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

Educational Objective
To understand the risk of pulmonary embolism in patients with acute exacerbation of chronic obstructive pulmonary disease.
1 Credit CME
Key Points

Question  How common is pulmonary embolism among patients with chronic obstructive pulmonary disease who are admitted to the hospital with acutely worsening respiratory symptoms?

Findings  In this cross-sectional study with prospective follow-up that used a predefined pulmonary embolism diagnostic algorithm and included 740 consecutive patients with chronic obstructive pulmonary disease, pulmonary embolism was detected in 5.9% of patients.

Meaning  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% patients using a predefined diagnostic algorithm.

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.

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Article Information

Corresponding Author: Francis Couturaud, MD, PhD, Département de Médecine Interne et Pneumologie, Hôpital de la Cavale Blanche, CHRU de Brest, 29609 Brest cedex, France (francis.couturaud@chu-brest.fr).

Accepted for Publication: November 11, 2020.

Author Contributions: Dr Couturaud had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Couturaud, Bertoletti, Hoffmann, Mismetti.

Acquisition, analysis, or interpretation of data: Couturaud, Bertoletti, Pastre, Roy, Le Mao, Gagnadoux, Paleiron, Schmidt, Sanchez, De Magalhaes, Kamara, Bressollette, Nonent, Tromeur, Salaun, Barillot, Gatineau, Mismetti, Girard, Lacut, Lemarié, Meyer, Leroyer.

Drafting of the manuscript: Couturaud, Bertoletti, Sanchez, Gatineau, Mismetti, Girard, Meyer, Leroyer.

Critical revision of the manuscript for important intellectual content: Couturaud, Bertoletti, Pastre, Roy, Le Mao, Gagnadoux, Paleiron, Schmidt, Sanchez, De Magalhaes, Kamara, Hoffmann, Bressollette, Nonent, Tromeur, Salaun, Barillot, Mismetti, Girard, Lacut, Lemarié, Meyer.

Statistical analysis: Gatineau.

Obtained funding: Couturaud.

Administrative, technical, or material support: Couturaud, Bertoletti, Schmidt, Bressollette, Barillot, Girard, Lacut, Meyer, Leroyer.

Supervision: Couturaud, Bertoletti, Paleiron, Meyer.

Other: Nonent, Tromeur.

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.

Funding/Support: The study was supported by grants from the Programme Hospitalier de Recherche Clinique (French Department of Health), and the sponsor was the University Hospital of Brest.

Role of the Funder/Sponsor: Neither sponsor had a role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. An academic steering committee assumed overall responsibility for all these steps.

Members of the PEP Study Group (all in France): Steering Committee: Francis Couturaud, MD (chair), and Christophe Leroyer, MD, Centre Hospitalo-Universitaire de Brest, Brest; Olivier Sanchez, MD, and Guy Meyer, MD, Hôpital Européen Georges Pompidou, Paris; and Laurent Bertoletti, MD, and Patrick Mismetti, MD, Centre Hospitalo-Universitaire de Saint-Etienne, Saint-Etienne. Coordinating Committee: Francis Couturaud, MD (chair), Sophie Barillot, MS, Elise Poulhazan, MS, and Anne Le Brestec, MS, Centre Hospitalo-Universitaire de Brest, Brest. Independent Central Adjudication Committee (Critical Events): Philippe Girard, MD (chair), Stéphane Lenoir, MD, and Christian Lamer, MD, Institut Mutualiste Montsouris, Paris; Statistical Analysis: Florence Gatineau, MS, Centre Hospitalo-Universitaire de Brest, Brest; Operation Team: Dauphou Eddy, MS, and Florence Morvan, MS, Centre Hospitalo-Universitaire de Brest, Brest; Computerised Tomographic Scan Panel: Michel Nonent, MD, Pierre-Yves Le Floch, MD, and Fabien Podeur, MD, Centre Hospitalo-Universitaire de Brest, Brest; Lung Scintigraphy Panel: Pierre-Yves Salaun, MD, Philippe Robin, MD, and Pierre-Yves Le Roux, MD, Centre Hospitalo-Universitaire de Brest, Brest; and Ultrasound Panel: Luc Bressollette, MD, and Clément Hoffmann, Centre Hospitalo-Universitaire de Brest, Brest; Investigators (in order of the number of patients enrolled): Francis Couturaud, MD, Christophe Leroyer, MD, Cécile Tromeur, MD, Romain Didier, MD, Karine Lacut, MD, Emmanuelle Lemoigne, MD, Raphael Le Mao, MD, Charles Orione, MD, Alexandre Fauché, MD, Christophe Gut-Gobert, MD, Claire De Moreuil, Centre Hospitalo-Universitaire de Brest, Brest (365); Olivier Sanchez, MD, Guy Meyer, MD, Benjamin Planquette, MD, and Jean Pastre, MD, Hôpital Européen Georges Pompidou, Paris (99); Pierre-Marie Roy, MD, and Frédéric Gagnadoux, MD, Centre Hopitalo-Universitaire d’Angers, Angers (84); Nicolas Paleiron, MD, Hôpital d’instruction militaire Clermont Tonnerre and Clermont Tonnerre, Hôpital d’instruction militaire, Brest (79); Patrick Mismetti, MD, Sandrine Accassat, MD, Laurent Bertoletti, MD, Elodie De Magalhaes, MD, Alain Viallon, MD, Centre Hospitalo-Universitaire de Saint-Etienne, Saint-Etienne (76); Mariam Kamara, MD, Centre Hospitalier Général de Quimper, Quimper (32); and Jeannot Schmidt, MD, Centre Hospitalo-Universitaire de Clermont-Ferrand, Clermont-Ferrand (15). No member of the PEP Study Group received compensation for his/her role in the study.

Meeting Presentations: The results of this study were presented in the late-breaking abstract session at the 29th European Respiratory Society Annual Meeting; October 1, 2019; Madrid, Spain.

Additional Information: Dedicated to Guy Meyer.

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