Prevalence of Pulmonary Embolism Among Patients With COPD Hospitalized With Acutely Worsening Respiratory Symptoms

Abstract

Importance: The prevalence of pulmonary embolism in patients with chronic obstructive pulmonary disease (COPD) and acutely worsening respiratory symptoms remains uncertain.

Objective: To determine the prevalence of pulmonary embolism in patients with COPD admitted to the hospital for acutely worsening respiratory symptoms.

Design, setting, and participants: Multicenter cross-sectional study with prospective follow-up conducted in 7 French hospitals. A predefined pulmonary embolism diagnostic algorithm based on Geneva score, D-dimer levels, and spiral computed tomographic pulmonary angiography plus leg compression ultrasound was applied within 48 hours of admission; all patients had 3-month follow-up. Patients were recruited from January 2014 to May 2017 and the final date of follow-up was August 22, 2017.

Exposures: Acutely worsening respiratory symptoms in patients with COPD.

Main outcomes and measures: The primary outcome was pulmonary embolism diagnosed within 48 hours of admission. Key secondary outcome was pulmonary embolism during a 3-month follow-up among patients deemed not to have venous thromboembolism at admission and who did not receive anticoagulant treatment. Other outcomes were venous thromboembolism (pulmonary embolism and/or deep vein thrombosis) at admission and during follow-up, and 3-month mortality, whether venous thromboembolism was clinically suspected or not.

Results: Among 740 included patients (mean age, 68.2 years [SD, 10.9 years]; 274 women [37.0%]), pulmonary embolism was confirmed within 48 hours of admission in 44 patients (5.9%; 95% CI, 4.5%-7.9%). Among the 670 patients deemed not to have venous thromboembolism at admission and who did not receive anticoagulation, pulmonary embolism occurred in 5 patients (0.7%; 95% CI, 0.3%-1.7%) during follow-up, including 3 deaths related to pulmonary embolism. The overall 3-month mortality rate was 6.8% (50 of 740; 95% CI, 5.2%-8.8%). The proportion of patients who died during follow-up was higher among those with venous thromboembolism at admission than the proportion of those without it at admission (14 [25.9%] of 54 patients vs 36 [5.2%] of 686; risk difference, 20.7%, 95% CI, 10.7%-33.8%; P < .001). The prevalence of venous thromboembolism was 11.7% (95% CI, 8.6%-15.9%) among patients in whom pulmonary embolism was suspected (n = 299) and was 4.3% (95% CI, 2.8%-6.6%) among those in whom pulmonary embolism was not suspected (n = 441).

Conclusions and relevance: Among patients with chronic obstructive pulmonary disease admitted to the hospital with an acute worsening of respiratory symptoms, pulmonary embolism was detected in 5.9% of patients using a predefined diagnostic algorithm. Further research is needed to understand the possible role of systematic screening for pulmonary embolism in this patient population.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Couturaud reported having received grant support from Bristol-Myers Squibb–Pfizer; fees for board memberships or symposia from Bayer, Bristol-Myers Squibb–Pfizer, and AstraZeneca; and travel support from Bayer, Bristol-Myers Squibb–Pfizer, Daiichi Sankyo, Leo Pharma, InterMune, and Actelion. Dr Bertoletti reported receiving grant support from Bayer and fees for board memberships or symposia from Actelion, Aspen, Bayer, Bristol-Myers Squibb–Pfizer, and Merck Sharp and Dohme; and travel support from Aspen, Bayer, Bristol-Myers Squibb–Pfizer, Daiichi Sankyo, Leo Pharma, Merck Sharp and Dohme, and Actelion. Dr Sanchez reported receiving grant support from Bayer, Daiichi Sankyo, and Portola Pharmaceuticals and fees or nonfinancial support for consultancy activities from Actelion, GlaxoSmithKline, Boehringer Ingelheim, and Chiesi. Dr Mismetti reported receiving grants from Bayer; fees for board memberships from Bayer, Bristol-Myers Squibb–Pfizer, and Daiichi Sankyo; lecture fees from Bayer, Boehringer Ingelheim, Bristol-Myers Squibb–Pfizer, Daiichi Sankyo, and Sanofi; and fees for development of educational presentations from Bayer and Bristol-Myers Squibb–Pfizer. Dr Girard reported receiving personal fees and nonfinancial support from Bayer and Leo Pharma. Dr Lacut reported receiving personal fees from Bayer Healthcare, Bristol Myers Squibb, and Boehringer Ingelheim. Dr Meyer reported receiving grant support from Bayer, Boehringer Ingelheim, Leo Pharma, and Sanofi, being an uncompensated board member and a consultant for Bayer, Boehringer-Ingelheim, Bristol Myers Squibb, Leo Pharma, and Pfizer, and receiving travel support from Bayer, Boehringer Ingelheim, Daiichi Sankyo, Leo Pharma, and Sanofi. Dr Leroyer reported receiving grant support from Pfizer, fees for board memberships or symposia from Bayer and AstraZeneca, travel support from Bayer, Daiichi Sankyo, Leo Pharma, InterMune, and Actelion. No other disclosures were reported.

Figures

Figure.. Study Flow of Patients Hospitalized With COPD With Acutely Worsening Respiratory Symptoms and Prevalence of Pulmonary Embolism

aMinor protocol violation. bThree patients with pulmonary embolism (PE) were not taking long-term anticoagulation before inclusion. cSpiral computed tomographic pulmonary angiography (CTPA) inconclusive (compression US, negative) for 1 patient; V̇/Q̇, high probability; CTPA, positive for PE. dTwo had a PE history but not receiving long-term anticoagulation before inclusion. eCTPA inconclusive for 4 patients: compression US negative; V̇/Q̇ not performed; CTPA, positive for PE. fMajor protocol violation. gThree patients, atrial fibrillation; 2, cancer, and 9, isolated PE not validated. hVenous thromboembolism (VTE) assessment at admission for all 3 patients.