Òscar Miró1, Sònia Jiménez1, Alexandre Mebazaa2, Yonathan Freund3, Guillermo Burillo-Putze4, Alfonso Martín5, Francisco Javier Martín-Sánchez6, Eric Jorge García-Lamberechts6, Aitor Alquézar-Arbé7, Javier Jacob8, Pere Llorens9, Pascual Piñera10, Víctor Gil1, Josep Guardiola7, Carlos Cardozo1, Josep Maria Mòdol Deltell11, Josep Tost12, Alfons Aguirre Tejedo13, Anna Palau-Vendrell14, Lluís LLauger García15, Maria Adroher Muñoz16, Carmen Del Arco Galán17, Teresa Agudo Villa18, Nieves López-Laguna19, María Pilar López Díez20, Fahd Beddar Chaib21, Eva Quero Motto22, Matilde González Tejera23, María Carmen Ponce24, Juan González Del Castillo6. 1. Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Villarroel 170, Barcelona 08036, Catalonia, Spain. 2. Department of Anesthesiology, Burn and Critical Care, University Hospitals Saint-Louis-Lariboisière, AP-HP Rue Ambroise Paré, 75010 Paris, France. 3. Emergency Department, HôpitalPitié-Salpêtrière, Assistance Publique-Hôpitaux 18 de Paris (APHP), Sorbonne Université, 47-83 Boulevard de l'Hôpital, 75013 Paris, France. 4. Emergency Department, Hospital Universitario de Canarias, Carretera Ofra S/N, 38320 San Cristóbal de La Laguna, Santa Cruz de Tenerife, Spain. 5. Emergency Department, Hospital Severo Ochoa, M-402, 8, 28914 Leganés, Madrid, Spain. 6. Emergency Department, Hospital Clínico San Carlos, IDISSC, UnivesdadComplutenseCalle del Prof Martín Lagos, s/n, 28040 Madrid, Spain. 7. Emergency Department, Hospital de la Santa Creu I Sant Pau, Carrer de Sant Quintí, 89, 08041 Barcelona, Spain. 8. Emergency Department, Hospital Universitari de Bellvitge, Carrer de la Feixa Llarga, s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain. 9. Emergency Department, Hospital General de Alicante, University Miguel Hernández, Calle Pintor Baeza, 11, 03010 Alicante, Spain. 10. Emergency Department, Hospital General Universitario Reina Sofía. Av. Intendente Jorge Palacios, 1, 30003 Murcia, Spain. 11. Emergency Department, Hospital Universitari Germans Trias i Pujol de Badalona, Carretera de Canyet, s/n, 08916 Badalona, Barcelona, Spain. 12. Emergency Department, Hospital de Terrassa, Carretera Torrebonica, s/n, 08227 Terrassa, Barcelona, Spain. 13. Emergency Department, Hospital del Mar, Passeig Marítim de la Barceloneta, 25, 29, 08003 Barcelona, Spain. 14. Emergency Department, Hospital Universitari Joan XXIII, Carrer Dr. Mallafrè Guasch, 4, 43005 Tarragona, Spain. 15. Emergency Department, Hospital Universitari de Vic, Carrer de Francesc Pla el Vigatà, 1, 08500 Vic Barcelona, Spain. 16. Emergency Department, Hospital Universitari de Girona Dr JosepTrueta, Avinguda de França, S/N, 17007 Girona, Spain. 17. Emergency Department, Hospital Universitario de la Princesa, Calle de Diego de León, 62, 28006 Madrid, Spain. 18. Emergency Department, Hospital Universitario Severo Ochoa, M-402, 8, 28914 Leganés, Madrid, Spain. 19. Emergency Department, Clínica Universidad Navarra, Calle Marquesado de Sta. Marta, 1, 28027 Madrid, Spain. 20. Emergency Department, Hospital Universitario de Burgos. Av. Islas Baleares, 3, 09006 Burgos, Spain. 21. Emergency Department, Complejo Asistencial de Soria, Paseo Sta. Bárbara, 42005 Soria, Spain. 22. Emergency Department, Hospital Clínico Universitario Virgen de la Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120 El Palmar, Murcia, Spain. 23. Emergency Department, Hospital General Universitario de Elche. Carrer Almazara, 11, 03203 Elche, Alicante, Spain. 24. Emergency Department, Hospital de la Vega Baja Orihuela. Carretera Orihuela - Almoradí, S/N, Orihuela, Alicante, Spain.
Abstract
AIMS: We investigated the incidence, risk factors, clinical characteristics, and outcomes of pulmonary embolism (PE) in patients with COVID-19 attending emergency departments (EDs), before hospitalization. METHODS AND RESULTS: We retrospectively reviewed all COVID-19 patients diagnosed with PE in 62 Spanish EDs (20% of Spanish EDs, case group) during the first COVID-19 outbreak. COVID-19 patients without PE and non-COVID-19 patients with PE were included as control groups. Adjusted comparisons for baseline characteristics, acute episode characteristics, and outcomes were made between cases and randomly selected controls (1:1 ratio). We identified 368 PE in 74 814 patients with COVID-19 attending EDs (4.92‰). The standardized incidence of PE in the COVID-19 population resulted in 310 per 100 000 person-years, significantly higher than that observed in the non-COVID-19 population [35 per 100 000 person-years; odds ratio (OR) 8.95 for PE in the COVID-19 population, 95% confidence interval (CI) 8.51-9.41]. Several characteristics in COVID-19 patients were independently associated with PE, the strongest being D-dimer >1000 ng/mL, and chest pain (direct association) and chronic heart failure (inverse association). COVID-19 patients with PE differed from non-COVID-19 patients with PE in 16 characteristics, most directly related to COVID-19 infection; remarkably, D-dimer >1000 ng/mL, leg swelling/pain, and PE risk factors were significantly less present. PE in COVID-19 patients affected smaller pulmonary arteries than in non-COVID-19 patients, although right ventricular dysfunction was similar in both groups. In-hospital mortality in cases (16.0%) was similar to COVID-19 patients without PE (16.6%; OR 0.96, 95% CI 0.65-1.42; and 11.4% in a subgroup of COVID-19 patients with PE ruled out by scanner, OR 1.48, 95% CI 0.97-2.27), but higher than in non-COVID-19 patients with PE (6.5%; OR 2.74, 95% CI 1.66-4.51). Adjustment for differences in baseline and acute episode characteristics and sensitivity analysis reported very similar associations. CONCLUSIONS: PE in COVID-19 patients at ED presentation is unusual (about 0.5%), but incidence is approximately ninefold higher than in the general (non-COVID-19) population. Moreover, risk factors and leg symptoms are less frequent, D-dimer increase is lower and emboli involve smaller pulmonary arteries. While PE probably does not increase the mortality of COVID-19 patients, mortality is higher in COVID-19 than in non-COVID-19 patients with PE. Published on behalf of the European Society of Cardiology. All rights reserved.
AIMS: We investigated the incidence, risk factors, clinical characteristics, and outcomes of pulmonary embolism (PE) in patients with COVID-19 attending emergency departments (EDs), before hospitalization. METHODS AND RESULTS: We retrospectively reviewed all COVID-19patients diagnosed with PE in 62 Spanish EDs (20% of Spanish EDs, case group) during the first COVID-19 outbreak. COVID-19patients without PE and non-COVID-19patients with PE were included as control groups. Adjusted comparisons for baseline characteristics, acute episode characteristics, and outcomes were made between cases and randomly selected controls (1:1 ratio). We identified 368 PE in 74 814 patients with COVID-19 attending EDs (4.92‰). The standardized incidence of PE in the COVID-19 population resulted in 310 per 100 000 person-years, significantly higher than that observed in the non-COVID-19 population [35 per 100 000 person-years; odds ratio (OR) 8.95 for PE in the COVID-19 population, 95% confidence interval (CI) 8.51-9.41]. Several characteristics in COVID-19patients were independently associated with PE, the strongest being D-dimer >1000 ng/mL, and chest pain (direct association) and chronic heart failure (inverse association). COVID-19patients with PE differed from non-COVID-19patients with PE in 16 characteristics, most directly related to COVID-19infection; remarkably, D-dimer >1000 ng/mL, leg swelling/pain, and PE risk factors were significantly less present. PE in COVID-19patients affected smaller pulmonary arteries than in non-COVID-19patients, although right ventricular dysfunction was similar in both groups. In-hospital mortality in cases (16.0%) was similar to COVID-19patients without PE (16.6%; OR 0.96, 95% CI 0.65-1.42; and 11.4% in a subgroup of COVID-19patients with PE ruled out by scanner, OR 1.48, 95% CI 0.97-2.27), but higher than in non-COVID-19patients with PE (6.5%; OR 2.74, 95% CI 1.66-4.51). Adjustment for differences in baseline and acute episode characteristics and sensitivity analysis reported very similar associations. CONCLUSIONS: PE in COVID-19patients at ED presentation is unusual (about 0.5%), but incidence is approximately ninefold higher than in the general (non-COVID-19) population. Moreover, risk factors and leg symptoms are less frequent, D-dimer increase is lower and emboli involve smaller pulmonary arteries. While PE probably does not increase the mortality of COVID-19patients, mortality is higher in COVID-19 than in non-COVID-19patients with PE. Published on behalf of the European Society of Cardiology. All rights reserved.
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