COVID-19-associated pulmonary embolism: Difference between revisions
Jump to navigation
Jump to search
Sara Mohsin (talk | contribs) |
Sara Mohsin (talk | contribs) |
||
| (43 intermediate revisions by 4 users not shown) | |||
| Line 1: | Line 1: | ||
__NOTOC__ | __NOTOC__ | ||
{{COVID-19}} | {{SI}} | ||
{{Main article|COVID-19}} | |||
'''For COVID-19 frequently asked inpatient questions, click [[COVID-19 frequently asked inpatient questions|here]]''' | '''For COVID-19 frequently asked inpatient questions, click [[COVID-19 frequently asked inpatient questions|here]]'''<br> | ||
'''For COVID-19 frequently asked outpatient questions, click [[COVID-19 frequently asked outpatient questions|here]]'''<br>'''For COVID-19 patient information, click [[COVID-19 (patient information)|here]]''' | |||
'''For COVID-19 frequently asked outpatient questions, click [[COVID-19 frequently asked outpatient questions|here]]''' | |||
{{CMG}}; {{AE}} {{Usman Ali Akbar}} | {{CMG}}; {{AE}} {{Usman Ali Akbar}} | ||
| Line 12: | Line 12: | ||
==Overview== | ==Overview== | ||
In May 2020, various [[Autopsy|autopsies]] studies revealed [[pulmonary embolism]] to be the common cause of death in [[COVID-19]] infected patients. The patients studied were in their mid-70s and had preexisting medical conditions such as cardiac diseases, [[hypertension]], [[diabetes]], and [[obesity]]. These studies highlight the role of [[hypercoagulability]] as a main contributor of the fatality in these patients. To support his theory, various studies have described [[Virchow's triad]] to be the main component of the hypercoagulable state in these patients. | |||
[[File:Screenshot.273.jpg|600px|center]] | |||
== Historical Perspective == | == Historical Perspective == | ||
* In late 2019, a [[novel coronavirus]] had been identified in [[Wuhan coronavirus|Wuhan ,China]] which has now reached a [[pandemic]] state across whole world. | * In late 2019, a [[novel coronavirus]] had been identified in [[Wuhan coronavirus|Wuhan, China]] which has now reached a [[pandemic]] state across the whole world. | ||
* Various case reports and case series have suggested [[hypercoagulability]] to be one of the | * In May 2020, various [[Autopsy|autopsies]] studies revealed [[pulmonary embolism]] to be the common cause of death in [[COVID-19]] infected patients. | ||
* The patients studied were in their mid-70s and had preexisting medical conditions such as cardiac diseases, [[hypertension]], [[diabetes]], and [[obesity]].<ref name="Wichmann Sperhake Lütgehetmann Steurer p.">{{cite journal | last=Wichmann | first=Dominic | last2=Sperhake | first2=Jan-Peter | last3=Lütgehetmann | first3=Marc | last4=Steurer | first4=Stefan | last5=Edler | first5=Carolin | last6=Heinemann | first6=Axel | last7=Heinrich | first7=Fabian | last8=Mushumba | first8=Herbert | last9=Kniep | first9=Inga | last10=Schröder | first10=Ann Sophie | last11=Burdelski | first11=Christoph | last12=de Heer | first12=Geraldine | last13=Nierhaus | first13=Axel | last14=Frings | first14=Daniel | last15=Pfefferle | first15=Susanne | last16=Becker | first16=Heinrich | last17=Bredereke-Wiedling | first17=Hanns | last18=de Weerth | first18=Andreas | last19=Paschen | first19=Hans-Richard | last20=Sheikhzadeh-Eggers | first20=Sara | last21=Stang | first21=Axel | last22=Schmiedel | first22=Stefan | last23=Bokemeyer | first23=Carsten | last24=Addo | first24=Marylyn M. | last25=Aepfelbacher | first25=Martin | last26=Püschel | first26=Klaus | last27=Kluge | first27=Stefan | title=Autopsy Findings and Venous Thromboembolism in Patients With COVID-19 | journal=Annals of Internal Medicine | publisher=American College of Physicians | date=2020-05-06 | issn=0003-4819 | doi=10.7326/m20-2003 | page=}}</ref> | |||
* Various case reports and case series have suggested [[hypercoagulability]] to be one of the causes of death in [[COVID-19|COVID-19 patients.]] | |||
* Proposed mechanism of multiple organ dysfunction that occurs in COVID-19 patients are multifactorial but they include a [[hypercoagulable state]] with micro and macro-circulatory [[Thrombosis|thrombosis.]] | * Proposed mechanism of multiple organ dysfunction that occurs in COVID-19 patients are multifactorial but they include a [[hypercoagulable state]] with micro and macro-circulatory [[Thrombosis|thrombosis.]] | ||
* Based on these case reports and case series, various guidelines have been proposed now to initiate [[anticoagulants]] in critically ill patients and those who are admitted to the hospital. | * Based on these case reports and case series, various guidelines have been proposed now to initiate [[anticoagulants]] in critically ill patients and those who are admitted to the hospital. | ||
| Line 26: | Line 26: | ||
== Classification == | == Classification == | ||
===Acute Pulmonary Embolism=== | ===Acute Pulmonary Embolism=== | ||
*Pathologically an [[embolus]] is said to be acute when it is situated centrally within the vascular [[lumen]], or in other cases, it causes | *Pathologically an [[embolus]] is said to be acute when it is situated centrally within the vascular [[lumen]], or in other cases, it causes an [[occlusion]] of the vessel. It can cause an immediate occurrence of symptoms. | ||
===Chronic Pulmonary Embolism=== | ===Chronic Pulmonary Embolism=== | ||
*An embolus is said to be chronic | *An embolus is said to be chronic if it is [[Eccentric Lesion|eccentric]] and lies within the vessel wall. | ||
*It occludes the [[lumen]] of the vessel wall by more than 50%. | *It occludes the [[lumen]] of the vessel wall by more than 50%. | ||
*There is also evidence of [[recanalization]] within the [[thrombus]]. | *There is also evidence of [[recanalization]] within the [[thrombus]]. | ||
| Line 41: | Line 41: | ||
{| class="wikitable" | {| class="wikitable" | ||
|+ | |+ | ||
!style="background: #4479BA; width: | !style="background: #4479BA; width: 500px;" | {{fontcolor|#FFF|Pathology}} | ||
!style="background: #4479BA; width: | !style="background: #4479BA; width: 500px;" | {{fontcolor|#FFF|Description of the underlying mechanism}} | ||
|- | |- | ||
|style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |[[Endothelial cells|Endothelial cells dysfunction]] <ref name="Teuwen Geldhof Pasut Carmeliet p.">{{cite journal | last=Teuwen | first=Laure-Anne | last2=Geldhof | first2=Vincent | last3=Pasut | first3=Alessandra | last4=Carmeliet | first4=Peter | title=COVID-19: the vasculature unleashed | journal=Nature Reviews Immunology | publisher=Springer Science and Business Media LLC | date=2020-05-21 | issn=1474-1733 | doi=10.1038/s41577-020-0343-0 | page=}}</ref> | |style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |[[Endothelial cells|Endothelial cells dysfunction]]<ref name="Teuwen Geldhof Pasut Carmeliet p.">{{cite journal | last=Teuwen | first=Laure-Anne | last2=Geldhof | first2=Vincent | last3=Pasut | first3=Alessandra | last4=Carmeliet | first4=Peter | title=COVID-19: the vasculature unleashed | journal=Nature Reviews Immunology | publisher=Springer Science and Business Media LLC | date=2020-05-21 | issn=1474-1733 | doi=10.1038/s41577-020-0343-0 | page=}}</ref> | ||
| | | | ||
*It has been proposed that [[endothelial cells]] contribute towards the initiation and propagation of [[ARDS]] by changing the vascular barrier permeability, increasing the chance of procoagulative state that leads to endotheliitis and infiltration of inflammatory cells in the [[Pulmonary vasculature|pulmonary vasculature.]] | *It has been proposed that [[endothelial cells]] contribute towards the initiation and propagation of [[ARDS]] by changing the vascular barrier permeability, increasing the chance of procoagulative state that leads to endotheliitis and infiltration of inflammatory cells in the [[Pulmonary vasculature|pulmonary vasculature.]] | ||
| Line 55: | Line 55: | ||
* Most hospitalized critically ill immobile [[COVID-19]] patients are prone to stasis of blood flow leading to another contributor towards the [[pathogenesis]] of [[pulmonary embolism]]. | * Most hospitalized critically ill immobile [[COVID-19]] patients are prone to stasis of blood flow leading to another contributor towards the [[pathogenesis]] of [[pulmonary embolism]]. | ||
|- | |- | ||
|style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |[[Hypercoagulable state]] <ref name="Panigada Bottino Tagliabue Grasselli p.">{{cite journal | last=Panigada | first=Mauro | last2=Bottino | first2=Nicola | last3=Tagliabue | first3=Paola | last4=Grasselli | first4=Giacomo | last5=Novembrino | first5=Cristina | last6=Chantarangkul | first6=Veena | last7=Pesenti | first7=Antonio | last8=Peyvandi | first8=Fora | last9=Tripodi | first9=Armando | title=Hypercoagulability of COVID‐19 patients in Intensive Care Unit. A Report of Thromboelastography Findings and other Parameters of Hemostasis | journal=Journal of Thrombosis and Haemostasis | publisher=Wiley | date=2020-04-17 | issn=1538-7933 | doi=10.1111/jth.14850 | page=}}</ref> | |style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |[[Hypercoagulable state]]<ref name="Panigada Bottino Tagliabue Grasselli p.">{{cite journal | last=Panigada | first=Mauro | last2=Bottino | first2=Nicola | last3=Tagliabue | first3=Paola | last4=Grasselli | first4=Giacomo | last5=Novembrino | first5=Cristina | last6=Chantarangkul | first6=Veena | last7=Pesenti | first7=Antonio | last8=Peyvandi | first8=Fora | last9=Tripodi | first9=Armando | title=Hypercoagulability of COVID‐19 patients in Intensive Care Unit. A Report of Thromboelastography Findings and other Parameters of Hemostasis | journal=Journal of Thrombosis and Haemostasis | publisher=Wiley | date=2020-04-17 | issn=1538-7933 | doi=10.1111/jth.14850 | page=}}</ref> | ||
| | | | ||
* Various clinical studies have reported different [[prothrombotic factors]] in patients who are critically ill and are hospitalized due to [[COVID-19|COVID-19.]] These studies report various key lab factors that play an important role in the pathogenesis of pulmonary embolism as mentioned below: | * Various clinical studies have reported different [[prothrombotic factors]] in patients who are critically ill and are hospitalized due to [[COVID-19|COVID-19.]] These studies report various key lab factors that play an important role in the pathogenesis of pulmonary embolism as mentioned below: | ||
| Line 63: | Line 63: | ||
**A decrease in [[Antithrombin|Antithrombin level]] | **A decrease in [[Antithrombin|Antithrombin level]] | ||
**Increased [[fibrinogen]] levels | **Increased [[fibrinogen]] levels | ||
|} | |} | ||
[[File: | [[File:Cd-PE-pathogenesis-temp.jpg |600px|center]] | ||
== Causes == | == Causes == | ||
* Recently, SARS-CoV-2 has been associated with pulmonary embolism and other coagulopathic disorders. Other than SARS-CoV-2, pulmonary embolism can be caused by a number of different factors: | * Recently, SARS-CoV-2 has been associated with pulmonary embolism and other coagulopathic disorders. Other than SARS-CoV-2, pulmonary embolism can be caused by a number of different factors: | ||
{| class="wikitable" | {| class="wikitable" | ||
|+Etiologies of Pulmonary Embolism | |+Etiologies of Pulmonary Embolism | ||
| Line 103: | Line 103: | ||
== Differentiating Pulmonary Embolism from other Diseases == | == Differentiating Pulmonary Embolism from other Diseases == | ||
* [[Pulmonary embolism]] in [[COVID|COVID-19]] patients can be sudden and can mimic symptoms of other disorders like [[pneumonia]] and [[Acute respiratory distress syndrome|ARDS]]. Therefore it has been suggested there should be lower threshold of imaging for [[DVT]] should be reserved for [[pulmonary embolism]] in COVID-19 patients admitted to the ICU setting. | * [[Pulmonary embolism]] in [[COVID|COVID-19]] patients can be sudden and can mimic symptoms of other disorders like [[pneumonia]] and [[Acute respiratory distress syndrome|ARDS]]. Therefore it has been suggested there should be a lower threshold of imaging for [[DVT]] should be reserved for [[pulmonary embolism]] in COVID-19 patients admitted to the ICU setting. | ||
**'''Differentiating from''' '''heart failure''': [[Congestive heart failure|Acute congestive Heart failure]] presents in context of previous [[myocardial infarction]],[[hypertension]] any other previous co-morbidities. There is usually no history of associated [[chest pain]], [[hemoptysis]] or [[Fever|low grade fever.]] Additionally there will be signs of volume overload e.g, [[Jugular venous pressure|distended jugular vein]], [[peripheral edema]], [[hepatomegaly]],[[pulmonary edema]] etc present in congestive heart failure patient | **'''Differentiating from''' '''heart failure''': [[Congestive heart failure|Acute congestive Heart failure]] presents in context of previous [[myocardial infarction]], [[hypertension]] any other previous co-morbidities. There is usually no history of associated [[chest pain]], [[hemoptysis]] or [[Fever|low grade fever.]] Additionally there will be signs of volume overload e.g, [[Jugular venous pressure|distended jugular vein]], [[peripheral edema]], [[hepatomegaly]], [[pulmonary edema]], etc present in congestive heart failure patient | ||
**'''Differentiating from [[Pericarditis]]''': Acute [[pericarditis]] presents similar | **'''Differentiating from [[Pericarditis]]''': Acute [[pericarditis]] presents similar to acute pulmonary embolism. However there is history of recent [[viral infection]], underlying disease such as [[uremia]], [[myocardial infarction]] and can also occur due to [[malignancy]]. There would be [[ST-segment elevation]] and [[Depressed PR segment|PR depression]] on ECG. The chest pain will be relieved by sitting up and leaning forward. | ||
**'''Differentiating from [[Pneumonia]]''': Studies have shown that [[pneumonia]] in COVID-19 patients is often the triggering factor for PE. However there will be [[Consolidation (medicine)|consolidation]] on chest x-ray, ground glass opacities, peribronchial nodules. There is also history of high grade [[fever]] and [[productive cough]] in [[bacterial pneumonia]]. | **'''Differentiating from [[Pneumonia]]''': Studies have shown that [[pneumonia]] in COVID-19 patients is often the triggering factor for PE. However there will be [[Consolidation (medicine)|consolidation]] on chest x-ray, ground glass opacities, peribronchial nodules. There is also history of high grade [[fever]] and [[productive cough]] in [[bacterial pneumonia]]. | ||
| Line 113: | Line 113: | ||
*The incidence of thrombotic complications is reported to be 31% in one study. In this study pulmonary embolism was the most common [[Thrombosis|thrombotic]] complication.<ref name="Klok Kruip van der Meer Arbous 2020 pp. 145–147">{{cite journal | last=Klok | first=F.A. | last2=Kruip | first2=M.J.H.A. | last3=van der Meer | first3=N.J.M. | last4=Arbous | first4=M.S. | last5=Gommers | first5=D.A.M.P.J. | last6=Kant | first6=K.M. | last7=Kaptein | first7=F.H.J. | last8=van Paassen | first8=J. | last9=Stals | first9=M.A.M. | last10=Huisman | first10=M.V. | last11=Endeman | first11=H. | title=Incidence of thrombotic complications in critically ill ICU patients with COVID-19 | journal=Thrombosis Research | publisher=Elsevier BV | volume=191 | year=2020 | issn=0049-3848 | doi=10.1016/j.thromres.2020.04.013 | pages=145–147}}</ref> | *The incidence of thrombotic complications is reported to be 31% in one study. In this study pulmonary embolism was the most common [[Thrombosis|thrombotic]] complication.<ref name="Klok Kruip van der Meer Arbous 2020 pp. 145–147">{{cite journal | last=Klok | first=F.A. | last2=Kruip | first2=M.J.H.A. | last3=van der Meer | first3=N.J.M. | last4=Arbous | first4=M.S. | last5=Gommers | first5=D.A.M.P.J. | last6=Kant | first6=K.M. | last7=Kaptein | first7=F.H.J. | last8=van Paassen | first8=J. | last9=Stals | first9=M.A.M. | last10=Huisman | first10=M.V. | last11=Endeman | first11=H. | title=Incidence of thrombotic complications in critically ill ICU patients with COVID-19 | journal=Thrombosis Research | publisher=Elsevier BV | volume=191 | year=2020 | issn=0049-3848 | doi=10.1016/j.thromres.2020.04.013 | pages=145–147}}</ref> | ||
*According to another study, there was found to be an overall 24% [[cumulative incidence]] of pulmonary embolism in patients with COVID-19 pneumonia, 50% (30–70%) in ICU and 18% (12–27%) in other patients.<ref name="Bompard Monnier Saab Tordjman p=2001365">{{cite journal | last=Bompard | first=Florian | last2=Monnier | first2=Hippolyte | last3=Saab | first3=Ines | last4=Tordjman | first4=Mickael | last5=Abdoul | first5=Hendy | last6=Fournier | first6=Laure | last7=Sanchez | first7=Olivier | last8=Lorut | first8=Christine | last9=Chassagnon | first9=Guillaume | last10=Revel | first10=Marie-pierre | title=Pulmonary embolism in patients with Covid-19 pneumonia | journal=European Respiratory Journal | publisher=European Respiratory Society (ERS) | date=2020-05-12 | issn=0903-1936 | doi=10.1183/13993003.01365-2020 | page=2001365}}</ref> | *According to another study, there was found to be an overall 24% [[cumulative incidence]] of pulmonary embolism in patients with COVID-19 pneumonia, 50% (30–70%) in ICU and 18% (12–27%) in other patients.<ref name="Bompard Monnier Saab Tordjman p=2001365">{{cite journal | last=Bompard | first=Florian | last2=Monnier | first2=Hippolyte | last3=Saab | first3=Ines | last4=Tordjman | first4=Mickael | last5=Abdoul | first5=Hendy | last6=Fournier | first6=Laure | last7=Sanchez | first7=Olivier | last8=Lorut | first8=Christine | last9=Chassagnon | first9=Guillaume | last10=Revel | first10=Marie-pierre | title=Pulmonary embolism in patients with Covid-19 pneumonia | journal=European Respiratory Journal | publisher=European Respiratory Society (ERS) | date=2020-05-12 | issn=0903-1936 | doi=10.1183/13993003.01365-2020 | page=2001365}}</ref> | ||
*In the non-ICU settings (in-patient), [[pulmonary embolism]] is reported to occur in 3% | *In the non-ICU settings (in-patient), [[pulmonary embolism]] is reported to occur in 3% of patients in one study.<ref name="Middeldorp Coppens van Haaps Foppen p.">{{cite journal | last=Middeldorp | first=Saskia | last2=Coppens | first2=Michiel | last3=van Haaps | first3=Thijs F. | last4=Foppen | first4=Merijn | last5=Vlaar | first5=Alexander P. | last6=Müller | first6=Marcella C.A. | last7=Bouman | first7=Catherine C.S. | last8=Beenen | first8=Ludo F.M. | last9=Kootte | first9=Ruud S. | last10=Heijmans | first10=Jarom | last11=Smits | first11=Loek P. | last12=Bonta | first12=Peter I. | last13=van Es | first13=Nick | title=Incidence of venous thromboembolism in hospitalized patients with COVID‐19 | journal=Journal of Thrombosis and Haemostasis | publisher=Wiley | date=2020-05-05 | issn=1538-7933 | doi=10.1111/jth.14888 | page=}}</ref> | ||
{| class="wikitable" | |||
|+Incidence/Prevalence of Pulmonary Embolism in COVID-19 Patients | |||
!style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Date of Publication}} | |||
!style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Author}} | |||
!style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Country/Setting}} | |||
!style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Total Number of Patients}} | |||
!style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Incidence/Prevalence Reported}} | |||
|- | |||
|04 May 2020 | |||
|Julie Helms et. al<ref name="Helms Tacquard Severac Leonard-Lorant pp. 1089–1098">{{cite journal | last=Helms | first=Julie | last2=Tacquard | first2=Charles | last3=Severac | first3=François | last4=Leonard-Lorant | first4=Ian | last5=Ohana | first5=Mickaël | last6=Delabranche | first6=Xavier | last7=Merdji | first7=Hamid | last8=Clere-Jehl | first8=Raphaël | last9=Schenck | first9=Malika | last10=Fagot Gandet | first10=Florence | last11=Fafi-Kremer | first11=Samira | last12=Castelain | first12=Vincent | last13=Schneider | first13=Francis | last14=Grunebaum | first14=Lélia | last15=Anglés-Cano | first15=Eduardo | last16=Sattler | first16=Laurent | last17=Mertes | first17=Paul-Michel | last18=Meziani | first18=Ferhat | title=High risk of thrombosis in patients with severe SARS-CoV-2 infection: a multicenter prospective cohort study | journal=Intensive Care Medicine | publisher=Springer Science and Business Media LLC | volume=46 | issue=6 | date=2020-05-04 | issn=0342-4642 | doi=10.1007/s00134-020-06062-x | pages=1089–1098}}</ref> | |||
|France (ICU) | |||
|150 | |||
|Prevalence : 16.7% | |||
Incidence : 25 % | |||
|- | |||
|27 May 2020 | |||
|Artifoni, M.<ref name="Artifoni Danic Gautier Gicquel pp. 211–216">{{cite journal | last=Artifoni | first=Mathieu | last2=Danic | first2=Gwenvael | last3=Gautier | first3=Giovanni | last4=Gicquel | first4=Pascal | last5=Boutoille | first5=David | last6=Raffi | first6=François | last7=Néel | first7=Antoine | last8=Lecomte | first8=Raphaël | title=Systematic assessment of venous thromboembolism in COVID-19 patients receiving thromboprophylaxis: incidence and role of D-dimer as predictive factors | journal=Journal of Thrombosis and Thrombolysis | publisher=Springer Science and Business Media LLC | volume=50 | issue=1 | date=2020-05-25 | issn=0929-5305 | doi=10.1007/s11239-020-02146-z | pages=211–216}}</ref> | |||
|France (Non-ICU) | |||
|71 | |||
|Incidence : 10 % | |||
|- | |||
|6 June 2020 | |||
|Edler, C.<ref name="Edler Schröder Aepfelbacher Fitzek pp. 1275–1284">{{cite journal | last=Edler | first=Carolin | last2=Schröder | first2=Ann Sophie | last3=Aepfelbacher | first3=Martin | last4=Fitzek | first4=Antonia | last5=Heinemann | first5=Axel | last6=Heinrich | first6=Fabian | last7=Klein | first7=Anke | last8=Langenwalder | first8=Felicia | last9=Lütgehetmann | first9=Marc | last10=Meißner | first10=Kira | last11=Püschel | first11=Klaus | last12=Schädler | first12=Julia | last13=Steurer | first13=Stefan | last14=Mushumba | first14=Herbert | last15=Sperhake | first15=Jan-Peter | title=Dying with SARS-CoV-2 infection—an autopsy study of the first consecutive 80 cases in Hamburg, Germany | journal=International Journal of Legal Medicine | publisher=Springer Science and Business Media LLC | volume=134 | issue=4 | date=2020-06-04 | issn=0937-9827 | doi=10.1007/s00414-020-02317-w | pages=1275–1284}}</ref> | |||
|Germany | |||
|76 | |||
|21% | |||
|- | |||
|31 May 2020 | |||
|Faggiano, P. <ref name="Faggiano Bonelli Paris Milesi 2020 pp. 129–131">{{cite journal | last=Faggiano | first=Pompilio | last2=Bonelli | first2=Andrea | last3=Paris | first3=Sara | last4=Milesi | first4=Giuseppe | last5=Bisegna | first5=Stefano | last6=Bernardi | first6=Nicola | last7=Curnis | first7=Antonio | last8=Agricola | first8=Eustachio | last9=Maroldi | first9=Roberto | title=Acute pulmonary embolism in COVID-19 disease: Preliminary report on seven patients | journal=International Journal of Cardiology | publisher=Elsevier BV | volume=313 | year=2020 | issn=0167-5273 | doi=10.1016/j.ijcard.2020.04.028 | pages=129–131}}</ref> | |||
|France | |||
|21 | |||
|33 % | |||
|- | |||
|02 June 2020 | |||
|Hékimian, G.<ref name="Hékimian Lebreton Bréchot Luyt p.">{{cite journal | last=Hékimian | first=Guillaume | last2=Lebreton | first2=Guillaume | last3=Bréchot | first3=Nicolas | last4=Luyt | first4=Charles-Edouard | last5=Schmidt | first5=Matthieu | last6=Combes | first6=Alain | title=Severe pulmonary embolism in COVID-19 patients: a call for increased awareness | journal=Critical Care | publisher=Springer Science and Business Media LLC | volume=24 | issue=1 | date=2020-06-02 | issn=1364-8535 | doi=10.1186/s13054-020-02931-5 | page=}}</ref> | |||
|France | |||
|51 | |||
|16 % | |||
|} | |||
=== Age === | |||
The data regarding age predilection is currently insufficient and shows no significant age difference in the development of pulmonary embolism in COVID-19 patients. | |||
=== Gender === | |||
There is no significant predilection for the development of pulmonary embolism in a specific gender who are COVID-19 positive. However, some studies do report increased risk in male patients. <ref name="Fauvel Weizman Trimaille Mika p.">{{cite journal | last=Fauvel | first=Charles | last2=Weizman | first2=Orianne | last3=Trimaille | first3=Antonin | last4=Mika | first4=Delphine | last5=Pommier | first5=Thibaut | last6=Pace | first6=Nathalie | last7=Douair | first7=Amine | last8=Barbin | first8=Eva | last9=Fraix | first9=Antoine | last10=Bouchot | first10=Océane | last11=Benmansour | first11=Othmane | last12=Godeau | first12=Guillaume | last13=Mecheri | first13=Yasmine | last14=Lebourdon | first14=Romane | last15=Yvorel | first15=Cédric | last16=Massin | first16=Michael | last17=Leblon | first17=Tiphaine | last18=Chabbi | first18=Chaima | last19=Cugney | first19=Erwan | last20=Benabou | first20=Léa | last21=Aubry | first21=Matthieu | last22=Chan | first22=Camille | last23=Boufoula | first23=Ines | last24=Barnaud | first24=Clement | last25=Bothorel | first25=Léa | last26=Duceau | first26=Baptiste | last27=Sutter | first27=Willy | last28=Waldmann | first28=Victor | last29=Bonnet | first29=Guillaume | last30=Cohen | first30=Ariel | last31=Pezel | first31=Théo | title=Pulmonary embolism in COVID-19 patients: a French multicentre cohort study | journal=European Heart Journal | publisher=Oxford University Press (OUP) | date=2020-07-13 | issn=0195-668X | doi=10.1093/eurheartj/ehaa500 | page=}}</ref> | |||
=== Race === | |||
There is no racial predilection for the development of pulmonary embolism in COVID-19 patients. | |||
==Risk Factors== | ==Risk Factors== | ||
| Line 141: | Line 190: | ||
* [[Pulmonary embolism]] in critically ill patients of [[COVID-19]] is a frequent finding. | * [[Pulmonary embolism]] in critically ill patients of [[COVID-19]] is a frequent finding. | ||
* It can lead to the development of [[cardiogenic shock]], [[Sudden cardiac death|sudden cardiac arrest]] and [[pulmonary hypertension]] if developed chronically. | * It can lead to the development of [[cardiogenic shock]], [[Sudden cardiac death|sudden cardiac arrest]] and [[pulmonary hypertension]] if developed chronically. | ||
* There | * There have been various investigational and treatment approaches to treat the [[hypercoagulability]] leading to these complications in COVID-19 patients. | ||
* Patients that are at risk of pulmonary embolism such as those with [[deep venous thrombosis]] are advised to take oral anticoagulants. | * Patients that are at risk of pulmonary embolism such as those with [[deep venous thrombosis]] are advised to take oral anticoagulants. | ||
* Studies show that there is high [[cumulative incidence]] of PE in COVID-19 patients which suggests more frequent use of contrast medium on CT for the evaluation of COVID-19 patients. | * Studies show that there is high [[cumulative incidence]] of PE in COVID-19 patients which suggests more frequent use of contrast medium on CT for the evaluation of COVID-19 patients. | ||
| Line 156: | Line 205: | ||
* It has been reported that despite adequate [[anticoagulation]] being advised to patients in ICU, there is still relatively high [[incidence]] of PE in these patients. | * It has been reported that despite adequate [[anticoagulation]] being advised to patients in ICU, there is still relatively high [[incidence]] of PE in these patients. | ||
* Few studies showed [[Venous thromboembolism|VTE]] to be the main cause of death in COVID-19 patients which suggests setting a lower threshold for [[diagnostic imaging]] for [[Deep vein thrombosis|DVT]] or [[Pulmonary embolism|PE]]. | * Few studies showed [[Venous thromboembolism|VTE]] to be the main cause of death in COVID-19 patients which suggests setting a lower threshold for [[diagnostic imaging]] for [[Deep vein thrombosis|DVT]] or [[Pulmonary embolism|PE]]. | ||
== Diagnosis == | == Diagnosis == | ||
[[File:Pe approach to diagnosis.jpg| | [[File:Pe approach to diagnosis-wikidoc.jpg|800px|center]] | ||
==== History and Symptoms ==== | ==== History and Symptoms ==== | ||
* COVID-19 patients are usually at high risk of hypercoagulability and as there is an increased incidence of pulmonary embolism in ICU patients, they mostly have overlapping symptoms with pneumonia, ARDS, and sometimes present only with fever progressing to pulmonary embolism and sudden cardiac arrest. | * COVID-19 patients are usually at high risk of hypercoagulability and as there is an increased incidence of pulmonary embolism in ICU patients, they mostly have overlapping symptoms with pneumonia, ARDS, and sometimes present only with fever progressing to pulmonary embolism and sudden cardiac arrest. | ||
*[[Pulmonary embolism]] | *[[Pulmonary embolism]] has a range of symptoms presentations, a patient could present with no symptoms, in [[shock]] or even [[Sudden cardiac death|sudden cardiac arrest]]. | ||
* The Prospective Investigation of Pulmonary Embolism Diagnosis II (PIOPED II) trial observed the following most common symptoms:<ref name="Stein Beemath Matta Weg 2007 pp. 871–879">{{cite journal | last=Stein | first=Paul D. | last2=Beemath | first2=Afzal | last3=Matta | first3=Fadi | last4=Weg | first4=John G. | last5=Yusen | first5=Roger D. | last6=Hales | first6=Charles A. | last7=Hull | first7=Russell D. | last8=Leeper | first8=Kenneth V. | last9=Sostman | first9=H. Dirk | last10=Tapson | first10=Victor F. | last11=Buckley | first11=John D. | last12=Gottschalk | first12=Alexander | last13=Goodman | first13=Lawrence R. | last14=Wakefied | first14=Thomas W. | last15=Woodard | first15=Pamela K. | title=Clinical Characteristics of Patients with Acute Pulmonary Embolism: Data from PIOPED II | journal=The American Journal of Medicine | publisher=Elsevier BV | volume=120 | issue=10 | year=2007 | issn=0002-9343 | doi=10.1016/j.amjmed.2007.03.024 | pages=871–879}}</ref> | * The Prospective Investigation of Pulmonary Embolism Diagnosis II (PIOPED II) trial observed the following most common symptoms:<ref name="Stein Beemath Matta Weg 2007 pp. 871–879">{{cite journal | last=Stein | first=Paul D. | last2=Beemath | first2=Afzal | last3=Matta | first3=Fadi | last4=Weg | first4=John G. | last5=Yusen | first5=Roger D. | last6=Hales | first6=Charles A. | last7=Hull | first7=Russell D. | last8=Leeper | first8=Kenneth V. | last9=Sostman | first9=H. Dirk | last10=Tapson | first10=Victor F. | last11=Buckley | first11=John D. | last12=Gottschalk | first12=Alexander | last13=Goodman | first13=Lawrence R. | last14=Wakefied | first14=Thomas W. | last15=Woodard | first15=Pamela K. | title=Clinical Characteristics of Patients with Acute Pulmonary Embolism: Data from PIOPED II | journal=The American Journal of Medicine | publisher=Elsevier BV | volume=120 | issue=10 | year=2007 | issn=0002-9343 | doi=10.1016/j.amjmed.2007.03.024 | pages=871–879}}</ref> | ||
**[[Dyspnea]] that is sudden in onset at rest or exertion (73%) | **[[Dyspnea]] that is sudden in onset at rest or exertion (73%) | ||
| Line 181: | Line 231: | ||
*[[Diaphoresis]] | *[[Diaphoresis]] | ||
*[[Cyanosis]] | *[[Cyanosis]] | ||
*[[Temperature]] > 38.5oC (>101.3oF) | *[[Temperature]] >38.5oC (>101.3oF) | ||
====== Cardiac examination ====== | ====== Cardiac examination ====== | ||
| Line 203: | Line 253: | ||
=====Laboratory findings===== | =====Laboratory findings===== | ||
*Lab findings of different case studies of patients having pulmonary embolism due to COVID-19 are given below:<ref name="Bikdeli Madhavan Jimenez Chuich 2020 pp. 2950–29732">{{cite journal | last=Bikdeli | first=Behnood | last2=Madhavan | first2=Mahesh V. | last3=Jimenez | first3=David | last4=Chuich | first4=Taylor | last5=Dreyfus | first5=Isaac | last6=Driggin | first6=Elissa | last7=Nigoghossian | first7=Caroline Der | last8=Ageno | first8=Walter | last9=Madjid | first9=Mohammad | last10=Guo | first10=Yutao | last11=Tang | first11=Liang V. | last12=Hu | first12=Yu | last13=Giri | first13=Jay | last14=Cushman | first14=Mary | last15=Quéré | first15=Isabelle | last16=Dimakakos | first16=Evangelos P. | last17=Gibson | first17=C. Michael | last18=Lippi | first18=Giuseppe | last19=Favaloro | first19=Emmanuel J. | last20=Fareed | first20=Jawed | last21=Caprini | first21=Joseph A. | last22=Tafur | first22=Alfonso J. | last23=Burton | first23=John R. | last24=Francese | first24=Dominic P. | last25=Wang | first25=Elizabeth Y. | last26=Falanga | first26=Anna | last27=McLintock | first27=Claire | last28=Hunt | first28=Beverley J. | last29=Spyropoulos | first29=Alex C. | last30=Barnes | first30=Geoffrey D. | last31=Eikelboom | first31=John W. | last32=Weinberg | first32=Ido | last33=Schulman | first33=Sam | last34=Carrier | first34=Marc | last35=Piazza | first35=Gregory | last36=Beckman | first36=Joshua A. | last37=Steg | first37=P. Gabriel | last38=Stone | first38=Gregg W. | last39=Rosenkranz | first39=Stephan | last40=Goldhaber | first40=Samuel Z. | last41=Parikh | first41=Sahil A. | last42=Monreal | first42=Manuel | last43=Krumholz | first43=Harlan M. | last44=Konstantinides | first44=Stavros V. | last45=Weitz | first45=Jeffrey I. | last46=Lip | first46=Gregory Y.H. | title=COVID-19 and Thrombotic or Thromboembolic Disease: Implications for Prevention, Antithrombotic Therapy, and Follow-Up | journal=Journal of the American College of Cardiology | publisher=Elsevier BV | volume=75 | issue=23 | year=2020 | issn=0735-1097 | doi=10.1016/j.jacc.2020.04.031 | pages=2950–2973}}</ref> | |||
* Lab findings of different case studies of patients having pulmonary embolism due to COVID-19 are given | |||
**Elevated [[D-dimer|d-dimers]] | **Elevated [[D-dimer|d-dimers]] | ||
**Elevated [[prothrombin time]] | **Elevated [[prothrombin time]] | ||
| Line 213: | Line 261: | ||
** Mild [[thrombocytopenia]] or [[thrombocytosis]] | ** Mild [[thrombocytopenia]] or [[thrombocytosis]] | ||
**[[Platelet count]] can be normal | **[[Platelet count]] can be normal | ||
===== X-ray ===== | |||
==== | * Chest radiograph is not used as a primarily [[diagnostic test]] in [[pulmonary embolism]] patients. | ||
* It is neither [[Sensitivity (tests)|sensitive]] nor [[Specificity|specific]]. | |||
* [[Chest-X ray|Chest-X ray i]]<nowiki/>s used to rule out other conditions that can mimic symptoms of [[pulmonary embolism]] such as [[bacterial pneumonia]], cardiogenic cause of [[dyspnea]] and [[pneumothorax]]. | |||
* Chest | ===Echocardiography or Ultrasound=== | ||
* It is neither [[Sensitivity (tests)|sensitive]] | * To view the echocardiographic findings on COVID-19, [[COVID-19 echocardiography and ultrasound|click here]].<br /> | ||
* [[Chest-X ray|Chest-X ray i]]<nowiki/>s used to rule out other conditions that can mimic symptoms of [[pulmonary embolism]] such as [[bacterial pneumonia]] ,cardiogenic cause of [[dyspnea]] and [[pneumothorax]]. | ===CT scan=== | ||
*To view the CT scan findings on COVID-19, [[COVID-19 CT scan|click here]]. | |||
===MRI=== | |||
* To view the MRI findings on COVID-19, [[COVID-19 MRI|click here]].<br /> | |||
===Other Imaging Findings=== | |||
===== CTPA & Ventilation Perfusion Scan ===== | ===== CTPA & Ventilation Perfusion Scan ===== | ||
*The prompt diagnosis of pulmonary embolism in COVID-19 patient is difficult as various symptoms of [[COVID-19]] overlap with that of [[pulmonary embolism]]. | |||
*Following are the guidelines provided by American Society of Hematology regarding the diagnosis of pulmonary embolism: | |||
** Normal [[d-dimers]] level in a patient with low to moderate [[Pretest probability of DVT|pretest probability]] is sufficient to rule out the diagnosis of PE. [[D-dimers|D-dimers level]] is usually elevated in COVID-19 patients. This does not apply to a patient with a high pretest probability. | |||
** Inpatient with suspected PE with symptoms like [[hypotension]], [[tachycardia]], and sudden drop in [[oxygen saturation]] with a high pretest probability of PE, computed [[tomography]] with [[pulmonary angiography]] is used for the diagnosis. Contraindication to the use of [[CT pulmonary angiogram|CTPA]] warrants investigation with [[Ventilation/perfusion scan|ventilation/perfusion scan.]] | |||
[[File:Covid-19-pneumonia-and-pulmonary-emboli.jpg|thumb|300px|none|Right-sided segmental and subsegmental pulmonary arterial filling defects (yellow arrows) in keeping with acute distal pulmonary emboli. [https://radiopaedia.org/cases/covid-19-pneumonia-and-pulmonary-emboli?lang=us Source: Dr. Gianluca Martinelli]]] | |||
[[ | ===Other Diagnostic Studies=== | ||
* To view other diagnostic studies for COVID-19, [[COVID-19 other diagnostic studies|click here]].<br /> | |||
== Treatment == | == Treatment == | ||
===Medical Therapy=== | |||
=== Medical Therapy === | |||
*Different treatment strategies for COVID-19 patients suffering from pulmonary embolism are given in the table below: | *Different treatment strategies for COVID-19 patients suffering from pulmonary embolism are given in the table below: | ||
| Line 239: | Line 290: | ||
|+ | |+ | ||
! style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF|Different treatment options}} | ! style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF|Different treatment options}} | ||
! style="background: #4479BA; width: | ! style="background: #4479BA; width: 600px;" |{{fontcolor|#FFF|Details}} | ||
|- | |- | ||
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |[[Prophylaxis]] | | style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |[[Prophylaxis]] | ||
|All hospitalized patients with COVID 19 should get proper venous thromboembolism prophylaxis in the absence of any contraindication of [[anticoagulation]]. However, the data is still controversial regarding this strategy as stated by the American Society of Hematology (ASH) and the Global COVID-19 Thrombosis Collaborative Group, demonstrating improved outcomes are lacking and it may also increase the risk of bleeding. Some centers suggest | | | ||
*All hospitalized patients with COVID 19 should get proper venous thromboembolism prophylaxis in the absence of any contraindication of [[anticoagulation]]. However, the data is still controversial regarding this strategy as stated by the American Society of Hematology (ASH) and the Global COVID-19 Thrombosis Collaborative Group, demonstrating improved outcomes are lacking and it may also increase the risk of bleeding. | |||
* In ICU setting, empiric use of intermediate or therapeutic dose anticoagulation should be instituted. | * Some centers suggest the following:<ref name="Bikdeli Madhavan Jimenez Chuich 2020 pp. 2950–2973">{{cite journal | last=Bikdeli | first=Behnood | last2=Madhavan | first2=Mahesh V. | last3=Jimenez | first3=David | last4=Chuich | first4=Taylor | last5=Dreyfus | first5=Isaac | last6=Driggin | first6=Elissa | last7=Nigoghossian | first7=Caroline Der | last8=Ageno | first8=Walter | last9=Madjid | first9=Mohammad | last10=Guo | first10=Yutao | last11=Tang | first11=Liang V. | last12=Hu | first12=Yu | last13=Giri | first13=Jay | last14=Cushman | first14=Mary | last15=Quéré | first15=Isabelle | last16=Dimakakos | first16=Evangelos P. | last17=Gibson | first17=C. Michael | last18=Lippi | first18=Giuseppe | last19=Favaloro | first19=Emmanuel J. | last20=Fareed | first20=Jawed | last21=Caprini | first21=Joseph A. | last22=Tafur | first22=Alfonso J. | last23=Burton | first23=John R. | last24=Francese | first24=Dominic P. | last25=Wang | first25=Elizabeth Y. | last26=Falanga | first26=Anna | last27=McLintock | first27=Claire | last28=Hunt | first28=Beverley J. | last29=Spyropoulos | first29=Alex C. | last30=Barnes | first30=Geoffrey D. | last31=Eikelboom | first31=John W. | last32=Weinberg | first32=Ido | last33=Schulman | first33=Sam | last34=Carrier | first34=Marc | last35=Piazza | first35=Gregory | last36=Beckman | first36=Joshua A. | last37=Steg | first37=P. Gabriel | last38=Stone | first38=Gregg W. | last39=Rosenkranz | first39=Stephan | last40=Goldhaber | first40=Samuel Z. | last41=Parikh | first41=Sahil A. | last42=Monreal | first42=Manuel | last43=Krumholz | first43=Harlan M. | last44=Konstantinides | first44=Stavros V. | last45=Weitz | first45=Jeffrey I. | last46=Lip | first46=Gregory Y.H. | title=COVID-19 and Thrombotic or Thromboembolic Disease: Implications for Prevention, Antithrombotic Therapy, and Follow-Up | journal=Journal of the American College of Cardiology | publisher=Elsevier BV | volume=75 | issue=23 | year=2020 | issn=0735-1097 | doi=10.1016/j.jacc.2020.04.031 | pages=2950–2973}}</ref> | ||
* In a non-ICU setting, all hospitalized patients should be treated with prophylactic low dose molecular weight [[heparin]]. | **In an ICU setting, empiric use of intermediate or therapeutic dose anticoagulation should be instituted. | ||
**In a non-ICU setting, all hospitalized patients should be treated with prophylactic low dose molecular weight [[heparin]]. | |||
|- | |- | ||
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |Acute Pulmonary embolism | | style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |Acute Pulmonary embolism | ||
| Line 256: | Line 308: | ||
*Critically ill patients that have recovered from COVID-19 and had a documented [[Venous thromboembolism|VTE]] are usually given a minimum of 3 months of anticoagulation. | *Critically ill patients that have recovered from COVID-19 and had a documented [[Venous thromboembolism|VTE]] are usually given a minimum of 3 months of anticoagulation. | ||
* Patients not admitted to hospitals but at risk of [[Venous thromboembolism|VTE]], such as prior VTE episode, recent surgery, prolonged immobilization are usually given a prophylactic dose of [[Rivaroxaban]] 10 mg daily for 31 days or 39 days. | * Patients not admitted to hospitals but at risk of [[Venous thromboembolism|VTE]], such as prior VTE episode, recent surgery, prolonged immobilization are usually given a prophylactic dose of [[Rivaroxaban]] 10 mg daily for 31 days or 39 days. | ||
|}[[File: | |}[[File:Cd-anticoagulation.jpg|800px|center]] | ||
===Primary Prevention=== | ===Primary Prevention=== | ||
*The best way to prevent being infected by COVID-19 is to avoid being exposed to this [[virus]] by adopting the following practices for [[infection]] control: | *The best way to prevent being infected by COVID-19 is to avoid being exposed to this [[virus]] by adopting the following practices for [[infection]] control: | ||
| Line 269: | Line 320: | ||
**Clean and [[Disinfection|disinfect]] the objects and surfaces which are touched frequently. | **Clean and [[Disinfection|disinfect]] the objects and surfaces which are touched frequently. | ||
*There is currently no [[vaccine]] available to prevent COVID-19. | *There is currently no [[vaccine]] available to prevent COVID-19. | ||
===Secondary Prevention=== | ===Secondary Prevention=== | ||
*The secondary prevention measures of Coronavirus disease 2019 (COVID-19) constitute protective measures to make sure that an infected individual does not transfer the disease to others by maintaining self-isolation at home or designated [[quarantine]] facilities. | *The secondary prevention measures of Coronavirus disease 2019 (COVID-19) constitute protective measures to make sure that an infected individual does not transfer the disease to others by maintaining self-isolation at home or designated [[quarantine]] facilities. | ||
*Patients not admitted to hospitals but at risk of [[Venous thromboembolism|VTE]], such as prior VTE episode, recent surgery, prolonged immobilization are usually given a prophylactic dose of [[Rivaroxaban]] 10 mg daily for 31 days or 39 days. | *Patients not admitted to hospitals but at risk of [[Venous thromboembolism|VTE]], such as prior VTE episode, recent surgery, prolonged immobilization are usually given a prophylactic dose of [[Rivaroxaban]] 10 mg daily for 31 days or 39 days. | ||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
[[Category:Up-To-Date]] | |||
{{WikiDoc Help Menu}} | |||
{{WikiDoc Sources}} | |||
Latest revision as of 17:54, 27 July 2020
For COVID-19 frequently asked inpatient questions, click here
For COVID-19 frequently asked outpatient questions, click here
For COVID-19 patient information, click here
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Usman Ali Akbar, M.B.B.S.[2]
Synonyms and keywords: 2019 novel coronavirus disease, COVID19, Wuhan virus, pulmonary embolism, venous thromboembolism
Overview
In May 2020, various autopsies studies revealed pulmonary embolism to be the common cause of death in COVID-19 infected patients. The patients studied were in their mid-70s and had preexisting medical conditions such as cardiac diseases, hypertension, diabetes, and obesity. These studies highlight the role of hypercoagulability as a main contributor of the fatality in these patients. To support his theory, various studies have described Virchow's triad to be the main component of the hypercoagulable state in these patients.
Historical Perspective
- In late 2019, a novel coronavirus had been identified in Wuhan, China which has now reached a pandemic state across the whole world.
- In May 2020, various autopsies studies revealed pulmonary embolism to be the common cause of death in COVID-19 infected patients.
- The patients studied were in their mid-70s and had preexisting medical conditions such as cardiac diseases, hypertension, diabetes, and obesity.[1]
- Various case reports and case series have suggested hypercoagulability to be one of the causes of death in COVID-19 patients.
- Proposed mechanism of multiple organ dysfunction that occurs in COVID-19 patients are multifactorial but they include a hypercoagulable state with micro and macro-circulatory thrombosis.
- Based on these case reports and case series, various guidelines have been proposed now to initiate anticoagulants in critically ill patients and those who are admitted to the hospital.
Classification
Acute Pulmonary Embolism
- Pathologically an embolus is said to be acute when it is situated centrally within the vascular lumen, or in other cases, it causes an occlusion of the vessel. It can cause an immediate occurrence of symptoms.
Chronic Pulmonary Embolism
- An embolus is said to be chronic if it is eccentric and lies within the vessel wall.
- It occludes the lumen of the vessel wall by more than 50%.
- There is also evidence of recanalization within the thrombus.
- Chronic thromboembolism can cause pulmonary hypertension especially when there are >3 months of effective anticoagulation therapy and one of the following criteria:
Pathophysiology
- As data on COVID-19 has been incomplete and evolving, the pathogenesis of pulmonary embolism has not yet been completely understood. Various contributors to the pathogenesis of pulmonary embolism in these patients are listed in the table below:
| Pathology | Description of the underlying mechanism |
|---|---|
| Endothelial cells dysfunction[2] |
|
| Stasis |
|
| Hypercoagulable state[3] |
|
Causes
- Recently, SARS-CoV-2 has been associated with pulmonary embolism and other coagulopathic disorders. Other than SARS-CoV-2, pulmonary embolism can be caused by a number of different factors:
| Hereditary Causes | Comorbidities | Miscellaneous |
|---|---|---|
| Factor V Leiden Mutation | Heart failure | Surgery |
| Protein C & S deficiency | Congenital heart disease | Pregnancy |
| Antithrombin deficiency | Antiphospholipid syndrome | OCPs |
| Obesity | Immobilization | |
| Myeloproliferative Disorders | Trauma | |
| Paroxysmal nocturnal hemoglobinuria | Malignancy |
Differentiating Pulmonary Embolism from other Diseases
- Pulmonary embolism in COVID-19 patients can be sudden and can mimic symptoms of other disorders like pneumonia and ARDS. Therefore it has been suggested there should be a lower threshold of imaging for DVT should be reserved for pulmonary embolism in COVID-19 patients admitted to the ICU setting.
- Differentiating from heart failure: Acute congestive Heart failure presents in context of previous myocardial infarction, hypertension any other previous co-morbidities. There is usually no history of associated chest pain, hemoptysis or low grade fever. Additionally there will be signs of volume overload e.g, distended jugular vein, peripheral edema, hepatomegaly, pulmonary edema, etc present in congestive heart failure patient
- Differentiating from Pericarditis: Acute pericarditis presents similar to acute pulmonary embolism. However there is history of recent viral infection, underlying disease such as uremia, myocardial infarction and can also occur due to malignancy. There would be ST-segment elevation and PR depression on ECG. The chest pain will be relieved by sitting up and leaning forward.
- Differentiating from Pneumonia: Studies have shown that pneumonia in COVID-19 patients is often the triggering factor for PE. However there will be consolidation on chest x-ray, ground glass opacities, peribronchial nodules. There is also history of high grade fever and productive cough in bacterial pneumonia.
Epidemiology and demographics
- Various case reports and case series report relatively high incidence of pulmonary embolism in ICU patients.
- The incidence of thrombotic complications is reported to be 31% in one study. In this study pulmonary embolism was the most common thrombotic complication.[4]
- According to another study, there was found to be an overall 24% cumulative incidence of pulmonary embolism in patients with COVID-19 pneumonia, 50% (30–70%) in ICU and 18% (12–27%) in other patients.[5]
- In the non-ICU settings (in-patient), pulmonary embolism is reported to occur in 3% of patients in one study.[6]
| Date of Publication | Author | Country/Setting | Total Number of Patients | Incidence/Prevalence Reported |
|---|---|---|---|---|
| 04 May 2020 | Julie Helms et. al[7] | France (ICU) | 150 | Prevalence : 16.7%
Incidence : 25 % |
| 27 May 2020 | Artifoni, M.[8] | France (Non-ICU) | 71 | Incidence : 10 % |
| 6 June 2020 | Edler, C.[9] | Germany | 76 | 21% |
| 31 May 2020 | Faggiano, P. [10] | France | 21 | 33 % |
| 02 June 2020 | Hékimian, G.[11] | France | 51 | 16 % |
Age
The data regarding age predilection is currently insufficient and shows no significant age difference in the development of pulmonary embolism in COVID-19 patients.
Gender
There is no significant predilection for the development of pulmonary embolism in a specific gender who are COVID-19 positive. However, some studies do report increased risk in male patients. [12]
Race
There is no racial predilection for the development of pulmonary embolism in COVID-19 patients.
Risk Factors
- Multivariate analysis showed the following risk factors that predispose a patient of COVID-19 to pulmonary embolism:[13]
| Risk factors for COVID-19 associated pulmonary embolism |
|---|
|
Natural History,Complications and Prognosis
- Pulmonary embolism in critically ill patients of COVID-19 is a frequent finding.
- It can lead to the development of cardiogenic shock, sudden cardiac arrest and pulmonary hypertension if developed chronically.
- There have been various investigational and treatment approaches to treat the hypercoagulability leading to these complications in COVID-19 patients.
- Patients that are at risk of pulmonary embolism such as those with deep venous thrombosis are advised to take oral anticoagulants.
- Studies show that there is high cumulative incidence of PE in COVID-19 patients which suggests more frequent use of contrast medium on CT for the evaluation of COVID-19 patients.
Complications
- Various complications have been reported ranging from acute right heart failure and sudden cardiac arrest due to pulmonary embolism in COVID-19 patients. The following complications have been frequently reported in various case reports and case series:
Prognosis
- COVID-19 patients presenting with pulmonary embolism have a poor prognosis.
- It has been reported that despite adequate anticoagulation being advised to patients in ICU, there is still relatively high incidence of PE in these patients.
- Few studies showed VTE to be the main cause of death in COVID-19 patients which suggests setting a lower threshold for diagnostic imaging for DVT or PE.
Diagnosis
History and Symptoms
- COVID-19 patients are usually at high risk of hypercoagulability and as there is an increased incidence of pulmonary embolism in ICU patients, they mostly have overlapping symptoms with pneumonia, ARDS, and sometimes present only with fever progressing to pulmonary embolism and sudden cardiac arrest.
- Pulmonary embolism has a range of symptoms presentations, a patient could present with no symptoms, in shock or even sudden cardiac arrest.
- The Prospective Investigation of Pulmonary Embolism Diagnosis II (PIOPED II) trial observed the following most common symptoms:[14]
- Dyspnea that is sudden in onset at rest or exertion (73%)
- Pleuritic pain (44%)
- Calf or thigh pain (44%)
- Calf or thigh swelling (41%)
- Cough (34%)
Physical Examination
- On physical examination following signs can be demonstrated in COVID-19 patients.[14]
General
- Tachypnea (>20/min)
- Tachycardia (>100/min)
- Diaphoresis
- Cyanosis
- Temperature >38.5oC (>101.3oF)
Cardiac examination
- Increased P2
- Right ventricular lift
- Jugular venous distension
Lung examination
- Rales (crackles)
- Wheezes
- Rhonchi
- Decreased breath sounds
- Pleural friction rub
DVT signs
- Calf or thigh
- Calf and thigh
Laboratory findings
- Lab findings of different case studies of patients having pulmonary embolism due to COVID-19 are given below:[15]
- Elevated d-dimers
- Elevated prothrombin time
- Elevated CRP
- Elevated Cardiac biomarkers
- High fibrinogen
- Mild thrombocytopenia or thrombocytosis
- Platelet count can be normal
X-ray
- Chest radiograph is not used as a primarily diagnostic test in pulmonary embolism patients.
- It is neither sensitive nor specific.
- Chest-X ray is used to rule out other conditions that can mimic symptoms of pulmonary embolism such as bacterial pneumonia, cardiogenic cause of dyspnea and pneumothorax.
Echocardiography or Ultrasound
- To view the echocardiographic findings on COVID-19, click here.
CT scan
- To view the CT scan findings on COVID-19, click here.
MRI
- To view the MRI findings on COVID-19, click here.
Other Imaging Findings
CTPA & Ventilation Perfusion Scan
- The prompt diagnosis of pulmonary embolism in COVID-19 patient is difficult as various symptoms of COVID-19 overlap with that of pulmonary embolism.
- Following are the guidelines provided by American Society of Hematology regarding the diagnosis of pulmonary embolism:
- Normal d-dimers level in a patient with low to moderate pretest probability is sufficient to rule out the diagnosis of PE. D-dimers level is usually elevated in COVID-19 patients. This does not apply to a patient with a high pretest probability.
- Inpatient with suspected PE with symptoms like hypotension, tachycardia, and sudden drop in oxygen saturation with a high pretest probability of PE, computed tomography with pulmonary angiography is used for the diagnosis. Contraindication to the use of CTPA warrants investigation with ventilation/perfusion scan.
Other Diagnostic Studies
- To view other diagnostic studies for COVID-19, click here.
Treatment
Medical Therapy
- Different treatment strategies for COVID-19 patients suffering from pulmonary embolism are given in the table below:
| Different treatment options | Details |
|---|---|
| Prophylaxis |
|
| Acute Pulmonary embolism |
|
| Outpatient treatment[17] |
|
Primary Prevention
- The best way to prevent being infected by COVID-19 is to avoid being exposed to this virus by adopting the following practices for infection control:
- Often wash hands with soap and water for at least 20 seconds.
- Use an alcohol-based hand sanitizer containing at least 60% alcohol in case soap and water are not available.
- Avoid touching the eyes, nose, and mouth without washing hands.
- Avoid being in close contact with people sick with COVID-19 infection.
- Stay home while being symptomatic to prevent spread to others.
- Cover mouth while coughing or sneezing with a tissue paper, and then throw the tissue in the trash.
- Clean and disinfect the objects and surfaces which are touched frequently.
- There is currently no vaccine available to prevent COVID-19.
Secondary Prevention
- The secondary prevention measures of Coronavirus disease 2019 (COVID-19) constitute protective measures to make sure that an infected individual does not transfer the disease to others by maintaining self-isolation at home or designated quarantine facilities.
- Patients not admitted to hospitals but at risk of VTE, such as prior VTE episode, recent surgery, prolonged immobilization are usually given a prophylactic dose of Rivaroxaban 10 mg daily for 31 days or 39 days.
References
- ↑ Wichmann, Dominic; Sperhake, Jan-Peter; Lütgehetmann, Marc; Steurer, Stefan; Edler, Carolin; Heinemann, Axel; Heinrich, Fabian; Mushumba, Herbert; Kniep, Inga; Schröder, Ann Sophie; Burdelski, Christoph; de Heer, Geraldine; Nierhaus, Axel; Frings, Daniel; Pfefferle, Susanne; Becker, Heinrich; Bredereke-Wiedling, Hanns; de Weerth, Andreas; Paschen, Hans-Richard; Sheikhzadeh-Eggers, Sara; Stang, Axel; Schmiedel, Stefan; Bokemeyer, Carsten; Addo, Marylyn M.; Aepfelbacher, Martin; Püschel, Klaus; Kluge, Stefan (2020-05-06). "Autopsy Findings and Venous Thromboembolism in Patients With COVID-19". Annals of Internal Medicine. American College of Physicians. doi:10.7326/m20-2003. ISSN 0003-4819.
- ↑ Teuwen, Laure-Anne; Geldhof, Vincent; Pasut, Alessandra; Carmeliet, Peter (2020-05-21). "COVID-19: the vasculature unleashed". Nature Reviews Immunology. Springer Science and Business Media LLC. doi:10.1038/s41577-020-0343-0. ISSN 1474-1733.
- ↑ Panigada, Mauro; Bottino, Nicola; Tagliabue, Paola; Grasselli, Giacomo; Novembrino, Cristina; Chantarangkul, Veena; Pesenti, Antonio; Peyvandi, Fora; Tripodi, Armando (2020-04-17). "Hypercoagulability of COVID‐19 patients in Intensive Care Unit. A Report of Thromboelastography Findings and other Parameters of Hemostasis". Journal of Thrombosis and Haemostasis. Wiley. doi:10.1111/jth.14850. ISSN 1538-7933.
- ↑ Klok, F.A.; Kruip, M.J.H.A.; van der Meer, N.J.M.; Arbous, M.S.; Gommers, D.A.M.P.J.; Kant, K.M.; Kaptein, F.H.J.; van Paassen, J.; Stals, M.A.M.; Huisman, M.V.; Endeman, H. (2020). "Incidence of thrombotic complications in critically ill ICU patients with COVID-19". Thrombosis Research. Elsevier BV. 191: 145–147. doi:10.1016/j.thromres.2020.04.013. ISSN 0049-3848.
- ↑ Bompard, Florian; Monnier, Hippolyte; Saab, Ines; Tordjman, Mickael; Abdoul, Hendy; Fournier, Laure; Sanchez, Olivier; Lorut, Christine; Chassagnon, Guillaume; Revel, Marie-pierre (2020-05-12). "Pulmonary embolism in patients with Covid-19 pneumonia". European Respiratory Journal. European Respiratory Society (ERS): 2001365. doi:10.1183/13993003.01365-2020. ISSN 0903-1936.
- ↑ Middeldorp, Saskia; Coppens, Michiel; van Haaps, Thijs F.; Foppen, Merijn; Vlaar, Alexander P.; Müller, Marcella C.A.; Bouman, Catherine C.S.; Beenen, Ludo F.M.; Kootte, Ruud S.; Heijmans, Jarom; Smits, Loek P.; Bonta, Peter I.; van Es, Nick (2020-05-05). "Incidence of venous thromboembolism in hospitalized patients with COVID‐19". Journal of Thrombosis and Haemostasis. Wiley. doi:10.1111/jth.14888. ISSN 1538-7933.
- ↑ Helms, Julie; Tacquard, Charles; Severac, François; Leonard-Lorant, Ian; Ohana, Mickaël; Delabranche, Xavier; Merdji, Hamid; Clere-Jehl, Raphaël; Schenck, Malika; Fagot Gandet, Florence; Fafi-Kremer, Samira; Castelain, Vincent; Schneider, Francis; Grunebaum, Lélia; Anglés-Cano, Eduardo; Sattler, Laurent; Mertes, Paul-Michel; Meziani, Ferhat (2020-05-04). "High risk of thrombosis in patients with severe SARS-CoV-2 infection: a multicenter prospective cohort study". Intensive Care Medicine. Springer Science and Business Media LLC. 46 (6): 1089–1098. doi:10.1007/s00134-020-06062-x. ISSN 0342-4642.
- ↑ Artifoni, Mathieu; Danic, Gwenvael; Gautier, Giovanni; Gicquel, Pascal; Boutoille, David; Raffi, François; Néel, Antoine; Lecomte, Raphaël (2020-05-25). "Systematic assessment of venous thromboembolism in COVID-19 patients receiving thromboprophylaxis: incidence and role of D-dimer as predictive factors". Journal of Thrombosis and Thrombolysis. Springer Science and Business Media LLC. 50 (1): 211–216. doi:10.1007/s11239-020-02146-z. ISSN 0929-5305.
- ↑ Edler, Carolin; Schröder, Ann Sophie; Aepfelbacher, Martin; Fitzek, Antonia; Heinemann, Axel; Heinrich, Fabian; Klein, Anke; Langenwalder, Felicia; Lütgehetmann, Marc; Meißner, Kira; Püschel, Klaus; Schädler, Julia; Steurer, Stefan; Mushumba, Herbert; Sperhake, Jan-Peter (2020-06-04). "Dying with SARS-CoV-2 infection—an autopsy study of the first consecutive 80 cases in Hamburg, Germany". International Journal of Legal Medicine. Springer Science and Business Media LLC. 134 (4): 1275–1284. doi:10.1007/s00414-020-02317-w. ISSN 0937-9827.
- ↑ Faggiano, Pompilio; Bonelli, Andrea; Paris, Sara; Milesi, Giuseppe; Bisegna, Stefano; Bernardi, Nicola; Curnis, Antonio; Agricola, Eustachio; Maroldi, Roberto (2020). "Acute pulmonary embolism in COVID-19 disease: Preliminary report on seven patients". International Journal of Cardiology. Elsevier BV. 313: 129–131. doi:10.1016/j.ijcard.2020.04.028. ISSN 0167-5273.
- ↑ Hékimian, Guillaume; Lebreton, Guillaume; Bréchot, Nicolas; Luyt, Charles-Edouard; Schmidt, Matthieu; Combes, Alain (2020-06-02). "Severe pulmonary embolism in COVID-19 patients: a call for increased awareness". Critical Care. Springer Science and Business Media LLC. 24 (1). doi:10.1186/s13054-020-02931-5. ISSN 1364-8535.
- ↑ Fauvel, Charles; Weizman, Orianne; Trimaille, Antonin; Mika, Delphine; Pommier, Thibaut; Pace, Nathalie; Douair, Amine; Barbin, Eva; Fraix, Antoine; Bouchot, Océane; Benmansour, Othmane; Godeau, Guillaume; Mecheri, Yasmine; Lebourdon, Romane; Yvorel, Cédric; Massin, Michael; Leblon, Tiphaine; Chabbi, Chaima; Cugney, Erwan; Benabou, Léa; Aubry, Matthieu; Chan, Camille; Boufoula, Ines; Barnaud, Clement; Bothorel, Léa; Duceau, Baptiste; Sutter, Willy; Waldmann, Victor; Bonnet, Guillaume; Cohen, Ariel; Pezel, Théo (2020-07-13). "Pulmonary embolism in COVID-19 patients: a French multicentre cohort study". European Heart Journal. Oxford University Press (OUP). doi:10.1093/eurheartj/ehaa500. ISSN 0195-668X.
- ↑ Poyiadi, Neo; Cormier, Peter; Patel, Parth Y.; Hadied, Mohamad O.; Bhargava, Pallavi; Khanna, Kanika; Nadig, Jeffrey; Keimig, Thomas; Spizarny, David; Reeser, Nicholas; Klochko, Chad; Peterson, Edward L.; Song, Thomas (2020-05-14). "Acute Pulmonary Embolism and COVID-19". Radiology. Radiological Society of North America (RSNA): 201955. doi:10.1148/radiol.2020201955. ISSN 0033-8419.
- ↑ 14.0 14.1 Stein, Paul D.; Beemath, Afzal; Matta, Fadi; Weg, John G.; Yusen, Roger D.; Hales, Charles A.; Hull, Russell D.; Leeper, Kenneth V.; Sostman, H. Dirk; Tapson, Victor F.; Buckley, John D.; Gottschalk, Alexander; Goodman, Lawrence R.; Wakefied, Thomas W.; Woodard, Pamela K. (2007). "Clinical Characteristics of Patients with Acute Pulmonary Embolism: Data from PIOPED II". The American Journal of Medicine. Elsevier BV. 120 (10): 871–879. doi:10.1016/j.amjmed.2007.03.024. ISSN 0002-9343.
- ↑ Bikdeli, Behnood; Madhavan, Mahesh V.; Jimenez, David; Chuich, Taylor; Dreyfus, Isaac; Driggin, Elissa; Nigoghossian, Caroline Der; Ageno, Walter; Madjid, Mohammad; Guo, Yutao; Tang, Liang V.; Hu, Yu; Giri, Jay; Cushman, Mary; Quéré, Isabelle; Dimakakos, Evangelos P.; Gibson, C. Michael; Lippi, Giuseppe; Favaloro, Emmanuel J.; Fareed, Jawed; Caprini, Joseph A.; Tafur, Alfonso J.; Burton, John R.; Francese, Dominic P.; Wang, Elizabeth Y.; Falanga, Anna; McLintock, Claire; Hunt, Beverley J.; Spyropoulos, Alex C.; Barnes, Geoffrey D.; Eikelboom, John W.; Weinberg, Ido; Schulman, Sam; Carrier, Marc; Piazza, Gregory; Beckman, Joshua A.; Steg, P. Gabriel; Stone, Gregg W.; Rosenkranz, Stephan; Goldhaber, Samuel Z.; Parikh, Sahil A.; Monreal, Manuel; Krumholz, Harlan M.; Konstantinides, Stavros V.; Weitz, Jeffrey I.; Lip, Gregory Y.H. (2020). "COVID-19 and Thrombotic or Thromboembolic Disease: Implications for Prevention, Antithrombotic Therapy, and Follow-Up". Journal of the American College of Cardiology. Elsevier BV. 75 (23): 2950–2973. doi:10.1016/j.jacc.2020.04.031. ISSN 0735-1097.
- ↑ Bikdeli, Behnood; Madhavan, Mahesh V.; Jimenez, David; Chuich, Taylor; Dreyfus, Isaac; Driggin, Elissa; Nigoghossian, Caroline Der; Ageno, Walter; Madjid, Mohammad; Guo, Yutao; Tang, Liang V.; Hu, Yu; Giri, Jay; Cushman, Mary; Quéré, Isabelle; Dimakakos, Evangelos P.; Gibson, C. Michael; Lippi, Giuseppe; Favaloro, Emmanuel J.; Fareed, Jawed; Caprini, Joseph A.; Tafur, Alfonso J.; Burton, John R.; Francese, Dominic P.; Wang, Elizabeth Y.; Falanga, Anna; McLintock, Claire; Hunt, Beverley J.; Spyropoulos, Alex C.; Barnes, Geoffrey D.; Eikelboom, John W.; Weinberg, Ido; Schulman, Sam; Carrier, Marc; Piazza, Gregory; Beckman, Joshua A.; Steg, P. Gabriel; Stone, Gregg W.; Rosenkranz, Stephan; Goldhaber, Samuel Z.; Parikh, Sahil A.; Monreal, Manuel; Krumholz, Harlan M.; Konstantinides, Stavros V.; Weitz, Jeffrey I.; Lip, Gregory Y.H. (2020). "COVID-19 and Thrombotic or Thromboembolic Disease: Implications for Prevention, Antithrombotic Therapy, and Follow-Up". Journal of the American College of Cardiology. Elsevier BV. 75 (23): 2950–2973. doi:10.1016/j.jacc.2020.04.031. ISSN 0735-1097.
- ↑