143 CMAAO
CORONA FACTS and MYTH BUSTER D DIMER
Dr K Aggarwal
President CMAAO
965: Predicting factors for
pulmonary embolism in non-critically ill COVID-19 patients D Dimer > 5000 [
DG ALERT]
A Spanish study published in
the Journal of
Thrombosis and Thrombolysis reported a high rate of
pulmonary embolism (PE) in non-critically ill hospitalised patients
with coronavirus disease 2019 (COVID-19) despite use of standard thromboprophylaxis.
B. Mestre-Gómez, Internal
Medicine Department, Infanta Leonor University Hospital, Madrid, Spain, and
colleagues said "we found 29 patients with proven PE and COVID-19
pneumonia out of 91 CTPA (computed tomography pulmonary angiography tests) performed
among the 452 patients admitted in the study period. That represents an
incidence of 6.4% in a medical ward and one third of positive CTPA despite
prophylactic doses of LMWH (low-molecular-weight heparin)."
They added that an increase
in D-dimer levels is a good predicting factor of PE, with a best cut-off point
of > 5,000 µg/dL.
The single cohort,
longitudinal study focused on patients admitted with COVID-19 diagnosis to
the internal medicine department of a secondary hospital in Madrid between
March 30 and April 12, 2020. Investigators retrospectively reviewed 452
electronic medical records, analyzing the cumulative incidence of PE, and
associated risk factors. Included were 91 patients who underwent a
multidetector CTPA during conventional hospitalization.
Of the 91 CT scans performed,
29 patients (31.9%) were diagnosed with acute PE, while the cumulative
incidence over the entire cohort was 6.4% (29/452 patients). Among these PE
patients, 23 were classified as COVID-19 infection via RT-PCR positive tests,
and 6 had positive CT scans and negative RT-PCR.
In the PE group, 72% (21/29)
of patients were male and the median age was 65 years (IQ 1–3: 56–73), while
median body mass index was 28.8 kg/m2 (IQ 1–3:26.8–31.8).
Median plasma D-dimer peak was 14,480 µg/dL (IQ 1–3:
5,540–33,170 µg/dL), median platelet counts were 137 × 103 (IQ
1–3: 248–260 × 103), median C-reactive protein 110.6 mg/dL
(Q1-3: 40–193) and median ferritin 829 ng/mL (Q1-3: 387–1272). There was
no associated coagulopathy, with a prothrombin time of 12.5 seconds
(Q1-Q3: 11.9–13.5). Most of the PE patients received LMWH (79.3%; 23/29) at
prophylactic doses at the time of diagnosis of PE.
Regarding radiological
findings, 51.7% of PE cases were bilateral (15/29 patients) and 48.3%
unilateral. Most PEs were in a peripheral location in segmental and
sub-segmental arteries (68.9%, 20/29 patients) and 31.0% (9/29 patients) in a
central location (main and lobar arteries).
When comparing PE and non-PE
patients, D-dimer peak was found to be significantly elevated in the PE group
(median 14,480 µg/dL, IQR 5,540–33,170) compared to patients without PE (7,230
µg/dL, IQR 2,100- 16,415, p = 0.03).
A multivariate analysis of
patients who underwent a CTPA indicated that plasma D-dimer peak was an
independent predictor of PE with a best cut off point of > 5,000 µg/dL (OR
3.77; IC95% (1.18–12.16), p = 0.03).
Statistically significant
differences were also found between the two groups for history of dyslipidemia
[10.7%, (3/29) in PE patients versus 40.3% (25/62) in non-PE patients,
p = 0.003], as well as for history of autoimmune disease [10.7% (3/29) versus
0% (0/62), p = 0.03)].
"Interestingly, we found
the history of dyslipidemia as a protector factor for PE in the multivariate
analysis. Patients who did not have this cardiovascular risk in their medical
records, had a nine-fold increased risk for PE compared to those with
dyslipidemia (OR 9.06; IC95% (1.88–43.60). A possible explanation could be
that patients previously treated with statins had a potential benefit either by
their immunomodulatory action or by preventing cardiovascular damage.
There were no statistical
differences in either mortality or admission to the intensive care unit (ICU)
between the PE and non-PE arms in this cohort of non-critically ill COVID 19
patients.
"In our study the
absence of classic risk factor for venous thromboembolism (advanced age,
history of thrombosis, thrombophilia, cancer and ICU admission) and the
peripherical localization of PE suggest microthrombosis in situ. Wells index
seems not to be accurate to predict PE in such a challenging context," the
authors said.
"There was no difference
in severity of pneumonia by CURB-65 score, also [no statistical] difference in
inflammation parameters (high in both groups), treatment or need of
non-invasive ventilation, although figures are higher for non PE group.
Importantly, the actual presence of PE on CT was not associated with mortality
in this small sample," the authors noted.
SOURCE: Journal of Thrombosis and Thrombolysis
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