Diagnosis and Treatment of Pulmonary Embolism During the Coronavirus Disease 2019 Pandemic: A Position Paper From the National PERT Consortium

Abstract

The coexistence of coronavirus disease 2019 (COVID-19) and pulmonary embolism (PE), two life-threatening illnesses, in the same patient presents a unique challenge. Guidelines have delineated how best to diagnose and manage patients with PE. However, the unique aspects of COVID-19 confound both the diagnosis and treatment of PE, and therefore require modification of established algorithms. Important considerations include adjustment of diagnostic modalities, incorporation of the prothrombotic contribution of COVID-19, management of two critical cardiorespiratory illnesses in the same patient, and protecting patients and health-care workers while providing optimal care. The benefits of a team-based approach for decision-making and coordination of care, such as that offered by pulmonary embolism response teams (PERTs), have become more evident in this crisis. The importance of careful follow-up care also is underscored for patients with these two diseases with long-term effects. This position paper from the PERT Consortium specifically addresses issues related to the diagnosis and management of PE in patients with COVID-19.

Keywords: COVID-19; PERT; catheter-directed thrombolysis; follow-up; prevention; pulmonary embolism; pulmonary embolism response team; systemic thrombolysis.

Figure 1

PERT addendum algorithm for patients with COVID-19. ^aPE probability scores to consider include Wells criteria, Geneva score, and Pulmonary Embolism Rule-out Criteria. ^bPlease refer to the PERT Consortium consensus practice document for specific details on risk stratification. ^cBecause of the fluid nature of COVID-19 hotspots, the ability to handle patients with COVID-19 in catheterization laboratories and operating rooms with regard to transport, staff exposure/preparedness, and so forth has evolved since the start of the pandemic and will continue to evolve. This algorithm represents how to treat patients in high-volume COVID-19 institutions where resources may be limited. In low-volume areas, providers may be less likely to shunt a patient down a systemic tissue plasminogen activator pathway if the patient would benefit from an invasive therapy and there are no barriers or limited resources. AC = anticoagulation; COVID-19 = coronavirus disease 2019; CTA = CT angiography; ECMO = extracorporeal membrane oxygenation; LE = lower extremity; LMWH = low-molecular-weight heparin; PCR = polymerase chain reaction; PE = pulmonary embolism; PERT = pulmonary embolism response team; PESI = PE severity index; RV = right ventricular; sPESI = simplified PE severity index; TTE = transthoracic echocardiogram.