Abstract

Introduction. Acute pulmonary embolism (APE) is a frequent condition in patients with COVID-19 and is associated with worse outcomes. Previous studies suggested an immunothrombosis instead of a thrombus embolism, but the precise mechanisms remain unknown. Objective. To assess the determinants and prognosis of APE during COVID-19. Methods. We retrospectively included all consecutive patients with APE confirmed by computed tomography pulmonary angiography hospitalized at Strasbourg University Hospital from 1 March to 31 May 2019 and 1 March to 31 May 2020. A comprehensive set of clinical, biological, and imaging data during hospitalization was collected. The primary outcome was transfer to the intensive care unit (ICU). Results. APE was diagnosed in 140 patients: 59 (42.1%) with COVID-19, and 81 (57.9%) without COVID-19. A 812% reduction of non-COVID-19 related APE was registered during the 2020 period. COVID-19 patients showed a higher simplified pulmonary embolism severity index (sPESI) score (1.15 ± 0.76 vs. 0.83 ± 0.83, p = 0.019) and were more frequently transferred to the ICU (45.8% vs. 6.2%, p < 0.001). No difference regarding the most proximal thrombus localization, Qanadli score (8.1 ± 6.9 vs. 9.0 ± 7.4, p = 0.45), the proportion of subsegmental (10.2% vs. 11.1%, p = 0.86), and segmental pulmonary embolism (35.6% vs. 24.7%, p = 0.16) was evidenced between COVID-19 and non-COVID-19 APE. In COVID-19 patients with subsegmental or segmental APE, thrombus was, in all cases (27/27 patients), localized in areas with COVID-19-related lung injuries. Marked inflammatory and prothrombotic biological markers were associated with COVID-19 APE. Conclusions. APE patients with COVID-19 have a particular clinico–radiological and biological profile and a dismal prognosis. Our results emphasize the preeminent role of inflammation and a prothrombotic state in these patients.

Highlights

  • Since the outbreak of coronavirus disease 2019 (COVID-19), acute pulmonary embolism (APE) has been recognized as a frequent complication that carried a dismal prognosis [1,2]

  • In the first model, including all candidates’ predictors, except lupus anticoagulant (LA), creatinine at peak (hazard ratio (HR) 1.01, confidence interval (CI) 95% [1.00–1.02], p = 0.011), CRP at peak (HR 1.00, CI95% [1.00–1.01], p = 0.012) and COVID-19 (HR 4.19, CI95% [1.27–13.76], p = 0.018) were independent predictors of transfer to the intensive care unit (ICU) in patients with Acute pulmonary embolism (APE)

  • In this temporal analysis of 140 patients with acute pulmonary embolism, we observed a marked decline in non-COVID-19 APE during the first European wave of the pandemic

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Summary

Introduction

Since the outbreak of coronavirus disease 2019 (COVID-19), acute pulmonary embolism (APE) has been recognized as a frequent complication that carried a dismal prognosis [1,2]. Evidence from autopsy series reported endotheliitis [3], pulmonary vascular microthrombosis [4], and intense inflammation within the pulmonary vasculature. A decline in incidence of APE and imaging procedures has been reported due to the COVID-19 pandemic [9]. In an effort to better characterize the pathological mechanisms underlying COVID-19 associated APE, we sought to compare COVID-19 and non-COVID-19 APE. The objectives of our study were to compare the difference regarding clinical, biological, and radiological characteristics of COVID-19 and non-COVID-19 patients with APE admitted to the general ward at our institution, and to assess the impact of COVID-19 in APE prognosis

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