Impact of the COVID-19 pandemic and a national lockdown on hospitalizations for venous thromboembolism and pulmonary embolism in France

Background: The COVID-19 pandemic and the national lockdown implemented in France have disturbed populations’ health behavior and overwhelmed hospitals. Furthermore, infection to SARS-CoV-2 has been found to be directly associated with an increased risk of venous thrombosis (VT) and pulmonary embolism (PE). Purpose: This study aimed to analyze the impact of the COVID-19 pandemic on the epidemiology of hospitalizations for VT and PE in France – with a special focus on the first lockdown period – in terms of the rates of patients hospitalized in 2020 versus 2017–19, their characteristics, and related in-patient and 90-day case-fatality rates. A secondary objective aimed at describe the prevalence of COVID-19 among patients hospitalized with VT and PE, respectively. Methods: All patients hospitalized with a diagnosis of VT and PE respectively in France between January and September (weeks 1–40) of each year from 2017 to 2020 were selected. Weekly incidence rates ratios (IRR) were computed to compare the rates of patients hospitalized between 2020 and 2017–2019. Results: Compared with the 2017–2019 study period, the rates of patients hospitalized with a primary diagnosis (PD) of VT or PE in 2020 were significantly (50 and 40%, respectively) lower during weeks 12–13. By contrast, the rate of patients hospitalized with an associated diagnosis (AD) of PE during the country's first lockdown (weeks 12–19 of 2020) was twice as high as in the same period in 2017–2019, and even three times higher in week 13. The prevalence of COVID-19 in patients hospitalized with a PD of VT and PE, and in those hospitalized with an AD of VT and PE reached, respectively, 4.0, 9.6, 17.2 and 44.6 during the lockdown (weeks 12–19). Inpatients case-fatality rates in patients hospitalized with an AD of PE increased significantly during weeks 12–13. Conclusion: This study highlights significant changes in the epidemiology of hospitalized VT and PE induced by the COVID-19 pandemic.

Adjusting D-dimer to lung disease extent to exclude pulmonary embolism in COVID-19 patients (Co-LEAD)

Background : D-dimer is a safe tool to exclude pulmonary embolism (PE) but its specificity is decreased in COVID-19. Aims : Our aim was to derive a new algorithm with D-dimer threshold adjusted to CT extent of lung damage. Methods : We conducted a multicenter, retrospective cohort study among 774 COVID-19 patients with suspected PE. D-dimer threshold adjusted to CT extent of lung damage was derived in a patient set ( n = 337), and its safety assessed in an independent validation set ( n = 337). Results : According to ROC curves, D-dimer safely excluded PE, with one false negative when using a 900 ng/mL threshold when lung damage extent was <50% and 1700 ng/mL when lung damage extent was ≥50%. In the derivation set, the algorithm's sensitivity was 98.2% (95% CI: 94.7-100.0), and its specificity 28.4% (95% CI: 24.1-32.3). The negative likelihood ratio (NLR) was 0.06 (95% CI: 0.01-0.44) and the AUC was 0.63 (95% CI: 0.60-0.67). In the validation set, sensitivity and specificity were 96.7% (95% CI: 88.7-99.6) and 39.2% (95% CI: 32.2-46.1), respectively. The NLR was 0.08 (95% CI: 0.02-0.33), and the AUC did not differ from that of the derivation set (0.68 (95% CI: 0.64-0.72), P = 0.097). Using the Co-LEAD algorithm, 76/250 (30.4%) COVID-19 patients with suspected PE could have been managed without CT pulmonary angiography (CTPA). Conclusions : The Co-LEAD algorithm safely excludes PE, and allows reducing the use of CTPA in COVID-19 patients. Prospective management studies are necessary to validate this strategy.

Impact of the COVID-19 pandemic and a national lockdown on hospitalizations for venous thromboembolism andpulmonary embolism in france

Background : The COVID-19 pandemic and the national lockdown implemented in France have disturbed populations behavior and overwhelmed hospitals. Furthermore, infection to SARS-CoV-2 has been found to be directly associated with an increased risk of pulmonary embolism (PE). Aims : The aims of this study were to analyze time-trends in patients hospitalized for PE in France, to describe the prevalence of a SARSCoV-2 infection over time among these patients and the related inhospital mortality rates. Methods : We used the French national healthcare database. All patients hospitalized with a diagnosis of PE in France between January and September (Weeks 1 -40) of each year from 2017 to 2020 were selected. Weekly incidence rates ratios (IRR) were computed to compare the rates of patients hospitalized between 2020 and 2017-2019.The COVID-19 diagnosis was based on biologic sample or CT scan. Results : During 2020 study period, 35,446 patients were hospitalized with a primary diagnosis of PE and 23,759 with an associated diagnosis of PE. The prevalence of COVID-19 diagnosis was respectively 3.1% and 15.9%, and reached 9.5% and 45.1% during the lockdown (weeks 12-19). As compared with same 2017-2019 weeks, rates of patients hospitalized with a primary diagnosis of PE in 2020 decreased significantly during the first week of the lockdown (-42%). By contrast, rates of patients hospitalized with an associated diagnosis of PE doubled during the lockdown. Adjusted in-hospital death probability was multiplied by 3 among patients hospitalized with an associated diagnosis of PE (OR = 3.1[2.0-4.8] for week 13 of 2020 vs 2017-2019) but remained steady among those hospitalized with a primary diagnosis of PE. Conclusions : Substantial changes in the epidemiology of PE have been found and were partly related to the global massive decrease in hospitalizations, and also directly linked to the increased number of PE with SARS-CoV-2 infections and their higher severity.

Prevalence of venous thromboembolism and pulmonary embolism among patients hospitalized with a COVID-19diagnosis in france

Background : Infection to SARS-CoV-2 has been found to be directly associated with an increased risk of venous thromboembolism (VTE). Thromboprophylaxy has been early implemented to reduce the risk of pulmonary embolism (PE) in COVID-19 patients. Aims : The aims were to analyze time-trends in the prevalence of VTE among patients hospitalized with a SARS-CoV-2 infection and to describe the related in-hospital mortality rates. Methods : We used the French national healthcare database. All patients hospitalized with COVID-19 diagnosis based on either biological sample or CT scan in France between January and September of 2020 were included. During the Covid19 hospitalization we identified concomitant VTE and specifically Pulmonary embolism (PE) using all diagnosis available during hospitalization. Results : During the 2020 study period, 151,908 Covid-19 patients were identified. Among them, the prevalence of overall VTE was 5.1% and 3.4% for PE. The prevalence increased up to 5.1% for PE and 6.3% for VTE in the middle of May 2020. Higher prevalence of PE and VTE were found in COVID-19 patients admitted to a resuscitation unit (9.5% and 15.6%) as compared to COVID-19 patients not admitted to those units (2.5% and 3.5%). In-hospital mortality rate was higher in patients with PE (20.9%) than in patients without PE (15.1%). Same results were observed in resuscitation units (31.9% vs 27.6%, P < 0.0001). Between the first week of March and June 2020, in-hospital mortality rates were divided by five for COVID-19 patients with PE (from 70.0% to 11.3%), and by four among those without PE (from 40.3% to 7.7%). Conclusions : Prevalence of hospitalized VTE decreased over the COVID-19 pandemic, as well as the related-in-hospital mortality rates, but seemed to increase again at the end of the study period, i.e. at the beginning of the second wave of the pandemic in France.

Thromboses artérielles au cours de la COVID-19

L’infection par SARS-CoV2 est associée à une activation de la coagulation qui a bien été associée à une augmentation du risque de maladie thromboembolique veineuse. Dès le début de la pandémie quelques cas de thromboses artérielles inhabituelles, comme des thrombus de l’aorte associés à des embolies cérébrales ou périphériques inhabituelles ont été décrits. Du point de vue épidémiologique, il est plus difficile de trouver une association évidente notamment en ce qui concerne les accidents vasculaires cérébraux et l’infarctus du myocarde. En effet, dans les études épidémiologiques il est apparu que le confinement a plutôt eu pour conséquence une diminution des hospitalisations pour ces deux pathologies, diminution qui pourrait être due à la peur de se faire hospitaliser durant cette période ou à une moindre incidence réelle. Ainsi, la fréquence des hospitalisations pour infarctus du myocarde a diminué dans de nombreuses études de l’ordre de 30 %. Certains ont proposé que la diminution de la pollution liée au confinement pouvait avoir participé pour une part à cette baisse d’hospitalisation. En tout état de cause, ce qui ressort clairement de la littérature est qu’en cas de thromboses artérielles hospitalisées, les cas étaient plus sévères avec plus de risques de complications lors de la phase aiguë et lors des tentatives thérapeutiques de désobstruction, avec un risque de re-thrombose élevé. Pour les AVC ischémiques, leur sévérité et la mortalité liée à l’accident vasculaire cérébral en cas de COVID-19 étaient significativement plus élevées. Pour l’ischémie aiguë des membres inférieurs, une revue de la littérature a estimé un risque de survenue augmenté par 5 en association avec la COVID-19 avec une sévérité des complications augmentée lors de la prise en charge en urgence.