Background There have been reports of procoagulant activity in patients with COVID‐19. Whether there is an association between pulmonary embolism (PE) and COVID‐19 in the emergency department (ED) is unknown. The aim of this study was to assess whether COVID‐19 is associated with PE in ED patients who underwent a computed tomographic pulmonary angiogram (CTPA). Methods A retrospective study in 26 EDs from six countries. ED patients in whom a CTPA was performed for suspected PE during a 2‐month period covering the pandemic peak. The primary endpoint was the occurrence of a PE on CTPA. COVID‐19 was diagnosed in the ED either on CT or reverse transcriptase–polymerase chain reaction. A multivariable binary logistic regression was built to adjust with other variables known to be associated with PE. A sensitivity analysis was performed in patients included during the pandemic period. Results A total of 3,358 patients were included, of whom 105 were excluded because COVID‐19 status was unknown, leaving 3,253 for analysis. Among them, 974 (30%) were diagnosed with COVID‐19. Mean (±SD) age was 61 (±19) years and 52% were women. A PE was diagnosed on CTPA in 500 patients (15%). The risk of PE was similar between COVID‐19 patients and others (15% in both groups). In the multivariable binary logistic regression model, COVID‐19 was not associated with higher risk of PE (adjusted odds ratio = 0.98, 95% confidence interval = 0.76 to 1.26). There was no association when limited to patients in the pandemic period. Conclusion In ED patients who underwent CTPA for suspected PE, COVID‐19 was not associated with an increased probability of PE diagnosis. These results were also valid when limited to the pandemic period. However, these results may not apply to patients with suspected COVID‐19 in general.

IMPORTANCE Uncontrolled studies suggest that pulmonary embolism (PE) can be safely ruled out using the YEARS rule, a diagnostic strategy that uses varying D-dimer thresholds.OBJECTIVE To prospectively validate the safety of a strategy that combines the YEARS rule with the pulmonary embolism rule-out criteria (PERC) rule and an age-adjusted D-dimer threshold. DESIGN, SETTINGS, AND PARTICIPANTSA cluster-randomized, crossover, noninferiority trial in 18 emergency departments (EDs) in France and Spain. Patients (N = 1414) who had a low clinical risk of PE not excluded by the PERC rule or a subjective clinical intermediate risk of PE were included from October 2019 to June 2020, and followed up until October 2020.INTERVENTIONS Each center was randomized for the sequence of intervention periods. In the intervention period (726 patients), PE was excluded without chest imaging in patients with no YEARS criteria and a D-dimer level less than 1000 ng/mL and in patients with 1 or more YEARS criteria and a D-dimer level less than the age-adjusted threshold (500 ng/mL if age <50 years or age in years × 10 in patients Ն50 years). In the control period (688 patients), PE was excluded without chest imaging if the D-dimer level was less than the age-adjusted threshold. MAIN OUTCOMES AND MEASURESThe primary end point was venous thromboembolism (VTE) at 3 months. The noninferiority margin was set at 1.35%. There were 8 secondary end points, including chest imaging, ED length of stay, hospital admission, nonindicated anticoagulation treatment, all-cause death, and all-cause readmission at 3 months. RESULTSOf the 1414 included patients (mean age, 55 years; 58% female), 1217 (86%) were analyzed in the per-protocol analysis. PE was diagnosed in the ED in 100 patients (7.1%). At 3 months, VTE was diagnosed in 1 patient in the intervention group (0.15% [95% CI, 0.0% to 0.86%]) vs 5 patients in the control group (0.80% [95% CI, 0.26% to 1.86%]) (adjusted difference, −0.64% [1-sided 97.5% CI, −ϱ to 0.21%], within the noninferiority margin). Of the 6 analyzed secondary end points, only 2 showed a statistically significant difference in the intervention group compared with the control group: chest imaging (30.4% vs 40.0%; adjusted difference, −8.7% [95% CI, −13.8% to −3.5%]) and ED median length of stay (6 hours [IQR, 4 to 8 hours] vs 6 hours [IQR, 5 to 9 hours]; adjusted difference, −1.6 hours [95% CI, −2.3 to −0.9]).CONCLUSIONS AND RELEVANCE Among ED patients with suspected PE, the use of the YEARS rule combined with the age-adjusted D-dimer threshold in PERC-positive patients, compared with a conventional diagnostic strategy, did not result in an inferior rate of thromboembolic events.

IMPORTANCE Clinical guidelines for the early management of acute heart failure in the emergency department (ED) setting are based on only moderate levels of evidence, with subsequent low adherence to these guidelines.OBJECTIVE To test the effect of an early guideline-recommended care bundle on short-term prognosis in older patients with acute heart failure in the ED. DESIGN, SETTING, AND PARTICIPANTSStepped-wedge cluster randomized trial in 15 EDs in France of 503 patients 75 years and older with a diagnosis of acute heart failure in the ED from December 2018 to September 2019 and followed up for 30 days until October 2019.INTERVENTIONS A care bundle that included early intravenous nitrate boluses; management of precipitating factors, such as acute coronary syndrome, infection, or atrial fibrillation; and moderate dose of intravenous diuretics (n = 200). In the control group, patient care was left to the discretion of the treating emergency physician (n = 303). Each center was randomized to the order in which they switched to the "intervention period." After the initial 4-week control period for all centers, 1 center entered in the intervention period every 2 weeks. MAIN OUTCOMES AND MEASURESThe primary end point was the number of days alive and out of hospital at 30 days. Secondary outcomes included 30-day all-cause mortality, 30-day cardiovascular mortality, unscheduled readmission, length of hospital stay, and kidney impairment.RESULTS Among 503 patients who were randomized (median age, 87 years; 298 [59%] women), 502 were analyzed. In the intervention group, patients received a median (interquartile range) of 27.0 (9-54) mg of intravenous nitrates in the first 4 hours vs 4.0 (2.0-6.0) mg in the control group (adjusted difference, 23.8 [95% CI, 13.5-34.1]). There was a significantly higher percentage of patients in the intervention group treated for their precipitating factors than in the control group (58.8% vs 31.9%; adjusted difference, 31.1% [95% CI, 14.3%-47.9%]). There was no statistically significant difference in the primary end point of the number of days alive and out of hospital at 30 days (median [interquartile range], 19 [0-24] d in both groups; adjusted difference, −1.9 [95% CI, −6.6 to 2.8]; adjusted ratio, 0.88 [95% CI, 0.64-1.21]). At 30 days, there was no significant difference between the intervention and control groups in mortality (8.0% vs 9.7%; adjusted difference, 4.1% [95% CI, −17.2% to 25.3%]), cardiovascular mortality (5.0% vs 7.4%; adjusted difference, 2.1% [95% CI, −15.5% to 19.8%]), unscheduled readmission (14.3% vs 15.7%; adjusted difference, −1.3% [95% CI, −26.3% to 23.7%]), median length of hospital stay (8 d in both groups; adjusted difference, 2.5 [95% CI, −0.9 to 5.8]), and kidney impairment (1% in both groups).CONCLUSIONS AND RELEVANCE Among older patients with acute heart failure, use of a guideline-based comprehensive care bundle in the ED compared with usual care did not result in a statistically significant difference in the number of days alive and out of the hospital a...

Introduction Worldwide, the COVID-19 epidemic has put health systems to the test. The excess mortality is partly due to the influx of patients requiring hospitalization and intensive care. We propose that the chronology of epidemic spread gives a window of time in which hospitals can act to prevent reaching capacity. Methods The out-of-hospital SAMU Emergency Medical System in an entry point into the French health care system. We recorded the number of patients managed, of patients transferred to emergency departments (ED), and of mobile intensive care units (MICUs) dispatched. Each criterion was compared to the mean of the same criterion over the previous 5 years. The alert threshold which indicated a public health crisis was defined as a 20% increase compared to the 5-year mean. Results The reference period, from January 2015 to December 2019, included 3 381 611 calls, and 1 137 856 patients. The study period, from 17 February to 28 March 2020, included 166 888 calls, and 56 708 patients. The daily numbers of patients managed crossed the threshold on February 25, and increased until the end of the study period. The daily number of patients transferred to ED crossed the threshold on March 16, and increased until the end of the period. The daily number of MICUs dispatched crossed the threshold on March 15, and increased until the end of the period. Conclusion The COVID-19 epidemic reached our department in three consecutive waves which overwhelmed the health care system. The first wave preceded by 30 days the massive arrival of critical patients. Health care systems must take advantage of this delay to prepare for the third wave.

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BackgroundOur purpose was to describe the care pathway of patients hospitalized for acute heart failure (AHF) and investigate whether a management involving a cardiology department had an impact on in-hospital mortality.MethodsBetween June 2014 and October 2018, we included patients hospitalized for AHF in 24 French hospitals. Characteristics of the episode, patient’s care pathway and outcomes were recorded on a specific assessment tool. The primary outcome was the association between patient care pathway and in-hospital mortality. The independent association between admission to a cardiology ward and in-hospital mortality was assessed through a multivariate regression model and propensity score matching.ResultsA total of 3677 patients, mean age of 78, were included. The in-hospital mortality rate was 8% (n = 287) and was associated on multivariate regression with advanced age, presence of sepsis, of cardiogenic shock, high New York Heart Association (NYHA) score and increased plasma creatinine level on admission. High blood pressure and admission to a cardiology department appeared as protective factors. After propensity score matching, hospitalization in a cardiology department remained a protective factor of in-hospital mortality (OR = 0.61 [0.44–0.84], p = 0.002).ConclusionA hospital course of care involving a cardiology department was associated with an increase in hospital survival in AHF patients. These finding may highlight the importance of collaboration between cardiologists and other in-hospitals specialties, such as emergency physicians, in order to find the best in-hospital pathway for patients with AHF.Clinical Trial NCT03903198.

Background The optimal strategy for the diagnosis of pulmonary embolism (PE) in the emergency department (ED) remains debated. To reduce the need of imaging testing, several rules have been recently validated using an elevated D-dimer threshold. Objective: To validate the safety of different diagnostic strategies and compare the efficacy in terms of chest imaging testing. Design and patients: Post-hoc analysis of individual data of 3330 adult patients without a high clinical probability of PE in the ED followed-up at 3 months in France and Spain (1916 from the PROPER cohort, 1414 from the MODIGLIANI cohort). Exposure: Four diagnostic strategies with an elevated D-dimer threshold if PE is unlikely. The YEARS combined with Pulmonary Embolism Rule-out Criteria (PERC) the pulmonary embolism graduated D-dimer (PEGeD) combined with PERC and the 4-level pulmonary embolism probability score (4PEPS) rules were assessed. A modified simplified (MODS) rule with a simplified YEARS reduced to the sole item of “Is PE the most likely diagnosis” combined with PERC was also tested. Outcome measure and analysis: The primary outcome was the proportion of diagnosed PE or deep venous thrombosis at 3 months in patients in whom PE could have been excluded without chest imaging according to the tested strategy. The safety of a strategy was confirmed if the failure rate was less than 1.85%. The secondary outcome was the use of imaging testing according to each rule. Results: Among 3330 analyzed patients, 150 (4.5%) had a PE. The number of missed PEs were 25, 29, 30 and 26 for the PERC+YEARS, PERC+PEGeD, 4PEPS and MODS rules respectively, with a failure rate of 0.75% (95% CI 0.51% to 1.10%), 0.87% (0.61% to 1.25%), 0.90% (0.63% to 1.28%) and 0.78% (0.53% to 1.14%) respectively. There was no significant difference in the failure rate between rules. Except for a significant lower use of chest imaging for 4PEPS compared to YEARS (14.9% vs 16.3%, difference -1.4% [95%CI -2.1% to -0.8%]), there was no difference in the proportion of imaging testing. Conclusion: In this post-hoc analysis of patients with suspicion of PE, YEARS and PEGeD combined with PERC, and 4PEPS were safe to exclude PE. The safety of the modified simplified MODS strategy was also confirmed. There was no significant difference of the failure rate between strategies.

Objective To compare the severity of pulmonary embolism (PE) between patients with and without COVID, and to assess the association between severity and in-hospital-mortality. Methods We performed an analysis of 549 COVID (71.3% PCR-confirmed) and 439 non-COVID patients with PE consecutively included by 62 Spanish and 16 French emergency departments. PE-severity was assessed by size, the presence of right ventricular dysfunction (RVD), and the sPESI. The association of PE-severity and in-hospital-mortality was assessed both in COVID and non-COVID patients, and the interaction of COVID status and PE severity/outcome associations was also evaluated. Results COVID patients had PEs of smaller size (43% vs 56% lobar or larger, 42% vs. 35% segmental and 13% vs. 9% subsegmental, respectively; p = 0.01 for trend), less RVD (22% vs. 16%, p = 0.02) and lower sPESI ( p = 0.03 for trend). Risk of in-hospital death was higher in COVID patients (12.8% vs. 5.3%, p < 0.001). PE-severity assessed by RVD and sPESI was independently associated with in-hospital-mortality in COVID patients, while PE size and sPESI were significantly associated with in-hospital-mortality in non-COVID. COVID status showed a significant interaction in the association of PE size and outcome ( p = 0.01), with OR for in-hospital mortality in COVID and non-COVID patients with lobar or larger PE of 0.92 (95%CI=0.19–4.47) and 4.47 (95%CI=1.60–12.5), respectively. Sensitivity analyses using only PCR-confirmed COVID cases confirmed these results. Conclusion COVID patients present a differential clinical picture, with PE of less severity than in non-COVID patients. An increased sPESI was associated with the risk of mortality in both groups but, PE size did not seem to be associated with in-hospital mortality in COVID patients.