| | - Léa Jilet
- Assistance Publique-Hôpitaux de Paris (AP-HP), Unité de Recherche Clinique, Hôpital Cochin, Paris, France
| | - Laure Fournier
- Université de Paris, 75006, Paris, France.,Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Radiologie, Hôpital Européen, Georges Pompidou, Paris, France
| | - Bastien Rance
- Université de Paris, 75006, Paris, France.,Assistance Publique-Hôpitaux de Paris (AP-HP), Département d'Informatique Médicale, Biostatistiques Et Santé Publique, Hôpital Européen Georges Pompidou, Paris, France
| | - Guillaume Chassagnon
- Université de Paris, 75006, Paris, France.,Radiology Department, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Cochin, Service de Radiologie27 rue du Faubourg Saint Jacques, 75014, Paris, France
| | - Michaela Fontenay
- Université de Paris, 75006, Paris, France.,Assistance Publique-Hôpitaux de Paris (AP-HP), Service de d'hématologie biologique, Hôpital Cochin, Paris, France.,Institut Cochin INSERM U1016, CNRS UMR8104, Paris, France
| | - Olivier Sanchez
- Université de Paris, 75006, Paris, France.,Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Pneumologie Et Soins Intensifs, Hôpital Européen, Georges Pompidou, INSERM UMRS-1140 Innovative Therapies in Hemostasis and Biosurgical Research Lab (Carpentier Foundation), Paris, France.,F-CRIN INNOVTE, Saint-Etienne, France
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19
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Tankere P, Cottenet J, Tubert-Bitter P, Mariet AS, Beltramo G, Cadranel J, Piroth L, Bonniaud P, Quantin C. Impact of COVID-19 and lockdowns on pulmonary embolism in hospitalized patients in France: a nationwide study. Respir Res 2021; 22:298. [PMID: 34801044 PMCID: PMC8605779 DOI: 10.1186/s12931-021-01887-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 11/03/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study assessed the impact of the COVID-19 epidemic on overall hospitalizations for pulmonary embolism (PE) in France in comparison with previous years, and by COVID-19 and non-COVID-19 status. METHODS Hospitalization data (2017-2020) were extracted from the French National Discharge database (all public and private hospitals). We included all patients older than 18 years hospitalized during the 3 years and extracted PE status and COVID-19 status (from March 2020). Age, sex and risk factors for PE (such as obesity, cancer) were identified. We also extracted transfer to an intensive care unit (ICU) and hospital death. The number of PE and the frequency of death in patients in 2019 and 2020 were described by month and by COVID-19 status. Logistic regressions were performed to identify the role of COVID-19 among other risk factors for PE in hospitalized patients. RESULTS The overall number of patients hospitalized with PE increased by about 16% in 2020 compared with 2019, and mortality also increased to 10.3% (+ 1.2%). These increases were mostly linked to COVID-19 waves, which were associated with PE hospitalization in COVID-19 patients (PE frequency was 3.7%; 2.8% in non-ICU and 8.8% in ICU). The final PE odds ratio for COVID-19 hospitalized patients was 4 compared with other hospitalized patients in 2020. The analyses of PE in non-COVID-19 patients showed a 2.7% increase in 2020 compared with the previous three years. CONCLUSION In 2020, the overall number of patients hospitalized with PE in France increased compared to the previous three years despite a considerable decrease in scheduled hospitalizations. Nevertheless, proactive public policy focused on the prevention of PE in all patients should be encouraged.
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Affiliation(s)
- Pierre Tankere
- Reference Center for Rare Pulmonary Diseases, Pulmonary Medicine and Intensive Care Unit Department, Dijon University Hospital, BP 77908, 21079, Dijon, France
| | - Jonathan Cottenet
- CHU de Dijon - Service de Biostatistique et d'Informatique Médicale, BP 77908, 21079, Dijon CEDEX, France
- University of Burgundy and Franche-Comté, Dijon, France
| | - Pascale Tubert-Bitter
- Université Paris-Saclay, UVSQ, Univ. Paris-Sud, Inserm, High-Dimensional Biostatistics for Drug Safety and Genomics, CESP, Villejuif, France
| | - Anne-Sophie Mariet
- CHU de Dijon - Service de Biostatistique et d'Informatique Médicale, BP 77908, 21079, Dijon CEDEX, France
- University of Burgundy and Franche-Comté, Dijon, France
- Clinical Investigation Center, Clinical Epidemiology/Clinical Trials Unit, Inserm, CIC 1432, Dijon, France ; Dijon University Hospital, Dijon, France
| | - Guillaume Beltramo
- Reference Center for Rare Pulmonary Diseases, Pulmonary Medicine and Intensive Care Unit Department, Dijon University Hospital, BP 77908, 21079, Dijon, France
| | - Jacques Cadranel
- Chest Department and Constitutive Center for Rare Pulmonary Disease, Hôpital Tenon, AP-HP, Inflammation-Immunopathology-Biotherapy Department (DHU i2B) and Sorbonne Université, 75020, Paris, France
| | - Lionel Piroth
- Clinical Investigation Center, Clinical Epidemiology/Clinical Trials Unit, Inserm, CIC 1432, Dijon, France ; Dijon University Hospital, Dijon, France
- Faculty of Medicine, University of Burgundy and Franche-Comté, Dijon, France
- Infectious Diseases Department, Dijon University Hospital, BP 77908, 21079, Dijon, France
| | - Philippe Bonniaud
- Reference Center for Rare Pulmonary Diseases, Pulmonary Medicine and Intensive Care Unit Department, Dijon University Hospital, BP 77908, 21079, Dijon, France
- Faculty of Medicine, University of Burgundy and Franche-Comté, Dijon, France
- INSERM, LNC UMR1231, LipSTIC LabEx Team, Dijon, France
| | - Catherine Quantin
- CHU de Dijon - Service de Biostatistique et d'Informatique Médicale, BP 77908, 21079, Dijon CEDEX, France.
- University of Burgundy and Franche-Comté, Dijon, France.
- Université Paris-Saclay, UVSQ, Univ. Paris-Sud, Inserm, High-Dimensional Biostatistics for Drug Safety and Genomics, CESP, Villejuif, France.
- Clinical Investigation Center, Clinical Epidemiology/Clinical Trials Unit, Inserm, CIC 1432, Dijon, France ; Dijon University Hospital, Dijon, France.
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20
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Kumar S, Kumar A, Sinha R, Mahto M. Endovascular thrombectomy for critical lower limb ischaemia in a patient with COVID-19. BMJ Case Rep 2021; 14:14/11/e244941. [PMID: 34785513 PMCID: PMC8596029 DOI: 10.1136/bcr-2021-244941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Hypercoagulable and proinflammatory states induced by the novel coronavirus (SARS-CoV-2) lead to thrombotic and embolic events. In this case report, the authors describe how they successfully managed acute critical limb ischaemia in a patient of COVID-19 illness with severe pulmonary disease and high thrombus burden in the infrapopliteal arteries.
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Affiliation(s)
- Subhash Kumar
- Department of Radiodiagnosis, All India Institute of Medical Sciences Patna, Patna, Bihar, India
| | - Anup Kumar
- Department of Orthopaedics, All India Institute of Medical Sciences Patna, Patna, Bihar, India
| | - Ruchi Sinha
- Department of Pathology & Lab Medicine, All India Institute of Medical Sciences Patna, Patna, Bihar, India
| | - Mala Mahto
- Department of Biochemistry, All India Institute of Medical Sciences Patna, Patna, Bihar, India
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21
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Ward A, Sarraju A, Lee D, Bhasin K, Gad S, Beetel R, Chang S, Bonafede M, Rodriguez F, Dash R. COVID-19 is associated with higher risk of venous thrombosis, but not arterial thrombosis, compared with influenza: Insights from a large US cohort. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2021. [PMID: 34704094 PMCID: PMC8547526 DOI: 10.1101/2021.10.15.21264137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Introduction Infection with SARS-CoV-2 is typically compared with influenza to contextualize its health risks. SARS-CoV-2 has been linked with coagulation disturbances including arterial thrombosis, leading to considerable interest in antithrombotic therapy for Coronavirus Disease 2019 (COVID-19). However, the independent thromboembolic risk of SARS-CoV-2 infection compared with influenza remains incompletely understood. We evaluated the adjusted risks of thromboembolic events after a diagnosis of COVID-19 compared with influenza in a large retrospective cohort. Methods We used a US-based electronic health record (EHR) dataset linked with insurance claims to identify adults diagnosed with COVID-19 between April 1, 2020 and October 31, 2020. We identified influenza patients diagnosed between October 1, 2018 and April 31, 2019. Primary outcomes [venous composite of pulmonary embolism (PE) and acute deep vein thrombosis (DVT); arterial composite of ischemic stroke and myocardial infarction (MI)] and secondary outcomes were assessed 90 days post-diagnosis. Propensity scores (PS) were calculated using demographic, clinical, and medication variables. PS-adjusted hazard ratios (HRs) were calculated using Cox proportional hazards regression. Results There were 417,975 COVID-19 patients (median age 57y, 61% women), and 345,934 influenza patients (median age 47y, 66% women). Compared with influenza, patients with COVID-19 had higher venous thromboembolic risk (HR 1.53, 95% CI 1.38–1.70), but not arterial thromboembolic risk (HR 1.02, 95% CI 0.95–1.10). Secondary analyses demonstrated similar risk for ischemic stroke (HR 1.11, 95% CI 0.98–1.25) and MI (HR 0.93, 95% CI 0.85–1.03) and higher risk for DVT (HR 1.36, 95% CI 1.19–1.56) and PE (HR 1.82, 95% CI 1.57–2.10) in patients with COVID-19. Conclusion In a large retrospective US cohort, COVID-19 was independently associated with higher 90-day risk for venous thrombosis, but not arterial thrombosis, as compared with influenza. These findings may inform crucial knowledge gaps regarding the specific thromboembolic risks of COVID-19.
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22
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Haimei MA. Concern About the Adverse Effects of Thrombocytopenia and Thrombosis After Adenovirus-Vectored COVID-19 Vaccination. Clin Appl Thromb Hemost 2021; 27:10760296211040110. [PMID: 34541935 PMCID: PMC8642058 DOI: 10.1177/10760296211040110] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Since the outbreak of Covid-19 in December, 2019, scientists worldwide have been
committed to developing COVID-19 vaccines. Only when most people have immunity
to SARS-CoV-2, COVID-19 can reduce even wholly overcome. So far, nine kinds of
COVID-19 vaccines have passed the phase III clinical trials and have approved
for use. At the same time, adverse reactions after COVID-19 vaccination have
also reported. This paper focuses on the adverse effects of thrombosis and
thrombocytopenia caused by the COVID-19 vaccine, especially the
adenovirus-vector vaccine from AstraZeneca and Pfizer, and discusses its
mechanism and possible countermeasures.
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Affiliation(s)
- M A Haimei
- Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
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23
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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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Porfidia A, Mosoni C, Talerico R, Porceddu E, Lupascu A, Tondi P, Landi F, Pola R. Pulmonary Embolism in COVID-19 Patients: Which Diagnostic Algorithm Should We Use? Front Cardiovasc Med 2021; 8:714003. [PMID: 34485411 PMCID: PMC8414135 DOI: 10.3389/fcvm.2021.714003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 07/23/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Although pulmonary embolism (PE) is a frequent complication of the clinical course of COVID-19, there is a lack of explicit indications regarding the best algorithm for diagnosing PE in these patients. In particular, it is not clear how to identify subjects who should undergo computed tomography pulmonary angiography (CTPA), rather than simply X-ray and/or high resolution computed tomography (HRCT) of the chest. Methods: We retrospectively analyzed COVID-19 patients who presented to the Emergency Department (ED) of our University hospital with acute respiratory failure, or that developed acute respiratory failure during hospital stay, to determine how many of them had a theoretical indication to undergo CTPA for suspected PE according to current guidelines. Next, we looked for differences between patients who underwent CTPA and those who only underwent X-ray and/or HRCT of the chest. Finally, we determined whether patients with a confirmed diagnosis of PE had specific characteristics that made them different from those with a CTPA negative for PE. Results: Out of 93 subjects with COVID-19 and acute respiratory failure, 73 (78.4%) had an indication to undergo CTPA according to the revised Geneva and Wells scores and the PERC rule-out criteria, and 54 (58%) according to the YEARS algorithm. However, in contrast with these indications, only 28 patients (30.1%) underwent CTPA. Of note, they were not clinically different from those who underwent X-ray and/or HRCT of the chest. Among the 28 subjects who underwent CTPA, there were 10 cases of PE (35.7%). They were not clinically different from those with CTPA negative for PE. Conclusions: COVID-19 patients with acute respiratory failure undergo CTPA, X-ray of the chest, or HRCT without an established criterion. Nonetheless, when CTPA is performed, the diagnosis of PE is anything but rare. Validated tools for identifying COVID-19 patients who require CTPA for suspected PE are urgently needed.
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Affiliation(s)
- Angelo Porfidia
- Department of Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Carolina Mosoni
- Department of Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Rosa Talerico
- Department of Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Enrica Porceddu
- Department of Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andrea Lupascu
- Department of Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Paolo Tondi
- Department of Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.,Division of Angiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Landi
- Department of Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Roberto Pola
- Department of Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.,Section of Internal Medicine and Thromboembolic Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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25
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Konstantinides SV. Thrombotic complications of vaccination against SARS-CoV-2: what pharmacovigilance reports tell us - and what they don't. Eur Respir J 2021; 58:13993003.01111-2021. [PMID: 33888525 PMCID: PMC8061197 DOI: 10.1183/13993003.01111-2021] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 04/19/2021] [Indexed: 01/18/2023]
Abstract
In the present issue of the European Respiratory Journal, Smadjaet al. [1] present an analysis of global pharmacovigilance reports of thrombotic events following severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV-2) vaccination. More specifically, the authors analysed the data entered into the World Health Organization (WHO) Global Database for Individual Case Safety Reports (VigiBase) between 13 December, 2020 and 16 March, 2021, covering, at that time, a population of almost 362 million vaccinated individuals across the world. The study focuses on three of the coronavirus disease 2019 (COVID-19) vaccines available to date, namely Pfizer-BioNtech (BNT162b2), Moderna (mRNA-1273) and OxfordAstraZeneca (ChAdOx1 nCov-19). The study by Smadjaet al. [1] confirms the rarity of possible thrombotic complications in association with COVID-19 vaccination, reporting only 0.21 (95% CI 0.19–0.22) cases of thrombotic events per million person vaccinated-days. However, there were also some unexpected observations which deserve closer attention and cautious interpretation. Thrombotic complications of COVID-19 vaccination are very rare, but awareness is needed https://bit.ly/3n4vaXe
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Affiliation(s)
- Stavros V Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany .,Dept of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
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26
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Akay T, Kaymaz C, Rüçhan Akar A, Orhan G, Yanartaş M, Gültekin B, Şırlak M, Kervan Ü, Gezer Taş S, Biçer M, Yağdı T, İspir S, Doğan R. Raising the bar to ultradisciplinary collaborations in management of chronic thromboembolic pulmonary hypertension. TURK GOGUS KALP DAMAR CERRAHISI DERGISI 2021; 29:417-431. [PMID: 34589266 PMCID: PMC8462103 DOI: 10.5606/tgkdc.dergisi.2021.21284] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 05/05/2021] [Indexed: 02/05/2023]
Abstract
Chronic thromboembolic pulmonary hypertension is an underdiagnosed and potentially fatal subgroup of pulmonary hypertension, if left untreated. Clinical signs include exertional dyspnea and non-specific symptoms. Diagnosis requires multimodality imaging and heart catheterization. Pulmonary endarterectomy, an open heart surgery, is the gold standard treatment of choice in selected patients in specialized centers. Targeted medical therapy and balloon pulmonary angioplasty can be effective in high-risk patients with significant comorbidities, distal pulmonary vascular obstructions, or recurrent/persistent pulmonary hypertension after pulmonary endarterectomy. Currently, there is a limited number of data regarding novel coronavirus-2019 infection in patients with chronic thromboembolic pulmonary hypertension and the changing spectrum of the disease during the pandemic. Challenging times during this outbreak due to healthcare crisis and relatively higher case-fatality rates require convergence; that is an ultradisciplinary collaboration, which crosses disciplinary and sectorial boundaries to develop integrated knowledge and new paradigms. Management strategies for the "new normal" such as virtual care, preparedness for further threats, redesigned standards and working conditions, reevaluation of specific recommendations, and online collaborations for optimal decisions for chronic thromboembolic pulmonary hypertension patients may change the poor outcomes.
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Affiliation(s)
- Tankut Akay
- Department of Cardiovascular Surgery, Başkent University Faculty of Medicine Ankara Hospital, Ankara, Turkey
| | - Cihangir Kaymaz
- Department of Cardiology, University of Health Sciences, Hamidiye Medical Faculty, Koşuyolu Heart Center, Istanbul, Turkey
| | - Ahmet Rüçhan Akar
- Department of Cardiovascular Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Gökçen Orhan
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Mehmed Yanartaş
- Department of Cardiovascular Surgery, Çam ve Sakura Hospital, Istanbul, Turkey
| | - Bahadır Gültekin
- Department of Cardiovascular Surgery, Başkent University Faculty of Medicine Ankara Hospital, Ankara, Turkey
| | - Mustafa Şırlak
- Department of Cardiovascular Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Ümit Kervan
- Department of Cardiovascular Surgery, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Serpil Gezer Taş
- Department of Cardiovascular Surgery, University of Health Sciences Hamidiye Medical Faculty, Koşuyolu Heart Center, İstanbul, Turkey
| | - Murat Biçer
- Department of Cardiovascular Surgery, Uludağ University Faculty of Medicine, Bursa, Turkey
| | - Tahir Yağdı
- Department of Cardiovascular Surgery, Ege University Faculty of Medicine, Izmir, Turkey
| | - Selim İspir
- Department of Cardiovascular Surgery, Acıbadem University Faculty of Medicine, Istanbul, Turkey
| | - Rıza Doğan
- Department of Cardiovascular Surgery, Hacettepe University Faculty of Medicine, Ankara, Turkey
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27
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Smadja DM, Yue QY, Chocron R, Sanchez O, Lillo-Le Louet A. Vaccination against COVID-19: insight from arterial and venous thrombosis occurrence using data from VigiBase. Eur Respir J 2021; 58:13993003.00956-2021. [PMID: 33863748 PMCID: PMC8051185 DOI: 10.1183/13993003.00956-2021] [Citation(s) in RCA: 96] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 04/13/2021] [Indexed: 12/16/2022]
Abstract
Coronavirus disease 2019 (COVID-19) is associated with a prothrombotic phenotype characterised by coagulopathy and endothelial dysfunction [1–4]. Following some cases of thrombosis after vaccination, the Oxford–AstraZeneca COVID-19 vaccine (AZD1222) was temporarily suspended by some European countries. The European Medicines Agency concluded that the benefits of the vaccine in combating the COVID-19 outbreak continue to outweigh the risk of side-effects. On 19 March, 2021, Germany reported 13 cases of sinus or cerebral vein thrombosis, with more than 1.6 million AstraZeneca COVID-19 vaccine doses administered. Some of these patients also had a heparin-induced thrombocytopenia (HIT)-like syndrome, which suggests an immunological event as one of the potential origins of thrombosis. This study observed an imbalance between venous and arterial thrombotic events in mRNA vaccines while with AZ1222 they are evenly shared. Our analysis highlights cerebral vein thrombosis with the three vaccines.https://bit.ly/3mZqguE
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Affiliation(s)
- David M Smadja
- Université de Paris, Innovative Therapies in Hemostasis, INSERM, Paris, France .,Hematology Dept and Biosurgical Research Lab (Carpentier Foundation), Assistance Publique Hôpitaux de Paris-Centre (APHP-CUP), Paris, France.,F-CRIN INNOVTE Network, Saint Etienne, France
| | | | - Richard Chocron
- Emergency Dept, Université de Paris, PARCC, INSERM U970, AP-HP-Centre Université de Paris (APHP-CUP), Paris, France
| | - Olivier Sanchez
- Université de Paris, Innovative Therapies in Hemostasis, INSERM, Paris, France.,F-CRIN INNOVTE Network, Saint Etienne, France.,Respiratory Medicine Dept and Biosurgical Research Lab (Carpentier Foundation), Assistance Publique Hôpitaux de Paris-Centre (APHP-CUP), Paris, France
| | - Agnes Lillo-Le Louet
- Université de Paris, Innovative Therapies in Hemostasis, INSERM, Paris, France.,Pharmacovigilance Dept, Assistance Publique Hôpitaux de Paris-Centre (APHP-CUP), Paris, France
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Jalde FC, Beckman MO, Svensson AM, Bell M, Sköld M, Strand F, Nyren S, Kistner A. Widespread Parenchymal Abnormalities and Pulmonary Embolism on Contrast-Enhanced CT Predict Disease Severity and Mortality in Hospitalized COVID-19 Patients. Front Med (Lausanne) 2021; 8:666723. [PMID: 34268322 PMCID: PMC8275973 DOI: 10.3389/fmed.2021.666723] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/27/2021] [Indexed: 12/11/2022] Open
Abstract
Purpose: Severe COVID-19 is associated with inflammation, thromboembolic disease, and high mortality. We studied factors associated with fatal outcomes in consecutive COVID-19 patients examined by computed tomography pulmonary angiogram (CTPA). Methods: This retrospective, single-center cohort analysis included 130 PCR-positive patients hospitalized for COVID-19 [35 women and 95 men, median age 57 years (interquartile range 51–64)] with suspected pulmonary embolism based on clinical suspicion. The presence and extent of embolism and parenchymal abnormalities on CTPA were recorded. The severity of pulmonary parenchymal involvement was stratified by two experienced radiologists into two groups: lesions affecting ≤50% or >50% of the parenchyma. Patient characteristics, radiological aspects, laboratory parameters, and 60-day mortality data were collected. Results: Pulmonary embolism was present in 26% of the patients. Most emboli were small and peripheral. Patients with widespread parenchymal abnormalities, with or without pulmonary embolism, had increased main pulmonary artery diameter (p < 0.05) and higher C-reactive protein (p < 0.01), D-dimer (p < 0.01), and troponin T (p < 0.001) and lower hemoglobin (p < 0.001). A wider main pulmonary artery diameter correlated positively with C-reactive protein (r = 0.28, p = 0.001, and n = 130) and procalcitonin. In a multivariant analysis, D-dimer >7.2 mg/L [odds ratio (±95% confidence interval) 4.1 (1.4–12.0)] and ICU stay were significantly associated with embolism (p < 0.001). The highest 60-day mortality was found in patients with widespread parenchymal abnormalities combined with pulmonary embolism (36%), followed by patients with widespread parenchymal abnormalities without pulmonary embolism (26%). In multivariate analysis, high troponin T, D-dimer, and plasma creatinine and widespread parenchymal abnormalities on CT were associated with 60-day mortality. Conclusions: Pulmonary embolism combined with widespread parenchymal abnormalities contributed to mortality risk in COVID-19. Elevated C-reactive protein, D-dimer, troponin-T, P-creatinine, and enlarged pulmonary artery were associated with a worse outcome and may mirror a more severe systemic disease. A liberal approach to radiological investigation should be recommended at clinical deterioration, when the situation allows it. Computed tomography imaging, even without intravenous contrast to assess the severity of pulmonary infiltrates, are of value to predict outcome in COVID-19. Better radiological techniques with higher resolution could potentially improve the detection of microthromboses. This could influence anticoagulant treatment strategies, preventing clinical detoriation.
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Affiliation(s)
- Francesca Campoccia Jalde
- Department of Anesthesiology, Surgical Services and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Mats O Beckman
- Department of Radiology, Solna, Karolinska University Hospital, Stockholm, Sweden
| | - Ann Mari Svensson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Radiology, Solna, Karolinska University Hospital, Stockholm, Sweden
| | - Max Bell
- Department of Anesthesiology, Surgical Services and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Sköld
- Respiratory Medicine Unit, Department of Medicine Solna and Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Respiratory Medicine and Allergy, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Fredrik Strand
- Department of Radiology, Solna, Karolinska University Hospital, Stockholm, Sweden.,Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Sven Nyren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Radiology, Solna, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Kistner
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
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Jevnikar M, Sanchez O, Humbert M, Parent F. Prevalence of pulmonary embolism in patients with COVID-19 at the time of hospital admission and role for pre-test probability scores and home treatment. Eur Respir J 2021; 58:13993003.01033-2021. [PMID: 33986033 PMCID: PMC8120138 DOI: 10.1183/13993003.01033-2021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 04/28/2021] [Indexed: 11/05/2022]
Abstract
We thank A. Porfidia and co-workers for their interest in our study describing the prevalence of pulmonary embolism (PE) in patients with coronavirus disease 2019 (COVID-19) at the time of hospital admission [1]. We fully agree on the need to consider a PE diagnostic algorithm in COVID-19 at the time of hospital admission, because indiscriminate execution of computed tomography pulmonary angiography (CTPA) cannot be a workable, routine approach in such patients. There is a high prevalence of pulmonary embolism in patients with COVID-19 at the time of hospital admission despite a low level of clinical suspicionhttps://bit.ly/3ungLrQ
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Affiliation(s)
- Mitja Jevnikar
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Le Kremlin-Bicêtre, France.,AP-HP, Service de Pneumologie et soins intensifs respiratoires, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Olivier Sanchez
- AP-HP, Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou, Paris, France.,INSERM UMR-S 1140, Paris, France.,INNOVTE, St-Etienne, France.,Université Paris Descartes, Faculty of Medicine, Paris, France
| | - Marc Humbert
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Le Kremlin-Bicêtre, France.,AP-HP, Service de Pneumologie et soins intensifs respiratoires, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Florence Parent
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Le Kremlin-Bicêtre, France.,AP-HP, Service de Pneumologie et soins intensifs respiratoires, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
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30
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Second wave of the COVID-19 pandemic: D-dimer levels are not so high anymore. J Thromb Thrombolysis 2021; 52:779-781. [PMID: 33886038 PMCID: PMC8060786 DOI: 10.1007/s11239-021-02454-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2021] [Indexed: 11/03/2022]
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31
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Porfidia A, Pola E, Pola R. Prevalence of pulmonary embolism on hospital admission in COVID-19 patients: is there a role for pre-test probability scores and home treatment? Eur Respir J 2021; 58:13993003.00785-2021. [PMID: 33833035 PMCID: PMC8034056 DOI: 10.1183/13993003.00785-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 03/26/2021] [Indexed: 11/05/2022]
Abstract
We read with interest the research letter recently authored by Jevnikaret al. [1] about the prevalence of pulmonary embolism (PE) in patients with coronavirus disease 2019 (COVID-19) at the time of hospital admission. In this prospective multicentre study, all consecutive adult outpatients that were hospitalised with a diagnosis of COVID-19 in three tertiary French hospitals between 15 April and 23 May 2020 underwent computed tomography pulmonary angiography (CTPA). Only patients with contraindications to the examination (mainly due to contraindication for iodinated contrast administration) were excluded. The strength of this study is that it finally provides precise information regarding the actual prevalence of PE in hospitalised COVID-19 patients. Over the past year, we have been bombarded almost daily with a seemingly infinite amount of data on the increased rate of venous thromboembolism (VTE) in COVID-19 patients, but all the studies available so far had the insurmountable flaw that CTPA was performed only in a minority of cases and mainly in patients with clinical suspicion of PE [2]. Another flaw of such previous studies was that CTPA was performed at various time-points during hospitalisation and, therefore, it was not possible to establish whether PE was an actual complication of COVID-19 or a consequence of the hospitalisation itself. In this scenario, the report of Jevnikaret al. [1] finally allows us to claim with substantiation that the prevalence of PE is high even at time of hospital admission in patients with COVID-19. Further confirmation that COVID-19 patients are at high risk of venous thromboembolismhttps://bit.ly/2OfPR5A
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Affiliation(s)
- Angelo Porfidia
- Dept of Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Enrico Pola
- Primo Policlinico di Napoli, Ortopedia e Traumatologia, Università della Campania "Luigi Vanvitelli", Naples, Italy
| | - Roberto Pola
- Dept of Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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32
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Kwee RM, Adams HJA, Kwee TC. Pulmonary embolism in patients with COVID-19 and value of D-dimer assessment: a meta-analysis. Eur Radiol 2021; 31:8168-8186. [PMID: 33966132 PMCID: PMC8106765 DOI: 10.1007/s00330-021-08003-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/24/2021] [Accepted: 04/19/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE To investigate, in a meta-analysis, the frequency of pulmonary embolism (PE) in patients with COVID-19 and whether D-dimer assessment may be useful to select patients for computed tomography pulmonary angiography (CTPA). METHODS A systematic literature search was performed for original studies which reported the frequency of PE on CTPA in patients with COVID-19. The frequency of PE, the location of PE, and the standardized mean difference (SMD) of D-dimer levels between patients with and without PE were pooled by random effects models. RESULTS Seventy-one studies were included. Pooled frequencies of PE in patients with COVID-19 at the emergency department (ED), general wards, and intensive care unit (ICU) were 17.9% (95% CI: 12.0-23.8%), 23.9% (95% CI: 15.2-32.7%), and 48.6% (95% CI: 41.0-56.1%), respectively. PE was more commonly located in peripheral than in main pulmonary arteries (pooled frequency of 65.3% [95% CI: 60.0-70.1%] vs. 32.9% [95% CI: 26.7-39.0%]; OR = 3.540 [95% CI: 2.308-5.431%]). Patients with PE had significantly higher D-dimer levels (pooled SMD of 1.096 [95% CI, 0.844-1.349]). D-dimer cutoff levels which have been used to identify patients with PE varied between 1000 and 4800 μg/L. CONCLUSION The frequency of PE in patients with COVID-19 is highest in the ICU, followed by general wards and the ED. PE in COVID-19 is more commonly located in peripheral than in central pulmonary arteries, which suggests local thrombosis to play a major role. D-dimer assessment may help to select patients with COVID-19 for CTPA, using D-dimer cutoff levels of at least 1000 μg/L. KEY POINTS • The frequency of PE in patients with COVID-19 is highest in the ICU, followed by general wards and the ED. • PE in COVID-19 is more commonly located in peripheral than in central pulmonary arteries. • D-dimer levels are significantly higher in patients with COVID-19 who have PE.
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Affiliation(s)
- Robert M Kwee
- Department of Radiology, Zuyderland Medical Center, Heerlen/Sittard/Geleen, The Netherlands.
| | | | - Thomas C Kwee
- Department of Radiology, Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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