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. 2023 Mar 23;18(3):e0283459.
doi: 10.1371/journal.pone.0283459. eCollection 2023.

Systematic screening versus clinical gestalt in the diagnosis of pulmonary embolism in COVID-19 patients in the emergency department

Inge H Y Luu  1 , Tim Frijns  1 , Jacqueline Buijs  1 , Jasenko Krdzalic  2 , Martijn D de Kruif  3 , Guy J M Mostard  1 , Hugo Ten Cate  4 , Remy J H Martens  5 , Remy L M Mostard  3 , Math P G Leers  5 , Daan J L van Twist  1
Affiliations

Systematic screening versus clinical gestalt in the diagnosis of pulmonary embolism in COVID-19 patients in the emergency department

Inge H Y Luu et al. PLoS One. .

Abstract

Background: Diagnosing concomitant pulmonary embolism (PE) in COVID-19 patients remains challenging. As such, PE may be overlooked. We compared the diagnostic yield of systematic PE-screening based on the YEARS-algorithm to PE-screening based on clinical gestalt in emergency department (ED) patients with COVID-19.

Methods: We included all ED patients who were admitted because of COVID-19 between March 2020 and February 2021. Patients already receiving anticoagulant treatment were excluded. Up to April 7, 2020, the decision to perform CT-pulmonary angiography (CTPA) was based on physician's clinical gestalt (clinical gestalt cohort). From April 7 onwards, systematic PE-screening was performed by CTPA if D-dimer level was ≥1000 ug/L, or ≥500 ug/L in case of ≥1 YEARS-item (systematic screening cohort).

Results: 1095 ED patients with COVID-19 were admitted. After applying exclusion criteria, 289 were included in the clinical gestalt and 574 in the systematic screening cohort. The number of PE diagnoses was significantly higher in the systematic screening cohort compared to the clinical gestalt cohort: 8.2% vs. 1.0% (3/289 vs. 47/574; p<0.001), even after adjustment for differences in patient characteristics (adjusted OR 8.45 (95%CI 2.61-27.42, p<0.001) for PE diagnosis). In multivariate analysis, D-dimer (OR 1.09 per 1000 μg/L increase, 95%CI 1.06-1.13, p<0.001) and CRP >100 mg/L (OR 2.78, 95%CI 1.37-5.66, p = 0.005) were independently associated with PE.

Conclusion: In ED patients with COVID-19, the number of PE diagnosis was significantly higher in the cohort that underwent systematic PE screening based on the YEARS-algorithm in comparison with the clinical gestalt cohort, with a number needed to test of 7.1 CTPAs to detect one PE.

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Conflict of interest statement

I have read the journal’s policy and the authors of this manuscript have the following competing interests: H.C. has received research grants from Bayer and Pfizer and consulting fees from Alveron, has participated on advisory boards for Galapagos, Alexion, and Viatris, and is a stockholder with Coagulation Profile, outside the submitted work. R.L.M.M. has participated on advisory boards for Boehringer-Ingelheim and Galapagos, outside the submitted work. D.J.L.T. has received research grants from Bayer and honoraria for lectures from Bayer and Amgen, and has participated on advisory boards for AstraZeneca and Sanofi, outside the submitted work. I.H.Y.L., T.F., J.B., J.K., M.D.K., G.J.M.M., R.J.H.M., and M.P.G.L. declare no competing interests. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Figures

Fig 1
Fig 1. Flowchart of study population, showing (A) cohorts and (B) further details of the systematic screening cohort.
1D-dimer cut-off ≥ 500 ug/L if ≥ 1 YEARS items; D-dimer cut-off is increased to 1000 ug/L if 0 YEARS items. ED, emergency department; CTPA; computed tomography pulmonary angiogram; PE, pulmonary embolism.
Fig 2
Fig 2. Scatter plot of the D-dimer levels in patients who underwent CTPA according to the YEARS algorithm, in whom PE was ruled out and confirmed, on a base-2 log scale.
Each dot represents one patient. Horizontal lines show the median, error bars show the interquartile range. PE, pulmonary embolism.
Fig 3
Fig 3. Chart of the total number of ED patients with COVID-19 in whom pulmonary embolism was confirmed (left axis, represented as the bar graph) and the proportion of confirmed PE among ED patients with COVID-19 (right axis, shown with the line graph), plotted for each month.
ED, emergency department; PE, pulmonary embolism.
See this image and copyright information in PMC

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