COVID-19-Associated Pulmonary Embolism: Review of the Pathophysiology, Epidemiology, Prevention, Diagnosis, and Treatment

Abstract

COVID-19 is associated with endothelial activation in the setting of a potent inflammatory reaction and a hypercoagulable state. The end result of this thromboinflammatory state is an excess in thrombotic events, in particular venous thromboembolism. Pulmonary embolism (PE) has been of special interest in patients with COVID-19 given its association with respiratory deterioration, increased risk of intensive care unit admission, and prolonged hospital stay. The pathophysiology and clinical characteristics of COVID-19-associated PE may differ from the conventional non–COVID-19-associated PE. In addition to embolic events from deep vein thrombi, in situ pulmonary thrombosis, particularly in smaller vascular beds, may be relevant in patients with COVID-19. Appropriate prevention of thrombotic events in COVID-19 has therefore become of critical interest. Several changes in viral biology, vaccination, and treatment management during the pandemic may have resulted in changes in incidence trends. This review provides an overview of the pathophysiology, epidemiology, clinical characteristics, and risk factors of COVID-19-associated PE. Furthermore, we briefly summarize the results from randomized controlled trials of preventive antithrombotic therapies in COVID-19, focusing on their findings related to PE. We discuss the acute treatment of COVID-19-associated PE, which is substantially similar to the management of conventional non-COVID-19 PE. Ultimately, we comment on the current knowledge gaps in the evidence and the future directions in the treatment and follow-up of COVID-19-associated PE, including long-term management, and its possible association with long-COVID.

Autoimmune Diseases Affecting Hemostasis: A Narrative Review

“…The identification of APS requires both the presence of clinical evidence of thrombosis or pregnancy/fetal morbidity, as well as laboratory evidence of presence of aPL. For the former, thrombosis is already a feature of severe COVID-19 through multiple pro-thrombotic mechanisms [ 78 , 79 , 80 , 81 , 82 ], so this confounds the clinical evidence required to identify APS. For the latter, aPL are present in a proportion of asymptomatic patients (potentially up to 5% of the general population may be positive in one or more aPL tests).…”

Risk of thrombosis recurrence among patients with COVID-19 and surgery-associated venous thromboembolism

“…Different meta-analyses confirmed that COVID-19 patients had a high risk of VTE, ranging from 12 to 26%, although all reported heterogeneity of the studies and a high risk of bias. 5 , 8 , 9 , 10 The incidence of PE among COVID-19 patients has decreased through the course of the pandemic, and this is attributed to the effect of vaccination and new strains of the virus. 11 , 12 However, the risk of recurrence in patients with COVID-19-associated VTE is unknown, and there are only small prospective studies.…”

One-year cardiovascular outcomes after coronavirus disease 2019: The cardiovascular COVID-19 registry

“…Coronavirus disease 2019 (COVID-19) has been associated with multi-organ involvement, including the cardiovascular (CV) system [1,2]. A high rate of thromboembolic complications has been consistently found in hospitalized patients with COVID-19 [3][4][5][6]. In particular, critically ill patients are at higher risk of major adverse CV outcomes, including in-hospital mortality [7].…”