Routine screening for pulmonary embolism in COVID-19 patients at the emergency department: impact of D-dimer testing followed by CTPA

Abstract

COVID-19 patients have increased risk of pulmonary embolism (PE), but symptoms of both conditions overlap. Because screening algorithms for PE in COVID-19 patients are currently lacking, PE might be underdiagnosed. We evaluated a screening algorithm in which all patients presenting to the ED with suspected or confirmed COVID-19 routinely undergo D-dimer testing, followed by CT pulmonary angiography (CTPA) if D-dimer is ≥ 1.00 mg/L. Consecutive adult patients presenting to the ED of two university hospitals in Amsterdam, The Netherlands, between 01-10-2020 and 31-12-2020, who had a final diagnosis of COVID-19, were retrospectively included. D-dimer and CTPA results were obtained. Of 541 patients with a final diagnosis of COVID-19 presenting to the ED, 25 (4.6%) were excluded because D-dimer was missing, and 71 (13.1%) because they used anticoagulation therapy. Of 445 included patients, 185 (41.6%; 95%CI 37.0–46.3) had a D-dimer ≥ 1.00 mg/L. CTPA was performed in 169 of them, which showed PE in 26 (15.4%; 95%CI 10.3–21.7), resulting in an overall detection rate of 5.8% (95%CI 3.9–8.4) in the complete study group. In patients with and without PE at CTPA, median D-dimer was 9.84 (IQR 3.90–29.38) and 1.64 (IQR 1.17–3.01), respectively (p < 0.001). PE prevalence increased with increasing D-dimer, ranging from 1.2% (95%CI 0.0–6.4) if D-dimer was 1.00–1.99 mg/L, to 48.6% (95%CI 31.4–66.0) if D-dimer was ≥ 5.00 mg/L. In conclusion, by applying this screening algorithm, PE was identified in a considerable proportion of COVID-19 patients. Prospective management studies should assess if this algorithm safely rules-out PE if D-dimer is < 1.00 mg/L.

Rethinking D-dimer’s role in the diagnosis of pulmonary thromboembolism in patients with COVID-19: analysis of a diagnostic test study

“…Given the low speci city of D-dimer for the diagnosis of PE in COVID-19, multiple studies are consistent with increasing the cut-off point to improve the operational characteristics of diagnostic performance (8,(17)(18)(19)(20)(21)(22).…”

A comparison of pulmonary embolism in pediatric and adult patients with acute COVID-19

“…D-dimer values were different between adults with PE and those without PE, as has been reported, 17. , 18. but unlike our adult groups, D-dimer values overlapped in the pediatric groups with and without PE.…”

Examining D-dimer and Empiric Anti-coagulation in COVID-19-Related Thrombosis

“…Comparing this to pre-pandemic studies rates of VTE, among hospitalized non-ICU patients the rate of VTE is estimated to be between 2.8 to 5.6% and rates among ICU patients can be as high as 37% [ 6 - 10 ]. Another recent analysis looking at 445 COVID-19 patients presenting to the ED in whom the treating physician suspected PE observed a rate of 5.8% in this population [ 25 ]. Comparatively, previous studies have shown that the rate of PE in acute chronic obstructive pulmonary disease (COPD) exacerbation is 5.9% [ 26 ].…”