Pulmonary Embolism in Patients With COVID-19

Quick Takes

  • Pulmonary embolism (PE) is an uncommon finding upon presentation to the emergency department for patients diagnosed with COVID-19.
  • Patients with COVID-19 and PE more often have smaller, more peripheral clot location and less often have a history of PE than patients without COVID-19.
  • Patients with COVID-19 and PE have a markedly higher mortality rate than non-COVID-19 patients.

Study Questions:

What is the incidence and what are the risk factors, clinical characteristics, and outcomes of pulmonary embolism (PE) in patients with coronavirus disease 2019 (COVID-19) attending the emergency department (ED) before hospitalization?

Methods:

The authors performed a retrospective, case-controlled analysis of all patients with COVID-19 presenting to 62 Spanish EDs (20% of all EDs in Spain) during the first COVID-19 outbreak (March 1–April 30, 2020). Comparison groups included patients with COVID-19 but no PE as well as patients with PE but no COVID-19. Cases were matched 1:1 with one of each control group patients (PE without COVID-19, COVID-19 without PE) across a range of demographic and clinical characteristics. Outcomes assessed were the need for intensive care unit (ICU) admission, hospital stay longer than 7 days, and all-cause in-hospital mortality.

Results:

Among the 74,814 patients with COVID-19, 368 (4.92%) developed PE. These cases were matched with 368 patients in each of the control groups (COVID-19 without PE, PE without COVID-19). The standard incidence of PE among patients with COVID-19 was 310/100,000 person-years, significantly higher than in non-COVID-19 populations (35/100,000 person-years; odds ratio [OR], 8.95; 95% confidence interval [CI], 8.51-9.41). Independent predictors of PE included elevated D-dimer >1000 ng/ml, chest pain, and chronic heart failure (inverse association). Patients with PE and COVID-19 differed from those without COVID-19 by less often having a prior thromboembolic event, less often using chronic estrogen therapy, and more often being restricted to segmental or subsegmental pulmonary arteries. In-hospital mortality was similar between patients with COVID-19 who did and did not have PE (16.0% for cases vs. 16.6% for COVID-19 controls; OR, 0.96; 95% CI, 0.65-1.42). However, in-hospital mortality was higher for patients with PE and COVID-19 than those with PE who did not have COVID-19 (16.0% vs. 6.5%; OR, 2.74; 95% CI, 1.66-4.51).

Conclusions:

The authors concluded that the presence of PE upon presentation in patients with COVID-19 is uncommon (0.5%), but is nearly nine-fold higher than the general population. The authors also concluded that in-hospital mortality was similar between patients with COVID-19 who did and did not have PE, but was higher among patients with COVID-19 and PE than patients with PE who did not have COVID-19.

Perspective:

Numerous prior observational studies have linked COVID-19 infection with thromboembolism. Most of these studies have identified the risk during hospital stay, especially for patients with critically severe COVID-19 who require organ support and/or ICU stay. This large, multicenter study from Spain adds to the understanding of COVID-19 and thromboembolism risk in a few important ways. First, the presence of PE is uncommon at the time of hospital presentation (0.5%), which differs significantly from the estimates of 17.0% during a hospital stay (Jiménez D, et al., Chest 2021;159:1182-96). Second, patients with COVID-19 who develop PE appear to have different characteristics than those who develop PE without COVID-19. These include more first-time venous thromboembolic events, less common use of estrogen therapy, and smaller/more peripheral clot location. This may reflect the current theory that COVID-19 promotes a “thrombus in situ” in the pulmonary arteries more so that a thromboembolism from the lower extremity deep vein mechanism. Finally, the markedly higher in-hospital mortality among patients with COVID-19 and PE as compared to those with PE but no COVID-19 is striking. However, the data presented here come from the first outbreak (March–April 2020) and its therapies targeting COVID-19 and supporting patients with COVID-19 have evolved significantly in the year since these data were collected.

Clinical Topics: Anticoagulation Management, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Anticoagulation Management and Venothromboembolism, Acute Heart Failure

Keywords: Anticoagulants, Chest Pain, Coronavirus, COVID-19, Disease Outbreaks, Emergency Service, Hospital, Estrogens, Heart Failure, Hospital Mortality, Intensive Care Units, Length of Stay, Pulmonary Embolism, Risk Factors, Secondary Prevention, Vascular Diseases, Venous Thromboembolism, Venous Thrombosis


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