Elevated D-dimers and lack of anticoagulation predict PE in severe COVID-19 patients

Background: Coronavirus disease 2019 (COVID-19) may predispose to venous thromboembolism. We determined factors independently associated with computed tomography pulmonary angiography (CTPA)confirmed pulmonary embolism (PE) in hospitalised severe COVID-19 patients. Methods: Among all (n=349) patients hospitalised for COVID-19 in a university hospital in a French region with a high rate of COVID-19, we analysed patients who underwent CTPA for clinical signs of severe disease (oxygen saturation measured by pulse oximetry <= 93% or breathing rate >= 30 breaths.min(-1)) or rapid clinical worsening. Multivariable analysis was performed using Firth penalised maximum likelihood estimates. Results: 162 (46.4%) patients underwent CTPA (mean +/- SD age 65.6 +/- 13.0 years; 67.3% male (95% CI 59.575.5%). PE was diagnosed in 44 (27.2%) patients. Most PEs were segmental and the rate of PE-related right ventricular dysfunction was 15.9%. By multivariable analysis, the only two significant predictors of CTPA-confirmed PE were D-dimer level and the lack of any anticoagulant therapy (OR 4.0 (95% CI 2.4-6.7) per additional quartile and OR 4.5 (95% CI 1.1-7.4), respectively). Receiver operating characteristic curve analysis identified a D-dimer cut-off value of 2590 ng.mL(-1) to best predict occurrence of PE (area under the curve 0.88, p<0.001, sensitivity 83.3%, specificity 83.8%). D-dimer level >2590 ng.mL(-1) was associated with a 17-fold increase in the adjusted risk of PE. Conclusion: Elevated D-dimers (>2590 ng.mL(-1)) and absence of anticoagulant therapy predict PE in hospitalised COVID-19 patients with clinical signs of severity. These data strengthen the evidence base in favour of systematic anticoagulation, and suggest wider use of D-dimer guided CTPA to screen for PE in acutely ill hospitalised patients with COVID-19.