Pulmonary embolism in patients with COVID-19: characteristics and outcomes in the Cardio-COVID Italy multicenter study

Abstract

Background Pulmonary embolism (PE) has been described in coronavirus disease 2019 (COVID-19) critically ill patients, but the evidence from more heterogeneous cohorts is limited. Methods Data were retrospectively obtained from consecutive COVID-19 patients admitted to 13 Cardiology Units in Italy, from March 1st to April 9th, 2020, and followed until in-hospital death, discharge, or April 23rd, 2020. The association of baseline variables with computed tomography-confirmed PE was investigated by Cox hazards regression analysis. The relationship between d-dimer levels and PE incidence was evaluated using restricted cubic splines models. Results The study included 689 patients (67.3 ± 13.2 year-old, 69.4% males), of whom 43.6% were non-invasively ventilated and 15.8% invasively. 52 (7.5%) had PE over 15 (9–24) days of follow-up. Compared with those without PE, these subjects had younger age, higher BMI, less often heart failure and chronic kidney disease, more severe cardio-pulmonary involvement, and higher admission d-dimer [4344 (1099–15,118) vs. 818.5 (417–1460) ng/mL, p < 0.001]. They also received more frequently darunavir/ritonavir, tocilizumab and ventilation support. Furthermore, they faced more bleeding episodes requiring transfusion (15.6% vs. 5.1%, p < 0.001) and non-significantly higher in-hospital mortality (34.6% vs. 22.9%, p = 0.06). In multivariate regression, only d-dimer was associated with PE (HR 1.72, 95% CI 1.13–2.62; p = 0.01). The relation between d-dimer concentrations and PE incidence was linear, without inflection point. Only two subjects had a baseline d-dimer < 500 ng/mL. Conclusions PE occurs in a sizable proportion of hospitalized COVID-19 patients. The implications of bleeding events and the role of d-dimer in this population need to be clarified. Graphic abstract

Incidence and characterization of acute pulmonary embolism in patients with SARS-CoV-2 pneumonia: A multicenter Italian experience

“…Our findings might be explained by the fact that DOAC therapy acts only on the coagulation cascade without the additional anti-inflammatory and endothelial-protection properties associated with heparin that could be particularly useful in this specific setting of patients [ 25 , 26 ]. In line with our results, a recent retrospective study by Ameri et al [ 27 ] reported that an oral anticoagulant therapy prior to the admission for COVID-19 tended to be more frequent among patients who eventually suffered from PE, suggesting a lingering pro-thrombotic status despite oral anticoagulant therapy in this subgroup of patients.…”

Lopinavir/Ritonavir and Darunavir/Cobicistat in Hospitalized COVID-19 Patients: Findings From the Multicenter Italian CORIST Study

“…It is possible that efficacy and side effects balanced for lopinavir (giving a null net effect on mortality) but not for darunavir (giving a net negative effect). Of interest, in an Italian cohort of 689 COVID-19 hospitalized patients followed for negative outcomes ( 39 ), it was found that the incidence of in-hospital pulmonary embolism was higher in patients using DRV/c but not LPV/r. On the contrary, other studies did not find an increased rate of severe adverse effects associated with DRV/c ( 28 , 40 ).…”

COVID-19 and Heart Failure: From Epidemiology During the Pandemic to Myocardial Injury, Myocarditis, and Heart Failure Sequelae

“…Consequently, anti-inflammatory therapies and thromboprophylaxis have been the mainly studied drugs for COVID-19 (51)(52)(53)(54). Dexamethasone was found to be associated with lower 28-day mortality in the controlled, open-label Randomized Evaluation of COVID-19 Therapy (RECOVERY) trial (51).…”