Widespread Parenchymal Abnormalities and Pulmonary Embolism on Contrast-Enhanced CT Predict Disease Severity and Mortality in Hospitalized COVID-19 Patients

Abstract

Purpose: Severe COVID-19 is associated with inflammation, thromboembolic disease, and high mortality. We studied factors associated with fatal outcomes in consecutive COVID-19 patients examined by computed tomography pulmonary angiogram (CTPA).Methods: This retrospective, single-center cohort analysis included 130 PCR-positive patients hospitalized for COVID-19 [35 women and 95 men, median age 57 years (interquartile range 51–64)] with suspected pulmonary embolism based on clinical suspicion. The presence and extent of embolism and parenchymal abnormalities on CTPA were recorded. The severity of pulmonary parenchymal involvement was stratified by two experienced radiologists into two groups: lesions affecting ≤50% or >50% of the parenchyma. Patient characteristics, radiological aspects, laboratory parameters, and 60-day mortality data were collected.Results: Pulmonary embolism was present in 26% of the patients. Most emboli were small and peripheral. Patients with widespread parenchymal abnormalities, with or without pulmonary embolism, had increased main pulmonary artery diameter (p < 0.05) and higher C-reactive protein (p < 0.01), D-dimer (p < 0.01), and troponin T (p < 0.001) and lower hemoglobin (p < 0.001). A wider main pulmonary artery diameter correlated positively with C-reactive protein (r = 0.28, p = 0.001, and n = 130) and procalcitonin. In a multivariant analysis, D-dimer >7.2 mg/L [odds ratio (±95% confidence interval) 4.1 (1.4–12.0)] and ICU stay were significantly associated with embolism (p < 0.001). The highest 60-day mortality was found in patients with widespread parenchymal abnormalities combined with pulmonary embolism (36%), followed by patients with widespread parenchymal abnormalities without pulmonary embolism (26%). In multivariate analysis, high troponin T, D-dimer, and plasma creatinine and widespread parenchymal abnormalities on CT were associated with 60-day mortality.Conclusions: Pulmonary embolism combined with widespread parenchymal abnormalities contributed to mortality risk in COVID-19. Elevated C-reactive protein, D-dimer, troponin-T, P-creatinine, and enlarged pulmonary artery were associated with a worse outcome and may mirror a more severe systemic disease. A liberal approach to radiological investigation should be recommended at clinical deterioration, when the situation allows it. Computed tomography imaging, even without intravenous contrast to assess the severity of pulmonary infiltrates, are of value to predict outcome in COVID-19. Better radiological techniques with higher resolution could potentially improve the detection of microthromboses. This could influence anticoagulant treatment strategies, preventing clinical detoriation.

A Prospective Study Evaluating Cumulative Incidence and a Specific Prediction Rule in Pulmonary Embolism in COVID-19

“…The true incidence of PE is not clear, since diagnostic tests were mostly performed only when thrombotic complications were clinically suspected, which is challenging, as symptoms of moderate-severe COVID-19 overlap with PE. In addition, all these studies were retrospective (7,8,15,16,(21)(22)(23)(24)(25). We present the largest prospective study to date evaluating the incidence of PE.…”

“…However, this incidence may have been conditioned by the limited sample size. Additionally, other studies that analyzed the incidence of PE in COVID-19 were of a retrospective nature; diagnostic procedures were only performed when thrombotic complications were suspected, so the reported incidence may not be considered definitive either (7,8,(21)(22)(23)(24)(25). Overall, all the above seem to indicate that high D-dimer values are common in patients with severe forms of COVID-19 and, as such, it is, therefore, reasonable to believe that patients with COVID-19 are at high risk of PE.…”

Covid-19 and comedications in atrial fibrillation – a case-control study in Stockholm

“…Additionally, coagulopathy is a common and dangerous complication, in particular among severe cases of COVID-19 in SARS-CoV-2-infected patients [3,4]. In critically ill COVID-19 patients, the incidence of thrombotic complications, including pulmonary embolism, is reported to be over 30% [3,5]. This insight led to changes in how hospitalized COVID-19 patients are treated with regards to thromboprophylaxis.…”

“…The infection principally causes respiratory symptoms, ranging from intermittent coughing, via dyspnea, to life threatening acute respiratory distress syndrome [2]. Additionally, coagulopathy is a common and dangerous complication, in particular among severe cases of COVID-19 in SARS-CoV-2-infected patients [3,4]. In critically ill COVID-19 patients, the incidence of thrombotic complications, including pulmonary embolism, is reported to be over 30% [3,5].…”

Association of the changes in pulmonary artery diameters with clinical outcomes in hospitalized patients with COVID-19 infection: A crosssectional study

“…It is well known that increased pulmonary thromboembolic events are responsible for increased morbidity and mortality in patients with coronavirus disease 2019 (COVID- 19) infection [1][2][3][4][5]. The detection of diffuse thromboembolism in the pulmonary arteries (PA) and dilatation of the right ventricle according to autopsy studies and clinical studies suggest that severe pulmonary hypertension (PH) secondary to pulmonary thromboembolism that develops in a large proportion of patients [6][7][8].…”