Age-Adjusted D-Dimer Levels May Improve Diagnostic Assessment for Pulmonary Embolism in COVID-19 Patients

Abstract

Introduction: SARS-CoV-2 infection leads to a hypercoagulable state. The prevalence of pulmonary embolism (PE) seems to be higher in this subgroup of patients. Patients and methods: We combined data from two tertiary referral centers specialized in the management of PE. The aims of this study were as follows: (1) to evaluate the prevalence of PE among a large population of consecutive patients admitted for COVID-19 pneumonia in two centers, (2) to identify a plasma D-dimer threshold that may be useful in PE diagnostic assessment, (3) to characterize the abnormalities associated with PE and mortality in COVID-19 patients. Results: The incidence of symptomatic acute PE was 19.3%. For diagnosing PE in COVID-19 patients, based on ROC curve analysis, we identified a D-dimer concentration/patient’s age ratio of 70, which improved D-dimer diagnostic capacity for PE and led to a reclassification improvement of 14% (NRI 0.14, p = 0.03) when compared to a cut-off level of 1000 ng/mL. Especially in severe COVID-19 lung involvement, D-dimer/age ratio cut-off equal to 70 was characterized by high diagnostic feasibility (sensitivity, specificity, negative predictive value, positive predictive value of 83%, 94%, 96%, and 73%, respectively). Apart from PE status, lung involvement and troponin T concentration were also independent predictors of in-hospital mortality. In the subgroup of PE patients, mortality was comparable with non-PE patients (19/88 (21.5%) vs. 101/368 (27.4%) for non-PE, p = 0.26) and was associated with older age, higher Bova scores, and higher troponin T concentrations. Age was the sole independent predictor for mortality in this subgroup. Conclusions: PE in COVID-19 patients is common, but it may not influence mortality when managed at a specialized center. In suspected PE, age-adjusted D-dimer levels (upper limit of normal obtained from the formula patient’s age × 70) may still be a useful tool to start the diagnostic workup. In COVID-19 patients without PE, older age, more extensive parenchymal involvement, or higher D-dimer levels are factors predicting mortality.

Permanent and Persistent Atrial Fibrillations Are Independent Risk Factors of Mortality after Severe COVID-19

“…Atrial fibrillation is a well-documented CV risk factor in the general population; however, the impact of AF on the clinical course of COVID-19 has not been adequately defined. Since the earliest published reports, the presence of pre-existing cardiovascular disease has been associated with a high risk of adverse COVID-19 outcomes, and cardiovascular complications during the infection are common [ 3 , 9 , 10 ]. Our results highlight the prognostic relevance of AF—34% of COVID-19 hospitalized patients had a history of AF associated with a fatal outcome.…”

The application of an age adjusted D-dimer threshold to rule out suspected venous thromboembolism (VTE) in an emergency department setting: a retrospective diagnostic cohort study

“…The use of D-Dimer assays to exclude VTE in patients with concurrent COVID-19 remains relatively under investigated and use of age adjusted D-Dimer has not been validated in this setting. Some retrospective analysis suggests the same validated threshold for non-COVID-19 patient should be used to exclude PE in patients with COVID-19 [ 21 ], and other suggests that age adjusted D-Dimers may improve diagnostic assessment for patients with PE [ 22 ]. Further investigation of the utility of the AADD in the COVID-19 patient population and methods to improve the performance of the tests is required.…”

Prognostic association between d-dimer thresholds and 30-day pulmonary embolism diagnosis among emergency department patients with suspected SARS-CoV-2 infection: a Canadian COVID-19 Emergency Department Rapid Response Network study

“…While prior research has explored the diagnostic performance of standard (500 ng/mL) and age-adjusted D-dimer for PE diagnosis in the setting of SARS-CoV-2 [ 5 , 6 ], as well as the prognostic association between D-dimer and mortality among hospitalized SARS-CoV-2 patients [ 7 , 8 ], an evaluation of the prognostic association between D-dimer and subsequent PE risk in a cohort of ED patients with suspected SARS-CoV-2 infection is lacking.…”