Ruling out Pulmonary Embolism in Patients with (Suspected) COVID-19—A Prospective Cohort Study

Stals, Milou A.M.; Kaptein, Fleur H.J.; Bemelmans, Remy H.H.; van Bemmel, Thomas; Boukema, Inge C.; Braeken, Dionne C.W.; Braken, Sander J.E.; Bresser, Carlinda; Cate, Hugo ten; Deenstra, Duco D.; Dooren, Yordi P.A. van; Faber, Laura M.; Grootenboers, Marco J.J.H.; Haan, Lianne R. de; Haazer, Carolien; Sol, Antonio Iglesias del; Kelliher, Sarah; Koster, Ted; Kroft, Lucia J.M.; Meijer, Rick I.; Pals, Fleur; van Thiel, Eric R.E.; Westerweel, Peter E.; Wolde, Marije ten; Klok, Frederikus A.; Huisman, Menno V.

Background Diagnostic strategies for suspected pulmonary embolism (PE) have not been prospectively evaluated in COVID-19 patients. Methods Prospective, multicenter, outcome study in 707 patients with both (suspected) COVID-19 and suspected PE in 14 hospitals. Patients on chronic anticoagulant therapy were excluded. Informed consent was obtained by opt-out approach. Patients were managed by validated diagnostic strategies for suspected PE. We evaluated the safety (3-month failure rate) and efficiency (number of computed tomography pulmonary angiographies [CTPAs] avoided) of the applied strategies. Results Overall PE prevalence was 28%. YEARS was applied in 36%, Wells rule in 4.2%, and “CTPA only” in 52%; 7.4% was not tested because of hemodynamic or respiratory instability. Within YEARS, PE was considered excluded without CTPA in 29%, of which one patient developed nonfatal PE during follow-up (failure rate 1.4%, 95% CI 0.04–7.8). One-hundred seventeen patients (46%) managed according to YEARS had a negative CTPA, of whom 10 were diagnosed with nonfatal venous thromboembolism (VTE) during follow-up (failure rate 8.8%, 95% CI 4.3–16). In patients managed by CTPA only, 66% had an initial negative CTPA, of whom eight patients were diagnosed with a nonfatal VTE during follow-up (failure rate 3.6%, 95% CI 1.6–7.0). Conclusion Our results underline the applicability of YEARS in (suspected) COVID-19 patients with suspected PE. CTPA could be avoided in 29% of patients managed by YEARS, with a low failure rate. The failure rate after a negative CTPA, used as a sole test or within YEARS, was non-negligible and reflects the high thrombotic risk in these patients, warranting ongoing vigilance.