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Routine screening for pulmonary embolism in COVID-19 patients at the emergency department: impact of D-dimer testing
Daniël A Korevaar1, Ilayda Aydemir2,3, Maartje W Minnema4
1Department of Respiratory Medicine, Amsterdam UMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. d.a.korevaar@amsterdamumc.nl.
Insights
COVID-19 patients face a higher risk of pulmonary embolism (PE), a condition often missed due to overlapping symptoms. A D-dimer test followed by CTPA if D-dimer is ≥1.00 mg/L effectively screened for PE in these patients.
Area of Science:
- Medical Diagnostics
- Cardiovascular Medicine
- Infectious Diseases
Background:
- COVID-19 patients exhibit an elevated risk for pulmonary embolism (PE).
- Symptomatic overlap between COVID-19 and PE complicates diagnosis.
- Existing PE screening algorithms are insufficient for COVID-19 patients, potentially leading to underdiagnosis.
Purpose of the Study:
- To evaluate a screening algorithm for pulmonary embolism (PE) in patients with suspected or confirmed COVID-19.
- To determine the diagnostic yield of D-dimer testing followed by CT pulmonary angiography (CTPA) in this population.
Main Methods:
- Retrospective analysis of adult patients diagnosed with COVID-19 presenting to emergency departments (ED) between October and December 2020.
- Implementation of a screening protocol: D-dimer testing for all, with CTPA if D-dimer ≥1.00 mg/L.
- Exclusion of patients with missing D-dimer results or those on anticoagulation therapy.
Main Results:
- Out of 445 included COVID-19 patients, 185 (41.6%) had a D-dimer ≥1.00 mg/L.
- CTPA identified PE in 26 of 169 patients (15.4%) with elevated D-dimer levels.
- Overall PE detection rate was 5.8% in the study group, with prevalence increasing significantly with higher D-dimer levels.
Conclusions:
- The D-dimer and CTPA screening algorithm identified a substantial proportion of pulmonary embolism cases in COVID-19 patients.
- Further prospective studies are warranted to validate the algorithm's ability to rule out PE when D-dimer is below 1.00 mg/L.
Abstract:
COVID-19 patients have increased risk of pulmonary embolism (PE), but symptoms of both conditions overlap. Because screening algorithms for PE in COVID-19 patients are currently lacking, PE might be underdiagnosed. We evaluated a screening algorithm in which all patients presenting to the ED with suspected or confirmed COVID-19 routinely undergo D-dimer testing, followed by CT pulmonary angiography (CTPA) if D-dimer is ≥ 1.00 mg/L. Consecutive adult patients presenting to the ED of two university hospitals in Amsterdam, The Netherlands, between 01-10-2020 and 31-12-2020, who had a final diagnosis of COVID-19, were retrospectively included. D-dimer and CTPA results were obtained. Of 541 patients with a final diagnosis of COVID-19 presenting to the ED, 25 (4.6%) were excluded because D-dimer was missing, and 71 (13.1%) because they used anticoagulation therapy. Of 445 included patients, 185 (41.6%; 95%CI 37.0-46.3) had a D-dimer ≥ 1.00 mg/L. CTPA was performed in 169 of them, which showed PE in 26 (15.4%; 95%CI 10.3-21.7), resulting in an overall detection rate of 5.8% (95%CI 3.9-8.4) in the complete study group. In patients with and without PE at CTPA, median D-dimer was 9.84 (IQR 3.90-29.38) and 1.64 (IQR 1.17-3.01), respectively (p < 0.001). PE prevalence increased with increasing D-dimer, ranging from 1.2% (95%CI 0.0-6.4) if D-dimer was 1.00-1.99 mg/L, to 48.6% (95%CI 31.4-66.0) if D-dimer was ≥ 5.00 mg/L. In conclusion, by applying this screening algorithm, PE was identified in a considerable proportion of COVID-19 patients. Prospective management studies should assess if this algorithm safely rules-out PE if D-dimer is < 1.00 mg/L.
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