Francis Couturaud1,2,3, Laurent Bertoletti3,4,5, Jean Pastre6,7, Pierre-Marie Roy3,8,9, Raphael Le Mao1,2,3, Frédéric Gagnadoux10,11, Nicolas Paleiron12, Jeannot Schmidt3,13,14, Olivier Sanchez3,6,7, Elodie De Magalhaes3,4,5, Mariam Kamara15, Clément Hoffmann2,16, Luc Bressollette2,3,16, Michel Nonent2,17, Cécile Tromeur1,2,3, Pierre-Yves Salaun3,18,19, Sophie Barillot20, Florence Gatineau20, Patrick Mismetti3,4,5, Philippe Girard3,21, Karine Lacut1,2,3, Catherine A Lemarié1,2,3,22, Guy Meyer3,6,23, Christophe Leroyer1,2,3. 1. Département de Médecine Interne et Pneumologie, Centre Hospitalo-Universitaire de Brest, Brest, France. 2. EA 3878, INSERM CIC 1412, Université de Bretagne Occidentale, Brest, France. 3. FCRIN INNOVTE, France. 4. Service de Médecine Vasculaire et Thérapeutique, Centre Hospitalo-Universitaire de Saint-Etienne, Saint-Etienne, France. 5. INSERM CIC 1408, INSERM UMR 1059, Université Jean Monnet, Saint-Etienne, France. 6. Service de Pneumologie et de Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, Paris, France. 7. INSERM UMR S 1140, Université de Paris; Paris, France. 8. Service des urgences, Centre Hospitalo-Universitaire d'Angers, France. 9. Institut MITOVASC, EA 3860, Université d'Angers, Angers, France. 10. Département de Pneumologie, Centre Hospitalo-Universitaire d'Angers, France. 11. INSERM UMR1063, Université d'Angers, Angers, France. 12. Service de pneumologie-allergologie-cancérologie thoracique, HIA Sainte Anne, Toulon, France. 13. Service des urgences, Centre Hospitalo-Universitaire de Clermont-Ferrand, France. 14. UMR 6024 UCA-CNRS, Université de Clermont-Ferrand, Clermont-Ferrand, France. 15. Service des urgences, Centre Hospitalier de Quimper, Quimper, France. 16. Service d'Echo-doppler Vasculaire, Centre Hospitalo-Universitaire de Brest, Brest, France. 17. Service de radiologie, Centre Hospitalo-Universitaire de Brest, Brest, France. 18. Service de Médecine Nucléaire, Centre Hospitalo-Universitaire de Brest, France. 19. EA 3878, Université de Bretagne Occidentale, Brest, France. 20. INSERM CIC 1412, Centre Hospitalo-Universitaire de Brest, Université de Bretagne Occidentale, Brest, France. 21. Département Thoracique, Institut Mutualiste Montsouris, Paris, France. 22. INSERM 1078, Université de Bretagne Occidentale, Brest, France. 23. INSERM UMR S 970, Université de Paris, Paris, France.
Abstract
IMPORTANCE: The prevalence of pulmonary embolism in patients with chronic obstructive pulmonary disease (COPD) and acutely worsening respiratory symptoms remains uncertain. OBJECTIVE: To determine the prevalence of pulmonary embolism in patients with COPD admitted to the hospital for acutely worsening respiratory symptoms. DESIGN, SETTING, AND PARTICIPANTS: Multicenter cross-sectional study with prospective follow-up conducted in 7 French hospitals. A predefined pulmonary embolism diagnostic algorithm based on Geneva score, D-dimer levels, and spiral computed tomographic pulmonary angiography plus leg compression ultrasound was applied within 48 hours of admission; all patients had 3-month follow-up. Patients were recruited from January 2014 to May 2017 and the final date of follow-up was August 22, 2017. EXPOSURES: Acutely worsening respiratory symptoms in patients with COPD. MAIN OUTCOMES AND MEASURES: The primary outcome was pulmonary embolism diagnosed within 48 hours of admission. Key secondary outcome was pulmonary embolism during a 3-month follow-up among patients deemed not to have venous thromboembolism at admission and who did not receive anticoagulant treatment. Other outcomes were venous thromboembolism (pulmonary embolism and/or deep vein thrombosis) at admission and during follow-up, and 3-month mortality, whether venous thromboembolism was clinically suspected or not. RESULTS: Among 740 included patients (mean age, 68.2 years [SD, 10.9 years]; 274 women [37.0%]), pulmonary embolism was confirmed within 48 hours of admission in 44 patients (5.9%; 95% CI, 4.5%-7.9%). Among the 670 patients deemed not to have venous thromboembolism at admission and who did not receive anticoagulation, pulmonary embolism occurred in 5 patients (0.7%; 95% CI, 0.3%-1.7%) during follow-up, including 3 deaths related to pulmonary embolism. The overall 3-month mortality rate was 6.8% (50 of 740; 95% CI, 5.2%-8.8%). The proportion of patients who died during follow-up was higher among those with venous thromboembolism at admission than the proportion of those without it at admission (14 [25.9%] of 54 patients vs 36 [5.2%] of 686; risk difference, 20.7%, 95% CI, 10.7%-33.8%; P < .001). The prevalence of venous thromboembolism was 11.7% (95% CI, 8.6%-15.9%) among patients in whom pulmonary embolism was suspected (n = 299) and was 4.3% (95% CI, 2.8%-6.6%) among those in whom pulmonary embolism was not suspected (n = 441). CONCLUSIONS AND RELEVANCE: Among patients with chronic obstructive pulmonary disease admitted to the hospital with an acute worsening of respiratory symptoms, pulmonary embolism was detected in 5.9% of patients using a predefined diagnostic algorithm. Further research is needed to understand the possible role of systematic screening for pulmonary embolism in this patient population.
IMPORTANCE: The prevalence of pulmonary embolism in patients with chronic obstructive pulmonary disease (COPD) and acutely worsening respiratory symptoms remains uncertain. OBJECTIVE: To determine the prevalence of pulmonary embolism in patients with COPD admitted to the hospital for acutely worsening respiratory symptoms. DESIGN, SETTING, AND PARTICIPANTS: Multicenter cross-sectional study with prospective follow-up conducted in 7 French hospitals. A predefined pulmonary embolism diagnostic algorithm based on Geneva score, D-dimer levels, and spiral computed tomographic pulmonary angiography plus leg compression ultrasound was applied within 48 hours of admission; all patients had 3-month follow-up. Patients were recruited from January 2014 to May 2017 and the final date of follow-up was August 22, 2017. EXPOSURES: Acutely worsening respiratory symptoms in patients with COPD. MAIN OUTCOMES AND MEASURES: The primary outcome was pulmonary embolism diagnosed within 48 hours of admission. Key secondary outcome was pulmonary embolism during a 3-month follow-up among patients deemed not to have venous thromboembolism at admission and who did not receive anticoagulant treatment. Other outcomes were venous thromboembolism (pulmonary embolism and/or deep vein thrombosis) at admission and during follow-up, and 3-month mortality, whether venous thromboembolism was clinically suspected or not. RESULTS: Among 740 included patients (mean age, 68.2 years [SD, 10.9 years]; 274 women [37.0%]), pulmonary embolism was confirmed within 48 hours of admission in 44 patients (5.9%; 95% CI, 4.5%-7.9%). Among the 670 patients deemed not to have venous thromboembolism at admission and who did not receive anticoagulation, pulmonary embolism occurred in 5 patients (0.7%; 95% CI, 0.3%-1.7%) during follow-up, including 3 deaths related to pulmonary embolism. The overall 3-month mortality rate was 6.8% (50 of 740; 95% CI, 5.2%-8.8%). The proportion of patients who died during follow-up was higher among those with venous thromboembolism at admission than the proportion of those without it at admission (14 [25.9%] of 54 patients vs 36 [5.2%] of 686; risk difference, 20.7%, 95% CI, 10.7%-33.8%; P < .001). The prevalence of venous thromboembolism was 11.7% (95% CI, 8.6%-15.9%) among patients in whom pulmonary embolism was suspected (n = 299) and was 4.3% (95% CI, 2.8%-6.6%) among those in whom pulmonary embolism was not suspected (n = 441). CONCLUSIONS AND RELEVANCE: Among patients with chronic obstructive pulmonary disease admitted to the hospital with an acute worsening of respiratory symptoms, pulmonary embolism was detected in 5.9% of patients using a predefined diagnostic algorithm. Further research is needed to understand the possible role of systematic screening for pulmonary embolism in this patient population.
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