Randomised trial of effect of compression stockings in patients with symptomatic proximalvein thrombosis Brandjes, D.P.M.; Büller, H.R.; Heijboer, H.; Huisman, M.V.; de Rijk, M.; Jagt, H.; ten Cate, J.W.

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Background Whereas accumulating studies on COVID‐19 patients report high incidences of thrombotic complications, large studies on clinically relevant thrombosis in patients with other respiratory tract infections are lacking. How this high risk in COVID‐19 patients compares to those observed in hospitalized patients with other viral pneumonias such as influenza is unknown. Objectives To assess the incidence of venous and arterial thrombotic complications in hospitalized influenza patients as opposed to that observed in hospitalized COVID‐19 patients. Methods Retrospective cohort study; we used data from Statistics Netherlands (study period: 2018) on thrombotic complications in hospitalized influenza patients. In parallel, we assessed the cumulative incidence of thrombotic complications – adjusted for competing risk of death ‐ in patients with COVID‐19 in three Dutch hospitals (February 24th ‐ April 26th 2020). Results Of the 13.217 hospitalized influenza patients, 437 (3.3%) were diagnosed with thrombotic complications, versus 66 (11%) of the 579 hospitalized COVID‐19 patients. The 30‐day cumulative incidence of any thrombotic complication in influenza was 11% (95%CI 9.4‐12) versus 25% (95%CI 18‐32) in COVID‐19. For venous thrombotic complications (VTE) and arterial thrombotic complications alone, these numbers were respectively 3.6% (95%CI 2.7‐4.6) and 7.5% (95%CI 6.3‐8.8) in influenza versus 23% (95%CI 16‐29) and 4.4% (95%CI 1.9‐8.8) in COVID‐19. Conclusions The incidence of thrombotic complications in hospitalized influenza patients was lower than in hospitalized COVID‐19 patients. This difference was mainly driven by a high risk of VTE complications in the COVID‐19 patients admitted to ICU. Remarkably, influenza patients were more often diagnosed with arterial thrombotic complications.

A cute pulmonary embolism (PE) is the third most common cardiovascular condition, after coronary artery disease and stroke (1). Due to lack of specific sets of symptoms that accurately predict or exclude the diagnosis of acute PE, the diagnosis strongly relies on noninvasive imaging techniques. Diagnostic strategies for evaluating PE have undergone important changes over the past decades (2). Due to rapid technical advances in speed and spatial resolution, the utility of computed tomography (CT) angiography has been recognized in vascular imaging. Particularly, after the development of multidetector row CT in 1998 (3), CT pulmonary angiography (CTPA) has become the imaging method of choice in the diagnosis of acute PE (4). CTPA has advantages over conventional invasive X-ray pulmonary angiography and nuclear ventilation-perfusion (V/Q) imaging. CT is a widely available, fast and noninvasive technique, has the capability to directly visualize emboli, and may provide alternative diagnoses (4).Despite adequate diagnosis and anticoagulant therapy, death rate after a diagnosis of acute PE is still 8%-15% (5, 6). The prognosis of acute PE mainly depends on residual pulmonary circulation and the severity of right ventricular (RV) dysfunction (7). Recent studies have shown that CT permits the assessment of acute right-sided heart failure. Furthermore, CT can predict adverse clinical outcome by using the RV/left ventricular (LV) diameter ratio (8, 9) or RV ejection fraction in patients with PE (10).The aim of this review is to discuss the developments of CT in PE diagnosis, and to analyze the added value of CT in estimating PE severity and prognosis. Furthermore, CT findings of chronic thromboembolic pulmonary arterial hypertension (CTEPH) as a complication of acute PE will be discussed. CT developments in PE diagnosisHistorically, pulmonary angiography and nuclear planar V/Q-imaging were the main imaging methods used for diagnosing PE. Both methods have recognized limitations. Pulmonary angiography has previously been regarded as reference standard, but the method CHEST IMAGING REVIEW ABSTRACT Pulmonary embolism (PE) is a potentially life threatening condition requiring adequate diagnosis and treatment. Computed tomography pulmonary angiography (CTPA) is excellent for including and excluding PE, therefore CT is the first-choice diagnostic imaging technique in patients suspected of having acute PE. Due to its wide availability and low invasiveness, CTPA tends to be overused. Correct implementation of clinical decision rules in diagnostic workup for PE improves adequate use of CT. Also, CT adds prognostic value by evaluating right ventricular (RV) function. CT-assessed RV dysfunction and to lesser extent central emboli location predicts PE-related mortality in normotensive and hypotensive patients, while PE embolic obstruction index has limited prognostic value. Simple RV/left ventricular (LV) diameter ratio measures >1.0 already predict risk for adverse outcome, whereas ratios <1.0 can safely exclude adverse outcome. Con...

Summary High D‐dimer levels are predictors of death in patients with pulmonary embolism (PE), as are more proximally located, larger emboli. The direct link between these three has not yet been described. A cohort of 674 consecutive patients with confirmed PE was studied. Patients were followed up for 3 months. D‐dimer levels were measured only in patients with an unlikely clinical probability (n = 262). The odds ratio (OR) for death of all variables was calculated. Multivariate analysis was performed to identify independent risk factors for mortality. The best predictive D‐dimer cut‐off point for mortality was a concentration >3000 ng/ml FEU (OR 7·29). High D‐dimer levels were correlated with active malignancy and age over 65 years, both being indicators of 3‐month mortality. High D‐dimer levels were also correlated with centrally located pulmonary emboli and 15‐d mortality. The combination of high D‐dimer levels and central emboli increased early mortality risk by 2·2. High D‐dimer levels in patients with an unlikely clinical probability were associated with fatal outcome after PE. Centrally located pulmonary emboli were associated with higher D‐dimer levels and worse 15‐d mortality. Active malignancy, being an inpatient at time of diagnosis and age over 65 years were associated with higher D‐dimer levels and worse 3‐month survival.