Ruling out Pulmonary Embolism in Patients with (Suspected) COVID-19-A Prospective Cohort Study.

Yordi P.A Van Dooren,Sarah Kelliher,Marco J.J.H Grootenboers,Lianne R De Haan,Laura M Faber,Thomas Van Bemmel,Fleur Pals,Ted Koster,Hugo Ten Cate,Menno V Huisman,Antonio Iglesias Del Sol,Peter E Westerweel,Marije Ten Wolde,Inge C Boukema,Sander J.E Braken,Fleur H.J Kaptein,Remy H.H Bemelmans,Dionne C.W Braeken,Carlinda Bresser,Frederikus A Klok,Milou A.M Stals,Carolien Haazer,Rick I Meijer,Lucia J.M Kroft,E Thiel ,Duco D Deenstra

doi:10.1055/s-0041-1735155

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.

Highlights

COVID-19 disease ranges from a mild disorder with flulike symptoms to a critical care respiratory condition requiring intensive care unit (ICU) admission and mechanical ventilation.[1,2] Patients with COVID-19 are known to be at high risk for thrombotic complications, especially when admitted to the ICU
Within YEARS, pulmonary embolism (PE) was considered excluded without computed tomography pulmonary angiography (CTPA) in 29%, of which one patient developed nonfatal PE during follow-up
In patients managed by CTPA only, 66% had an initial negative CTPA, of whom eight patients were diagnosed with a nonfatal venous thromboembolism (VTE) during follow-up

Summary

Introduction

COVID-19 disease ranges from a mild disorder with flulike symptoms to a critical care respiratory condition requiring intensive care unit (ICU) admission and mechanical ventilation.[1,2] Patients with COVID-19 are known to be at high risk for thrombotic complications, especially (but not exclusively) when admitted to the ICU. Diagnosing PE is long recognized to be challenging, as signs and symptoms of PE—for instance shortness of breath, coughing, and chest pain—are nonspecific and show overlap with mimicking conditions, including respiratory tract infections.[9] Imaging tests are required to confirm or rule out the diagnosis, and as a consequence many patients are referred for diagnostic imaging, with a low proportion of confirmed cases among those tested.[10] These imaging tests are associated with radiation exposure and contrast material-induced complications.[11,12]. Diagnostic strategies for suspected pulmonary embolism (PE) have not been prospectively evaluated in COVID-19 patients

Methods

Results

Conclusion