Pulmonary embolism and COVID-19: A comparative analysis of different diagnostic models performance

Abstract

Objective Pulmonary embolism (PE) is a common complication of SARS-CoV-2 infection. Several diagnostic prediction rules based on pretest probability and D-dimer have been validated in non-COVID patients, but it remains unclear if they can be safely applied in COVID-19 patients. We aimed to compare the diagnostic accuracy of the standard approach based on Wells and Geneva scores combined with a standard D-dimer cut-off of 500 ng/ml with three alternative strategies (age-adjusted, YEARS and PEGeD algorithms) in COVID-19 patients. Methods This retrospective study included all COVID-19 patients admitted to the Emergency Department (ED) who underwent computed tomography pulmonary angiography (CTPA) due to PE suspicion. The diagnostic prediction rules for PE were compared between patients with and without PE. Results We included 300 patients and PE was confirmed in 15%. No differences were found regarding comorbidities, traditional risk factors for PE and signs and symptoms between patients with and without PE. Wells and Geneva scores showed no predictive value for PE occurrence, whether a standard or an age-adjusted cut-off was considered. YEARS and PEGeD algorithms were associated with increased specificity (19% CTPA reduction) but raising non-diagnosed PE. Despite elevated in all patients, those with PE had higher D-dimer levels. However, incrementing thresholds to select patients for CTPA was also associated with a substantial decrease in sensitivity. Conclusion None of the diagnostic prediction rules are reliable predictors of PE in COVID-19. Our data favour the use of a D-dimer threshold of 500 ng/ml, considering that higher thresholds increase specificity but limits this strategy as a screening test.

Predictors of venous thromboembolism in COVID-19 patients: results of the COVID-19 Brazilian Registry

“…The main available scores for predicting VTE in medical patients do not seem to perform well in patients with COVID-19 [ 22 , 23 ]. Furthermore, the score originally developed to predict VTE in patients hospitalized for COVID-19 (CHOD) still needs to be validated in larger populations to confirm its accuracy [ 23 ].…”

Automated Quantitative Lung CT Improves Prognostication in Non-ICU COVID-19 Patients beyond Conventional Biomarkers of Disease

“…Moreover, D-dimer and NLR-as also reported in literature-correlate with the severity of inflammation, a poor prognosis, and fatal outcome [71,[75][76][77][78][79].…”

Examining D-dimer and Empiric Anti-coagulation in COVID-19-Related Thrombosis

“…There was a quick adoption of empiric anticoagulation strategies without confirmatory imaging despite recommendations against such strategies from professional societies [27][28][29][30][31]. Specifically, D-dimer shifted from being a screening test for patients with low to moderate clinical suspicion for PE to being utilized as a blanket screening tool for all comers to help guide physicians on the need to start empiric anticoagulation [14,16,17,32]. Presently, the practice of empiric anticoagulation persists despite a lack of substantiating evidence.…”

“…Some studies suggest that higher D-dimer thresholds, such as two to four times the normal cut-off value, could be used to trigger workup for VTE or initiation of empiric full anticoagulation (AC) among COVID-19 patients [14][15][16]. However, other studies suggest that even these higher cut-offs may have inadequate sensitivity in an ED population to rule out pulmonary embolism (PE) [17]. Several professional societies including the American College of Chest Physicians (CHEST), the National Institute of Health (NIH), and the American Society of Hematology have published guidelines regarding thrombosis in COVID-19.…”