Pulmonary embolism in hospitalised patients with COVID-19

Abstract

Background

Coronavirus disease 2019 (COVID-19) is characterised by dyspnoea and abnormal coagulation parameters, including raised D-dimer. Data suggests a high incidence of pulmonary embolism (PE) in ventilated patients with COVID-19.

Objectives

To determine the incidence of PE in hospitalised patients with COVID-19 and the diagnostic yield of Computer Tomography Pulmonary Angiography (CTPA) for PE. We also examined the utility of D-dimer and conventional pre-test probability for diagnosis of PE in COVID-19.

Patients/methods

Retrospective review of single-centre data of all CTPA studies in patients with suspected or confirmed COVID-19 identified from Electronic Patient Records (EPR).

Results

There were 1477 patients admitted with COVID-19 and 214 CTPA scans performed, of which n = 180 (84%) were requested outside of critical care. The diagnostic yield for PE was 37%. The overall proportion of PE in patients with COVID-19 was 5.4%. The proportions with Wells score of ≥4 (‘PE likely’) was 33/134 (25%) without PE vs 20/80 (25%) with PE ( P = 0.951). The median National Early Warning-2 (NEWS2) score (illness severity) was 5 (interquartile range [IQR] 3–9) in PE group vs 4 (IQR 2–7) in those without PE ( P = 0.133). D-dimer was higher in PE (median 8000 ng/mL; IQR 4665–8000 ng/mL) than non-PE (2060 ng/mL, IQR 1210–4410 ng/mL, P < 0.001). In the ‘low probability’ group, D-dimer was higher ( P < 0.001) in those with PE but had a limited role in excluding PE.

Conclusions

Even outside of the critical care environment, PE in hospitalised patients with COVID-19 is common. Of note, approaching half of PE events were diagnosed on hospital admission. More data are needed to identify an optimal diagnostic pathway in patients with COVID-19. Randomised controlled trials of intensified thromboprophylaxis are urgently needed.

Highlights

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  COVID-19 is associated with a higher rate of PE, particularly in critically-ill patients

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  Identifying those requiring PE investigations is challenging due to overlapping clinical presentation and high D-dimer seen in COVID-19

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  Single-centre study of imaging outcomes (for PE), in patients with suspected/confirmed COVID-19

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  37% of inpatients scanned had PE. D-dimer >4200 ng/mL risk stratified, but could not exclude PE.

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  Clinicians should have high index of suspicion for PE in COVID-19