Higher Prevalence Of Pulmonary Embolism Research Articles

The challenges of identifying pulmonary embolism in patients hospitalized for exacerbations of COPD

BackgroundChronic obstructive pulmonary disease (COPD) is associated with airflow obstruction that threatens global health. During the hospitalization of patients with acute exacerbations of COPD (AECOPD), the high prevalence of pulmonary embolism (PE) seriously affects the prognosis of disease. This study aims to assess the differences in clinical data between patients with AECOPD and patients with AECOPD-PE, and to identify the relevant factors of PE. MethodsWe performed a retrospective case-control study in AECOPD patients between January 2018 and December 2021. Due to suspected PE, all patients underwent radiological examination. Patients without PE were included as controls. Clinical data and laboratory tests were recorded. Univariate analysis and multivariate logistic regression analysis were used to investigate the independent predictors of PE. Receiver operating characteristics (ROC) curves was performed to evaluate the effect of risk factors on PE prediction. ResultsA total of 191 patients were included for analysis, divided into the AECOPD group (96 cases) and AECOPD-PE group (95 cases). No statistic differences were detected in demographic characteristics between patients with AECOPD and patients with AECOPD and PE. Average PO2 and PCO2 levels, lung function, and Echocardiographic indicator were not associated with PE. The concentration of D-dimer, the proportion of simplified wells score ≥ 2, and the incidence rate of lower extremity deep vein thrombosis (DVT) remarkably increased in AECOPD-PE group than AECOPD individuals. At multivariate analysis, the above three indicators were closely relevant to the occurrence of PE. The AUC value for D-dimer combined with lower extremity DVT and Simplified Wells Score was 0.729. ConclusionsD-dimer, lower extremity DVT, and simplified wells score ≥ 2 were relevant to higher risks of PE, which will help to improve clinicians’ understanding of PE secondary to AECOPD.

Diagnostic Strategies in Pulmonary Embolism

AbstractKey to the diagnosis of pulmonary embolism (PE) is a careful bedside evaluation. After this, there are three further diagnostic steps. In all patients, estimation of the clinical probability of PE is performed. The other two steps are measurement of D-dimer when indicated and chest imaging when indicated. The clinical probability of PE is estimated at low, moderate, or high. The prevalence of PE is less than 15% among patients with low clinical probability, 15 to 40% with moderate clinical probability, and >40% in patients with high clinical probability. Clinical gestalt has been found to be very useful in estimating probability of PE. However, clinical prediction rules, such as Wells criteria, the modified Geneva score, and the PE rule out criteria have been advocated as adjuncts. In patients with high clinical probability, the high prevalence of PE can lower the D-dimer negative predictive value, which could increase the risk of diagnostic failure. Consequently, patients with high probability for PE need to proceed directly to chest imaging, without prior measurement of D-dimer level. Key studies in determining which low to moderate probability patients require chest imaging are the Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism (ADJUST-PE), the Simplified diagnostic management of suspected pulmonary embolism (YEARS), and the Pulmonary Embolism Graduated D-Dimer trials. In patients with low clinical probability, PE can be excluded without imaging studies if D-dimer is less than 1,000 ng/mL. In patients in whom there is not a low likelihood for PE, this can be excluded without imaging studies if the D-dimer is below the age-adjusted threshold.

Successful Management of High-Risk Acute Pulmonary Embolism in Patients with Undetected Hepatocellular Carcinoma: A Case Report

Background: Acute pulmonary embolism (PE) as the first sign of hepatocellular carcinoma (HCC) is rare. It is a deadly disease with high morbidity and mortality. Despite the high prevalence of PE, the diagnosis is still challenging, mainly due to the unpredictability of symptoms. The stratification of acute pulmonary embolism is important because it determines the right steps in decision-making. Case Illustration: A 45-year-old man went to a private hospital's emergency room (ER) with sudden shortness of breath. He was desaturated and shocked. He was assessed as having an acute coronary syndrome (ACS), got loaded with dual antiplatelets, and was referred to our hospital. We rule out ACS because the patient's complaint is sudden shortness of breath and desaturation. Acute PE was diagnosed after bedside transthoracal echocardiography (TTE) in the ER revealed right ventricular (RV) dysfunction. We continued with the computed tomography pulmonary artery (CTPA) examination and found a thrombus in the pulmonary artery. We assessed patients with high-risk PE and performed thrombolysis. Initially, we suspected unprovoked PE because we did not find a clear trigger, such as malignancy, prolonged bedriddenness, recent surgery, or old age. We accidentally found HCC from the patient's CTPA evaluation, and HBsAg was reactive. Conclusion: Every case of dyspnea that shows up at an emergency room should have acute PE taken into consideration in the differential diagnosis. In patients with suspected PE without obvious risk factors, we can use CT to triple-rule out ACS, aortic dissection, and pulmonary embolism. Patients treated with thrombolytic therapy show rapid improvement, which may lead to a lower rate of mortality and morbidity. Keyword: Acute Coronary Syndrome, Acute Pulmonary Embolism, Hepatocellular Carcinoma, Thrombolysis, Unprovoked.

Nomogram for predicting pulmonary embolism in gynecologic inpatients with isolated distal deep venous thrombosis.

To investigate the incidence of isolated distal deep venous thrombosis (IDDVT) concurrent with pulmonary embolism (PE) in gynecologic inpatients, analyze the risk factors for IDDVT with PE, and establish a nomogram model for IDDVT patients with PE. A total of 260 patients were diagnosed with IDDVT between December 2017 and November 2020. The incidence of PE in these patients was determined using computed tomography pulmonary angiography. Logistic regression analysis was used to identify the related risk factors. On this basis, nomogram risk prediction models were established. Among 260 patients with IDDVT, 106 (40.8%) had concurrent PE, of whom 74 (28.5%) experienced silent PE. Univariate logistic analysis demonstrated statistical significance for body mass index (BMI; P = 0.044), glucocorticoid therapy (P = 0.009), hypertension (P < 0.001), and diabetes (P < 0.001). Multivariate logistic analysis revealed that these were independent risk factors for IDDVT with PE that retained statistical significance. A nomogram based on these factors was constructed to predict PE in patients with IDDVT. Its receiver operating characteristic (ROC) showed an area under the curve of 0.710 (95% confidence interval 0.642-0.779), with prediction sensitivity of 64.2% and prediction specificity of 76.6%. In the present study, a high prevalence of PE was found in gynecologic inpatients with IDDVT. Glucocorticoid therapy, hypertension, diabetes, and BMI were independent risk factors for IDDVT patients with PE. Taking these risk factors into account, a nomogram risk prediction model was developed to help facilitate early detection of concurrent PE.

Pulmonary Embolism in Critically Ill COVID-19 And Non-COVID-19 Patients: Systematic Analysis of Risk Factors, Diagnostic and Management Strategies, and Prognosis.

Background: Coronavirus disease of 2019 or COVID-19 is characterised by two main features: the first is the respiratory compromise which corresponds to acute respiratory distress syndrome while the second corresponds to the state of hypercoagulability responsible for thromboembolic complications particularly pulmonary embolism which is the subject of this work. Indeed, a high prevalence of pulmonary embolism has been reported throughout the pandemic period with a significant morbidity and mortality. This reflects the severity of this life-threatening emergency chiefly in the elderly, hemodynamically unstable patients, and patients with severe underlying conditions, mainly cardio-pulmonary comorbidities. The aim of our study is to point out the incidence, the risk factors, the clinical and paraclinical features, the management strategies, and the overall prognosis of pulmonary embolism in critically ill COVID-19 and non-COVID-19 patients. Patients and methods: It is a retrospective observational study carried out over a two-year-period from January 2019 (non-COVID-19) to December 2020 (COVID-19). Over the study period, 42 cases of COVID-19 and non-COVID-19 pulmonary embolism were collected from an overall set of 611 patients admitted to the medical intensive care unit of the IBN ROCHD university hospital of Casablanca. Results: The mean age in the COVID-19 group was 64-year-old versus 46-year-old in the non-COVID-19 group. The sex ratio was 1.2 and 0.94 in the non-COVID-19 and COVID-19 group, respectively. Clinical symptomatology was dominated by respiratory failure and chest pain in non-COVID-19 patients while in the COVID-19 group, semiology was dominated by dyspnea, cough, and chest pain. The major sign of severity in both groups was tachypnea. The chest X-ray was performed in all our patients, it displayed radiological abnormalities in all patients mainly hyper clarity in pulmonary fields. D-dimers were performed in all patients within the two study groups. A chest computed tomography angiogram was performed for all patients and showed unilateral pulmonary embolism in 61% of cases in the non-COVID-19 group versus 61.3% in the COVID-19 group. Cardiac ultrasound was performed for all patients. It showed dilatation of right cavities in both groups (81.8% in non-COVID-19 versus 93.5% in COVID-19 patients). Venous ultrasound of the lower limbs was performed in 96.8% of COVID-19 patients and in 72.7% of non-COVID-19 patients. With regards to management, all COVID-19 and non-COVID-19 patients received anticoagulation therapy based on standard heparin and anti-vitamin K. Mortality accounted for 54.5% in non-COVID-19 patients versus 74.2% in COVID-19 patients. Conclusion: COVID-19 pulmonary embolism is often associated with significantly higher morbidity and mortality as compared with non-COVID-19 pulmonary embolism.

COVID-19 infection and its impact on case-fatality in patients with pulmonary embolism

Abstract Background Although a high prevalence of pulmonary embolism (PE) has been reported as a complication during severe COVID-19 infections in critical ill patients, nationwide data of hospitalized patients with COVID-19 with PE is still limited. Thus, we sought to analyze seasonal trends and predictors of in-hospital case-fatality in patients with COVID-19 and PE in Germany. Methods We used the German nationwide inpatient sample to analyze all data on hospitalizations for COVID-19 patients with and without PE in Germany during the year 2020 and to compare changes of PE prevalence to 2019. Results We analyzed data of 176,137 hospitalizations because of COVID-19 in 2020. Among those, PE was recorded in 1.9% (n=3,362) of discharge or death certificates. Almost one third of patients with COVID-19 and PE died during the in-hospital course (28.7%). The case-fatality rate increased with patients' age peaking in the 9th life-decade. Regardless of COVID-19, 196,203 inpatients were diagnosed with PE in Germany between 2019 and 2020. The number of PE hospitalizations were widely equally distributed between both years (98,485 vs. 97,718), while the case-fatality rate of all patients with PE was slightly lower in 2019 compared to 2020 (12.7% vs. 13.1%, P&amp;lt;0.001). In contrast, considerable differences in prevalence and case-fatality were demonstrated in 2020 regarding PE patients with and without COVID-19 infection (28.7% vs. 13.1%, P&amp;lt;0.001) (Figure 1). A COVID-19-infection was associated with a 2.8-fold increased risk of case-fatality in patients with PE (OR 2.81, 95% CI 1.66–2.12, P&amp;lt;0.001). Conclusions In Germany, the prevalence of PE events complicating hospitalizations was similar in 2019 and 2020. However, the fatality rate among patients with COVID-19-associated PE was substantially higher than that in those without either COVID-19 or PE, indicating an additive prognostic effect of these two conditions. Funding Acknowledgement Type of funding sources: None.

COVID-19 infection and its impact on case fatality in patients with pulmonary embolism.

BackgroundAlthough a high prevalence of pulmonary embolism (PE) has been reported in association with coronavirus disease (COVID)-19 in critically ill patients, nationwide data on the outcome of hospitalised patients with COVID-19 and PE is still limited. Thus, we investigated seasonal trends and predictors of in-hospital death in patients with COVID-19 and PE in Germany.MethodsWe used the German nationwide inpatient sample to analyse data on hospitalisations among COVID-19 patients with and without PE during 2020, and to detect changes in PE prevalence and case fatality in comparison to 2019.ResultsWe analysed 176,137 COVID-19 hospitalisations in 2020; PE was recorded in 1.9% (n=3362) of discharge certificates. Almost one third of patients with COVID-19 and PE died during the in-hospital course (28.7%) compared to COVID-19 patients without PE (17.7%). Between 2019 and 2020, numbers of PE-related hospitalisations were largely unchanged (98,485 versus 97,718), whereas the case-fatality rate of PE increased slightly in 2020 (from 12.7% to 13.1%, p<0.001). Differences in case fatality were found between PE patients with and without COVID-19 in 2020 (28.7% versus 12.5%, p<0.001), corresponding to a 3.1-fold increased risk of PE-related death (OR 3.16, 95% CI 2.91–3.42, p<0.001) in the presence of COVID-19.ConclusionsIn Germany, the prevalence of PE events during hospitalisations was similar in 2019 and 2020. However, the fatality rate among patients with both COVID-19 and PE was substantially higher than that in those with only one of these diseases, suggesting a life-threatening additive prognostic impact of the COVID-PE combination.

Ex-Vivo Pulmonary Artery Angioscopy: A Novel Technique for Management of Donor Lung Pulmonary Embolism

<h3>Purpose</h3> Although organ donors have high prevalence of pulmonary embolism (PE), the diagnosis of PE in donor lungs can be challenging and can have a detrimental effect on lung transplantion (LTx) outcomes. The aim of this study was to investigate the feasibility of a novel technique using ex-vivo pulmonary artery (EXPLORE) angioscopy for the diagnosis and treatment of PE in donor lungs post-procurement. <h3>Methods</h3> An adult fiber optic bronchoscope was utilized for the EXPLORE angioscopy technique (off-label use). EXPLORE angioscopy was first tested in donor lungs deemed non-suitable for LTx after ex-vivo lung perfusion (EVLP) (test group). It was then routinely utilized for screening of donor lungs with suspected PE before EVLP (application group). Criteria for PE suspicion included: consistently low P/F ratio during donor management, observed clots during retrograde flushing, and inadequate flushing of donor lungs presented as abnormal coloring of some lung areas. <h3>Results</h3> In the testing group, using EXPLORE angioscopy we were able to identify and remove pulmonary emboli from 4 lungs (<b>Figure 1</b>). In the application group, 16 lungs fulfilled the criteria for PE suspicion and were screened with EXPLORE angioscopy. In 5 cases, pulmonary emboli were identified and removed before EVLP, two of which were deemed suitable for LTx post-EVLP evaluation and were transplanted with good outcomes. Both recipients were extubated on post-transplant day 1 and primary graft dysfunction (PGD) grades at 72 hours post-transplant were 1. In the other 11 cases, PE screening was negative, 6 of which were transplanted. Four recipients had PGD 1 and two had PGD 0 at 72 hours. Median time to extubation was 2 days. <h3>Conclusion</h3> EXPLORE angioscopy can be a useful tool for PE screening in donor lungs post-procurement which can improve the outcomes of LTx. Additionally, it can be utilized for embolectomy prior to EVLP evaluation which can increase the number of initially declined donor lungs treated with EVLP and ultimately transplanted.

Clinical presentation of isolated calf deep vein thrombosis in inpatients and prevalence of associated pulmonary embolism

ObjectiveControversy exists regarding the clinical significance and optimal treatment of isolated calf deep vein thrombosis (DVT). In the present study, the clinical presentation of isolated calf DVT and the association of isolated calf DVT with pulmonary embolism (PE) in hospitalized patients were investigated. MethodsA total of 1435 hospitalized patients had undergone whole leg duplex ultrasound between January 2018 and June 2020. Isolated calf vein DVT was diagnosed in 135 of these 1435 patients. ResultsThe soleal vein was the most frequently involved (52.6%). Thrombus was detected only in the axial veins in 57 patients (42.2%), muscular veins in 46 patients (34.4%), and both axial and muscular veins in 32 patients (23.7%). Of the 135 patients, 44 (32.6%) had undergone recent orthopedic surgery, 31 (23.0%) had active cancer, and 22 (16.3%) had a history of recent stroke. The reasons for duplex ultrasound examination were leg edema and/or pain for 57 patients (42.2%), the diagnosis of PE for 33 (24.4%), and an elevated D-dimer level for 27 patients (20.0%). For 16 patients (11.9%), DVT had been diagnosed as an incidental finding on imaging studies performed for other purposes. Of the 135 patients, 96 (71.1%) had received anticoagulation therapy. Concurrent PE was diagnosed in 45 patients (33.3%), 14 of whom had had lesions in the main pulmonary artery. Of the 45 patients with concurrent PE, 35 had not experienced leg edema and/or pain. Recurrent venous thromboembolism was observed in four patients (3.0%) at a mean follow-up of 15.5 ± 12.7 months. ConclusionsIn the present study, isolated calf DVT was associated with a high prevalence of PE in the hospitalized patients. Patients with isolated calf DVT, even without leg edema and/or pain, could have concurrent PE. Anticoagulation therapy should be considered for inpatients with isolated calf DVT. The muscular veins were frequently involved and, thus, should be thoroughly evaluated with imaging studies.

Sex Differences in the Incidence and Outcomes of Patients Hospitalized by Idiopathic Pulmonary Fibrosis (IPF) in Spain from 2016 to 2019.

(1) Background: To assess sex differences in the incidence, characteristics, procedures and outcomes of patients admitted with idiopathic pulmonary fibrosis (IPF); and to analyze variables associated with in-hospital mortality (IHM). (2) Methods: We analyzed data collected by the Spanish National Hospital Discharge Database, 2016–2019. (3) Results: We identified 13,278 hospital discharges (66.4% men) of IPF (primary diagnosis 32.33%; secondary diagnosis: 67.67%). Regardless of the diagnosis position, IPF incidence was higher among men than women, increasing with age. Men had 2.74 times higher IPF incidence than women. Comorbidity was higher for men in either primary or secondary diagnosis. After matching, men had higher prevalence of pulmonary embolism and pneumonia, and women of congestive heart failure, dementia, rheumatoid disease and pulmonary hypertension. Invasive ventilation, bronchoscopy and lung transplantation were received more often by men than women. IHM was higher among men with IPF as primary diagnosis than among women and increased with age in both sexes and among those who suffered cancer, pneumonia or required mechanical ventilation. (4) Conclusions: Incidence of IPF was higher among men than women, as well as comorbidity and use of bronchoscopy, ventilation and lung transplantation. IHM was worse among men than women with IPF as primary diagnosis, increasing with age, cancer, pneumonia or mechanical ventilation use.

The prevalence of pulmonary embolism in non-hospitalised de-isolated patients diagnosed with mild COVID-19 disease.

Pulmonary embolism (PE) is a known complication of COVID-19 disease. The mechanism of thromboembolic events appears to be stimulated by excessive thrombin production, inhibition of fibrinolysis and deposition of antiphospholipids and thrombi, as well as microvascular dysfunction in multiple vascular beds. The occurrence of PE has been well demonstrated in hospitalised patients with severe disease. Very few data are available on its incidence or prevalence in non-hospitalised patients diagnosed with a milder form of the disease. To assess the prevalence of PE in non-hospitalised patients diagnosed with mild COVID-19 who presented with raised D-dimer levels and persistent or new-onset cardiopulmonary symptoms. This was a retrospective study conducted in the Department of Nuclear Medicine at Universitas Academic Hospital, Bloemfontein, South Africa. We reviewed the studies of 65 non-hospitalised patients with COVID-19 referred to the department from July 2020 to January 2021 for a perfusion-only single-photon emission computed tomography/computed tomography (SPECT/CT) study or a ventilation/perfusion (VQ) SPECT/CT study. All 65 patients had raised D-dimer levels with persistent, worsening or new-onset cardiopulmonary symptoms after the diagnosis of COVID-19. Sixty-five patients were studied. The median (interquartile range) age was 46 (41 - 54) years and the majority (88.2%) were female. There were 22 patients (33.8%) with lung perfusion defects in keeping with PE. Two of these patients had a false-negative computed tomography pulmonary angiography (CTPA) study for PE performed the same day as their VQ SPECT/CT study. We confirm a high prevalence of PE in non-hospitalised patients diagnosed with mild COVID-19 who presented with raised D-dimer levels and persistent or new-onset cardiopulmonary symptoms. We recommend that irrespective of disease severity, hospitalised and non-hospitalised patients with COVID-19 presenting with persistent or new-onset cardiopulmonary symptoms and raised D-dimer levels should be investigated further for PE.

White blood count, D-dimers, and ferritin levels as predictive factors of pulmonary embolism suspected upon admission in noncritically ill COVID-19 patients: The French multicenter CLOTVID retrospective study.

BackgroundA high prevalence of pulmonary embolism (PE) has been described during COVID‐19. Our aim was to identify predictive factors of PE in non‐ICU hospitalized COVID‐19 patients.MethodsData and outcomes were collected upon admission during a French multicenter retrospective study, including patients hospitalized for COVID‐19, with a CT pulmonary angiography (CTPA) performed in the emergency department for suspected PE. Predictive factors significantly associated with PE were identified through a multivariate regression model.ResultsA total of 88 patients (median [IQR] age of 68 years [60‐78]) were analyzed. Based on CTPA, 47 (53.4%) patients were diagnosed with PE, and 41 were not. D‐dimer ≥3000 ng/mL (OR 8.2 [95% CI] 1.3‐74.2, sensitivity (Se) 0.84, specificity (Sp) 0.78, P = .03), white blood count (WBC) ≥12.0 G/L (29.5 [2.3‐1221.2], Se 0.47, Sp 0.92, P = .02), and ferritin ≥480 µg/L (17.0 [1.7‐553.3], Se 0.96, Sp 0.44, P = .03) were independently associated with the PE diagnosis. The presence of the double criterion D‐dimer ≥3000 ng/mL and WBC ≥12.0 G/L was greatly associated with PE (OR 21.4 [4.0‐397.9], P = .004).ConclusionThe white blood count, the D‐dimer and ferritin levels could be used as an indication for CTPA to confirm PE on admission in non‐ICU COVID‐19 patients.

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

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 suspicion https://bit.ly/3ungLrQ

High prevalence of pulmonary embolism prior to cancer therapies in patients with ovarian and endometrial cancers detected by contrast-enhanced CT using D-dimer as an index.

We aimed to evaluate the prevalence of pulmonary embolism (PE) before cancer therapies in patients with ovarian and endometrial cancers with enhanced computed tomography (CT) using D-dimer (DD), and determine the optimal cut-off level of DD. Since 2009, we have performed preoperative venous thromboembolism (VTE) screening of patients with ovarian and endometrial cancer. For patients with DD levels of more than 1.0 μg/ml, enhanced CT images were obtained from the pulmonary apex to the foot to detect PE and deep venous thrombosis (DVT) simultaneously. Among patients with ovarian cancer, 84 of 413 (20.3%) had VTEs (DVT alone, n = 31 [7.5%]; PE with or without DVT, n = 53 [12.8%]; PE alone, n = 12 [2.9%]). Among patients with endometrial cancer, 50 of 455 (11.0%) had VTEs (DVT alone, n = 19 [4.2%]; PE with or without DVT, n = 31 [6.8%], PE alone, n = 14 [3.1%]). The optimal cut-off level of DD was estimated to be ≥1.5 and ≥1.2 μg/ml in ovarian and endometrial cancers, respectively. Our study revealed a high prevalence of PE before cancer therapies in patients with ovarian and endometrial cancers by enhanced CT using DD.

Derivation and Validation of a 4-Level Clinical Pretest Probability Score for Suspected Pulmonary Embolism to Safely Decrease Imaging Testing

In patients with suspected pulmonary embolism (PE), overuse of diagnostic imaging is an important point of concern. To derive and validate a 4-level pretest probability rule (4-Level Pulmonary Embolism Clinical Probability Score [4PEPS]) that makes it possible to rule out PE solely on clinical criteria and optimized D-dimer measurement to safely decrease imaging testing for suspected PE. This study included consecutive outpatients suspected of having PE from US and European emergency departments. Individual data from 3 merged management studies (n = 11 114; overall prevalence of PE, 11%) were used for the derivation cohort and internal validation cohort. The external validation cohorts were taken from 2 independent studies, the first with a high PE prevalence (n = 1548; prevalence, 21.5%) and the second with a moderate PE prevalence (n = 1669; prevalence, 11.7%). A prior definition of pretest probability target values to achieve a posttest probability less than 2% was used on the basis of the negative likelihood ratios of D-dimer. Data were collected from January 2003 to April 2016, and data were analyzed from June 2018 to August 2019. The rate of PE diagnosed during the initial workup or during follow-up and the rate of imaging testing. Of the 5588 patients in the derivation cohort, 3441 (61.8%) were female, and the mean (SD) age was 52 (18.5) years. The 4PEPS comprises 13 clinical variables scored from -2 to 5. It results in the following strategy: (1) very low probability of PE if 4PEPS is less than 0: PE ruled out without testing; (2) low probability of PE if 4PEPS is 0 to 5: PE ruled out if D-dimer level is less than 1.0 μg/mL; (3) moderate probability of PE if 4PEPS is 6 to 12: PE ruled out if D-dimer level is less than the age-adjusted cutoff value; (4) high probability of PE if 4PEPS is greater than 12: PE ruled out by imaging without preceding D-dimer test. In the first and the second external validation cohorts, the area under the receiver operator characteristic curves were 0.79 (95% CI, 0.76 to 0.82) and 0.78 (95% CI, 0.74 to 0.81), respectively. The false-negative testing rates if the 4PEPS strategy had been applied were 0.71% (95% CI, 0.37 to 1.23) and 0.89% (95% CI, 0.53 to 1.49), respectively. The absolute reductions in imaging testing were -22% (95% CI, -26 to -19) and -19% (95% CI, -22 to -16) in the first and second external validation cohorts, respectively. The 4PEPS strategy compared favorably with all recent strategies in terms of imaging testing. The 4PEPS strategy may lead to a substantial and safe reduction in imaging testing for patients with suspected PE. It should now be tested in a formal outcome study.

Pulmonary embolism prevalence among emergency department cohorts: A systematic review and meta‐analysis by country of study

Unlabelled Box AbstractBackgroundThere is an impression that North American emergency department (ED) patients tested for pulmonary embolism (PE) differ from European ones. ObjectivesWe compared the PE prevalence, frequency of use, and positive yield of imaging among ED patients tested for PE in Europe and North America. MethodsWe searched for studies reporting consecutive ED patients tested for PE. Two authors screened full texts, performed risk of bias assessment, and data extraction. We conducted a meta‐analysis of proportions for each outcome and a multiple meta‐regression. ResultsFrom 3109 publications, 44 were included in the systematic review. The prevalence of PE in Europe was 23% (95% confidence interval [CI], 21‐26) and in North America 8% (95% CI, 6‐9). The adjusted mean difference (aMD) in the prevalence of PE in the European compared with North American studies, was 15% (95% CI, 10‐20). Computed tomography pulmonary angiography (CTPA) was used in 60% (95% CI, 52%‐68) of European and 38% (95% CI, 24‐51) of North American patients tested for PE (aMD, 23% [95% CI, 7‐39]). The CTPA diagnostic yield was 29% (95% CI, 26‐32) in Europe and 13% (95% CI, 9‐17) in North America (aMD, 15% [95% CI, 8‐21]). ConclusionCompared with North America, European ED studies have a higher prevalence of PE and diagnostic yield from CTPA, despite a higher frequency of CTPA use among patients tested for PE. This supports the hypothesis that those tested for PE in North American EDs have a lower risk of PE compared with Europe.

Prevalence of pulmonary embolism in patients with COVID-19 pneumonia and high D-dimer values: A prospective study.

IntroductionCoronavirus disease 2019 (COVID-19) pneumonia is associated to systemic hyper-inflammation and abnormal coagulation profile. D-dimer elevation is particularly frequent, and values higher than 1μg/mL have been associated with disease severity and in-hospital mortality. Previous retrospective studies found a high pulmonary embolism (PE) prevalence, however, it should be highlighted that diagnoses were only completed when PE was clinically suspected.Material and methodsSingle-center prospective cohort study. Between April 6th and April 17th 2020, consecutive confirmed cases of COVID-19 pneumonia with D-dimer >1 μg/mL underwent computed tomography pulmonary angiography (CTPA) to investigate the presence and magnitude of PE. Demographic and laboratory data, comorbidities, CTPA scores, administered treatments, and, clinical outcomes were analysed and compared between patients with and without PE.ResultsThirty consecutive patients (11 women) were included. PE was diagnosed in 15 patients (50%). In patients with PE, emboli were located mainly in segmental arteries (86%) and bilaterally (60%). Patients with PE were significantly older (median age 67.0 (IQR 63.0–73.0) vs. 57.0 (IQR 48.0–69.0) years, p = .048) and did not differ in sex or risk factors for thromboembolic disease from the non-PE group. D-dimer, platelet count, and, C reactive protein values were significantly higher among PE patients. D-dimer values correlated with the radiologic magnitude of PE (p<0.001).ConclusionsPatients with COVID-19 pneumonia and D-dimer values higher than 1 μg/mL presented a high prevalence of PE, regardless of clinical suspicion. We consider that these findings could contribute to improve the prognosis of patients with COVID-19 pneumonia, by initiating anticoagulant therapy when a PE is found.

Prevalence and risk factors for pulmonary embolism in patients with suspected acute exacerbation of COPD: a multi-center study.

Introduction: Pulmonary embolism (PE) prevalence in acute exacerbations of COPD is highly variable. Methods: To investigate the prevalence and risk factors of PE in patients hospitalized in Departments of Internal Medicine because of AECOPD and suspected PE we conducted a retrospective multicenter study in patients with an AECOPD undergoing chest angio-computed tomography (angio-CT) because of clinical suspect of PE. Results1043 patients (mean age 75.8 years ± 9.7 years, 34.5 % women) were included; 132 patients had PE (mean prevalence 12.66%, 95% confidence interval 10.73, 14.77%).) confirmed by angio-CT and 54 patients died during hospitalization (5.18 %). At multivariate analysis, age, female gender, clinical signs and symptoms suggestive of deep vein thrombosis, hypertension, PaCO2 ≤ 40 mmHg, and normal chest-x-ray were significantly associated with a higher PE prevalence. Prevalence of PE in patients with 0, 1, 2, 3 or ≥4 risk factors progressively increase from 1.76 to 30.43%. Mean length of hospitalization (LOH) (15.7 vs 14.2 days, p 0.07) and in-hospital mortality (6.1% vs 5.1%, P=0.62) were slightly but not significantly higher in in patients with PE (6.1% vs 5.1%, P=0.62). Conclusions: PE prevalence is not negligible in this setting. A number of risk factors may help clinicians in identification of patients at increased risk of PE.

Prevalence of Pulmonary Embolism in Patients Presenting With Syncope.

Prevalence of Pulmonary Embolism in Patients Presenting With Syncope.

The rationale, design, and methods of a randomized, controlled trial to evaluate the efficacy and safety of an active strategy for the diagnosis and treatment of acute pulmonary embolism during exacerbations of chronic obstructive pulmonary disease

IntroductionSome previous studies have suggested a high prevalence of pulmonary embolism (PE) during exacerbations of chronic obstructive pulmonary disease (ECOPD). The SLICE trial aims to assess the efficacy and safety of an active strategy for the diagnosis and treatment of PE (vs usual care) in patients hospitalized because of ECOPD.MethodsSLICE is a phase III, prospective, international, multicenter, randomized, open‐label, and parallel‐group trial. A total of 746 patients hospitalized because of ECOPD will be randomized in a 1:1 fashion to receive either an active strategy for the diagnosis and anticoagulant treatment of PE or usual care (ie, standard care without any diagnostic test for diagnosing PE). The primary outcome is a composite of all‐cause death, non‐fatal (recurrent) venous thromboembolism (VTE), or readmission for ECOPD within 90 days after enrollment. Secondary outcomes are (a) death from any cause within 90 days after enrollment, (b) non‐fatal (recurrent) VTE within 90 days after enrollment, (c) readmission within 90 days after enrollment, and (d) length of hospital stay.ResultsEnrollment started in September 2014 and is expected to proceed until 2020. Median age of the first 443 patients was 71 years (interquartile range, 64‐78), and 26% were female.ConclusionsThis multicenter trial will determine the value of detecting PEs in patients with ECOPD. This has implications for COPD patient morbidity and mortality. Trial registration number: NCT02238639.