Pulmonary embolism in patients with COVID-19: characteristics and outcomes in the Cardio-COVID Italy multicenter study
Pietro Ameri, Riccardo M. Inciardi, Mattia Di Pasquale, Piergiuseppe Agostoni, Antonio Bellasi, Rita Camporotondo, Claudia Canale, Valentina Carubelli, Stefano Carugo, Francesco Catagnano, Giambattista Danzi, Laura Adelaide Dalla Vecchia, Stefano Giovinazzo, Massimiliano Gnecchi, Marco Guazzi, Anita Iorio, Maria Teresa La Rovere, Sergio Leonardi, Gloria Maccagni, Massimo Mapelli, Davide Margonato, Marco Merlo, Luca Monzo, Andrea Mortara, Vincenzo Nuzzi, Massimo Piepoli, Italo Porto, Andrea Pozzi, Giovanni Provenzale, Filippo M. Sarullo, Gianfranco Sinagra, Chiara Tedino, Daniela Tomasoni, Maurizio Volterrani, G Zaccone, Carlo Lombardi, Michele Senni, Marco Metra
Abstract
BACKGROUND: Pulmonary embolism (PE) has been described in coronavirus disease 2019 (COVID-19) critically ill patients, but the evidence from more heterogeneous cohorts is limited. METHODS: Data were retrospectively obtained from consecutive COVID-19 patients admitted to 13 Cardiology Units in Italy, from March 1st to April 9th, 2020, and followed until in-hospital death, discharge, or April 23rd, 2020. The association of baseline variables with computed tomography-confirmed PE was investigated by Cox hazards regression analysis. The relationship between D-dimer levels and PE incidence was evaluated using restricted cubic splines models. RESULTS: The study included 689 patients (67.3 ± 13.2 year-old, 69.4% males), of whom 43.6% were non-invasively ventilated and 15.8% invasively. 52 (7.5%) had PE over 15 (9-24) days of follow-up. Compared with those without PE, these subjects had younger age, higher BMI, less often heart failure and chronic kidney disease, more severe cardio-pulmonary involvement, and higher admission D-dimer [4344 (1099-15,118) vs. 818.5 (417-1460) ng/mL, p < 0.001]. They also received more frequently darunavir/ritonavir, tocilizumab and ventilation support. Furthermore, they faced more bleeding episodes requiring transfusion (15.6% vs. 5.1%, p < 0.001) and non-significantly higher in-hospital mortality (34.6% vs. 22.9%, p = 0.06). In multivariate regression, only D-dimer was associated with PE (HR 1.72, 95% CI 1.13-2.62; p = 0.01). The relation between D-dimer concentrations and PE incidence was linear, without inflection point. Only two subjects had a baseline D-dimer < 500 ng/mL. CONCLUSIONS: PE occurs in a sizable proportion of hospitalized COVID-19 patients. The implications of bleeding events and the role of D-dimer in this population need to be clarified.