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.
Highlights
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 pulmonary embolism (PE) in these patients
The clinical course of COVID-19 is often accompanied by a hyperinflammatory response and systemic coagulation derangement, which may evolve into overt disseminated intravascular coagulopathy (DIC)
The systemic activation of blood coagulation and pulmonary thrombo-inflammation with local vascular damage caused by COVID-19 and other important risk factors, such as reduced mobility, may increase the risk of deep vein thrombosis (DVT) and pulmonary embolism (PE) [1,2,3,4]
Summary
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. There is a lack of explicit indications regarding the best algorithm for diagnosing PE in COVID-19 patients [5] It is not clear whether the most recent guidelines for the diagnosis and management of acute PE, that have been developed in 2019 by the European Respiratory Society and the European Society of Cardiology [6], may be applied with success to COVID-19 patients with respiratory insufficiency. These guidelines consider the use of the revised Geneva and Wells pre-test probability scores [7, 8] a key step in the diagnosis of PE. For these algorithms it is not clear whether they perform well in the COVID-19 population [11]
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