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

• DOI: 10.1007/s00392-020-01766-y
• Publication Date: 2020-11-03T11:03:17Z
• Authors: Pietro Ameri; Riccardo M. Inciardi; Mattia Di Pasquale; Piergiuseppe Agos...; Antonio Bellasi; Rita Camporotondo; Claudia Canale; Valentina Carubelli; Stefano Carugo; Francesco Catagnano; Giambattista Danzi; Laura Dalla Vecchia; Stefano Giovinazzo; Massimiliano Gnecchi; Marco Guazzi; Anita Iorio; Maria Teresa La R...; Sergio Leonardi; Gloria Maccagni; Massimo Mapelli; Davide Margonato; Marco Merlo; Luca Monzo; Andrea Mortara; Vincenzo Nuzzi; Massimo Piepoli; Italo Porto; Andrea Pozzi; Giovanni Provenzale; Filippo Sarullo; Gianfranco Sinagra; Chiara Tedino; Daniela Tomasoni; Maurizio Volterrani; Gregorio Zaccone; Carlo Mario Lombardi; Michele Senni; Marco Metra
• Keywords: Male; COVID-19; Thromboembolism; d-dimer; Coagulopathy; Anticoagulant; Death;; 610; Hemorrhage; Anticoagulant; Coagulopathy; COVID-19; d-dimer; Death; Thromboembolism;; Cohort Studies; Fibrin Fibrinogen Degradation Products; 03 medical and health sciences; 0302 clinical medicine; Coagulopathy; Risk Factors; Thromboembolism; 616; Humans; Anticoagulant; COVID-19; Coagulopathy; D-dimer; Death; Thromboembolism; Aged; Aged, 80 and over; COVID-19; Cohort Studies; Female; Fibrin Fibrinogen Degradation Products; Follow-Up Studies; Hemorrhage; Hospital Mortality; Humans; Incidence; Italy; Male; Middle Aged; Pulmonary Embolism; Respiration, Artificial; Retrospective Studies; Risk Factors; Tomography, X-Ray Computed; Hospitalization; Hospital Mortality; d-dimer; anticoagulant; coagulopathy; COVID-19; d-dimer; death; thromboembolism; Aged; Retrospective Studies; Aged, 80 and over; Anticoagulant, COVID-19, Coagulopathy, D-dimer, Death, Thromboembolism; Original Paper; Incidence; Anticoagulant; Anticoagulant; COVID-19; Coagulopathy; D-dimer; Death; Thromboembolism; COVID-19; General Medicine; Middle Aged; Respiration, Artificial; 3. Good health; Death; Hospitalization; Italy; D-dimer; Female; Cardiology and Cardiovascular Medicine; Pulmonary Embolism; Tomography, X-Ray Computed; Follow-Up Studies

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