Pulmonary Embolism Prevalence in Patients With COVID-19 at Hospitalization

A high prevalence of pulmonary embolism (PE) has been reported among patients with COVID-19 at the time of hospital admission. A prospective, multicenter study was conducted at 3 tertiary hospitals in France, and results of the analysis were published in the European Respiratory Journal.

Investigators sought to evaluate all consecutive adult outpatients who were hospitalized between April 15, 2020, and May 23, 2020, with a diagnosis of COVID-19 and who underwent a computed tomography pulmonary angiography (CTPA). A diagnosis of COVID-19 was confirmed with the presence of a positive SARS-CoV-2 real-time polymerase chain reaction (RT-PCR) test and/or such typical CT abnormalities as ground-glass opacities, consolidation in the lung periphery, or both. In most instances, the diagnosis of PE was incidental, with patients undergoing CTPA for aggravation of their respiratory condition.

All patients with renal failure (ie, estimated creatinine clearance of <30 mL/min) or contraindication to iodinated contrast material used in the CTPA were excluded from the analysis (29 out of 135 consecutive outpatients hospitalized for COVID-19).

Both a senior radiologist and a pulmonologist analyzed all of the CT patterns of COVID-19 pneumonia and the presence of PE. All patients without PE were treated with prophylactic anticoagulation during their hospital stay, based on local practice. All of the patients were followed up prospectively for 3 months or until death, via a telephone interview within 3 months after hospital admission.

Among the 106 patients included in the study, 4.7% (5 of 106) were admitted directly to an intensive care unit (ICU). Study results showed that PE was diagnosed in 14.2% (15 of 106) of patients, yielding a prevalence of 14.2% (95% CI, 7.5-20.8). Of the 5 patients who were admitted directly to an ICU, 1 had confirmed PE at hospital admission. The CTPA was well tolerated, with no aggravation of renal function and only 1 complication was reported related to iodinated material extravasation, with no severe consequences.

Patients with confirmed PE on hospital admission had significantly higher D-dimer median concentrations, required the administration of oxygen more often in the emergency department, and experienced longer median time from symptoms to hospitalization, compared with those without PE. Per multivariable analysis, only high D-dimer median concentrations (odds ratio [OR], 1.001; 95% CI, 1.000-1.002) and time from symptoms to hospitalization (OR, 1.103; 95% CI, 1.019-1.193) were independently associated with PE.

No statistically significant differences were reported for CT staging of COVID-19 lung involvement between those patients with PE and those without PE (P =.85). Overall, 33.3% (5 of 15) of patients had a PE in the same location as their COVID-19 pneumonia.

PE was lobar in 46.7% (7 of 15) of patients, segmental in 40% (6 of 15) of patients, and sub-segmental in 13.3% (2 of 15) of patients.

Overall, 13.2% (14 of 106) of patients died during hospitalization. Death was associated with COVID-19 in 93% (13 of 14) of the patients and with PE in 7% (1 of 14) of the patients. The median interval between hospital admission and death was 11 days (range, 6-29 days). Those patients who died were significantly older (median, 83 years; range, 79.5-89.5 years; P =.001). More patients who died had severe, very severe, or critical features of COVID-19 pneumonia on CTPA at hospitalization (P <.001). Hospital mortality among patients who had confirmed PE on admission was 26.6%, which did not differ significantly from the hospital mortality of 11.0% in the group without PE (P =.09), although this may have been driven by the small study size.

Although PE is known to be a common complication among patients with COVID-19, this is the first study that describes the prevalence of PE at hospital admission. Of note is the fact that in the current study, CTPA was performed routinely on hospital admission, regardless of whether PE was clinically suspected. No additional PEs were diagnosed at 3-month follow-up, which suggests that looking for PE at the time of hospital admission and use of a prophylactic anticoagulant without the presence of PE is safe, effective, and prevents the development of new PEs from hospitalization through 3-month follow-up.

The investigators concluded that based on the results of the current study, they support the use of CTPA examinations on hospital admissions in patients with COVID-19 who require supplemental oxygen, have high D-dimer concentrations, or have a long history of symptoms of COVID-19, unless contraindicated.

Reference

Jevnikar M, Sanchez O, Chocron R, et al. Prevalence of pulmonary embolism in patients with COVID 19 at the time of hospital admission. Eur Respir J. Published online March 10, 2021. doi:10.1183/13993003.00116-2021