Clinical characteristics of COVID-19 patients with pulmonary embolism in 1st and 2nd waves

ABSTRACT

Introduction and ObjectivesMultiple studies have demonstrated increased risk of pulmonary embolism (PE) in COVID-19. Our study at a major NHS Trust examined the clinical characteristics, attributes and outcomes of PE in COVID-19, which have infrequently been explored in literature.MethodsWe performed a retrospective cohort study of COVID-19 patients with PE diagnosed on CT pulmonary angiogram (CTPA) over 2 months in 1st and 2nd waves (April 2020 and January 2021). Data collected from electronic health and imaging records included patient demographics, D-dimers, oxygen requirements, clinical outcomes, thromboprophylaxis/treatment and PE attributes on CTPA.ResultsWe identified 76 COVID-19 patients with PE (mean age 62.2 years, 69.7% male, 40.8% Caucasian). Patients experienced prolonged periods of COVID-19 symptoms prior to PE diagnosis - 19.6 day symptoms in 1st wave (n = 16, 21.9%) compared to 15.2 days in 2nd wave (n = 57, 78.1%). Average D-dimer was highly elevated (mean = 11576 ng/mL). 43 (56.5%) patients had high oxygen requirements - 21 (27.6%) required ≥10 litres/min via mask, 13 (17.1%) required non-invasive ventilation and 9 (11.8%) were intubated and ventilated. 22 patients (28.9%) were admitted to intensive care and 11 patients (14.5%) died. On admission, 48 patients (63.2%) were started on treatment dose enoxaparin (high PE suspicion) and 12 (15.8%) had intermediate (prophylactic) dose enoxaparin. PEs were largely treated with 3–6 months of rivaroxaban (n = 43, 56.6%) or apixaban (n = 7, 9.2%). 65.5% (n = 49) of patients had bilateral PEs;largest sizes being segmental (n = 32, 42.1%), subsegmental (n = 17, 22.4%), lobar (n = 16, 21.1%), main pulmonary artery (n= 5, 6.6%) and saddle (n = 5, 6.6%). 15 patients (19.7%) had evidence of right heart strain on CTPA.ConclusionsOur study suggests that PE in COVID-19 is more common in males and in those with COVID symptoms greater than 2 weeks, high oxygen requirements and highly elevated D-dimers. There should be a low threshold for investigating such patients for PE. Moreover, we found COVID-19 patients with PE have high likelihood of having a bilateral pulmonary distribution with right heart strain.