Pulmonary embolism in patients with COVID-19: incidence, risk factors, clinical characteristics, and outcome

Abstract

Aims We investigated the incidence, risk factors, clinical characteristics, and outcomes of pulmonary embolism (PE) in patients with COVID-19 attending emergency departments (EDs), before hospitalization. Methods and Results We retrospectively reviewed all COVID-19 patients diagnosed with PE in 62 Spanish EDs (20% of Spanish EDs, case group) during the first COVID-19 outbreak. COVID-19 patients without PE and non-COVID-19 patients with PE were included as control groups. Adjusted comparisons for baseline characteristics, acute episode characteristics, and outcomes were made between cases and randomly selected controls (1:1 ratio). We identified 368 PE in 74 814 patients with COVID-19 attending EDs (4.92‰). The standardized incidence of PE in the COVID-19 population resulted in 310 per 100 000 person-years, significantly higher than that observed in the non-COVID-19 population [35 per 100 000 person-years; odds ratio (OR) 8.95 for PE in the COVID-19 population, 95% confidence interval (CI) 8.51–9.41]. Several characteristics in COVID-19 patients were independently associated with PE, the strongest being D-dimer >1000 ng/mL, and chest pain (direct association) and chronic heart failure (inverse association). COVID-19 patients with PE differed from non-COVID-19 patients with PE in 16 characteristics, most directly related to COVID-19 infection; remarkably, D-dimer >1000 ng/mL, leg swelling/pain, and PE risk factors were significantly less present. PE in COVID-19 patients affected smaller pulmonary arteries than in non-COVID-19 patients, although right ventricular dysfunction was similar in both groups. In-hospital mortality in cases (16.0%) was similar to COVID-19 patients without PE (16.6%; OR 0.96, 95% CI 0.65–1.42; and 11.4% in a subgroup of COVID-19 patients with PE ruled out by scanner, OR 1.48, 95% CI 0.97–2.27), but higher than in non-COVID-19 patients with PE (6.5%; OR 2.74, 95% CI 1.66–4.51). Adjustment for differences in baseline and acute episode characteristics and sensitivity analysis reported very similar associations. Conclusions PE in COVID-19 patients at ED presentation is unusual (about 0.5%), but incidence is approximately ninefold higher than in the general (non-COVID-19) population. Moreover, risk factors and leg symptoms are less frequent, D-dimer increase is lower and emboli involve smaller pulmonary arteries. While PE probably does not increase the mortality of COVID-19 patients, mortality is higher in COVID-19 than in non-COVID-19 patients with PE.

Impact of COVID-19 and lockdowns on pulmonary embolism in hospitalized patients in France: a nationwide study

“…Furthermore, our database shows that mortality was significantly greater for COVID-19 patients with PE versus COVID-19 patients without PE. This result contrasts with a previous study [ 24 ] which found no difference . This might be due to the greater power of our national data or to national differences in patient management.…”

“…Further investigations will be needed to clarify the relationship between deep vein thrombosis (DVT) and PE in COVID-19 and in comparison with other ARDS. As suggested in metanalyses on DVT and PE [ 24 , 31 ], there is a major to identify the proportion of PE resulting from DVT embolism and the proportion resulting from COVID-19 pulmonary vasculopathy. The endothelial effect of ARDS, which is well-known, is more correlated with duration of disease than with a specific cause [ 32 , 33 ]).…”

Association between Early Absolute Neutrophil Count and Level of D-Dimer among Patients with COVID-19 Infection in Central Taiwan

“…Unlike a consistent finding with an apparently high prevalence of thromboembolic events among patients with COVID-19 infection in western countries, the ethnic difference remains an essential issue with regard to the prevalence of thromboembolic events and the need for routine thromboprophylaxis among patients with COVID-19 infection in Asian countries, highlighting the need for real-world data on thromboembolic events in the Asian population [7][8][9][10]. Additionally, recent studies have implicated neutrophilic inflammatory response, particularly neutrophil extracellular traps (NETs), with the pathogenesis of thrombosis formation in COVID-19 infection [11].…”

“…Recent evidence has found highly prevalent thromboembolic events, including deep venous thrombosis (DVT), pulmonary embolism (PE) and acute ischemic stroke, in patients with COVID-19 infection, and D-dimer has been attributed as an essential biomarker for thromboembolic events in patients with COVID-19 infection [4][5][6]. Miro et al, investigating 74,814 patients with COVID-19 with 1,388,879 non-COVID-19 controls in Spain, recently reported that the incidence of PE in patients with COVID-19 was approximately nine-fold higher than those in the non-COVID-19 population (310 vs. 35 per 100,000 person-years) [7].…”

miRNAs, from Evolutionary Junk to Possible Prognostic Markers and Therapeutic Targets in COVID-19

“…Pulmonary embolism (PE) can contribute to a sudden deterioration in oxygen exchange. Although unusual in COVID-19 patients (around 0.5%), the incidence is approximately nine times higher than in the general population [78,79]. The upregulation of miR-9 in SARS-CoV-2 infection dysregulates transcription factor EP300, which increases plasminogen activator inhibitor 1 (PAI-1).…”