Written by Bo Stubblefield
Prevalence of pulmonary embolism (PE) was about 6% in this prospective trial looking at patients admitted to the hospital with worsening respiratory symptoms in the setting of known COPD.
Why does this matter?
In a patient with a history of COPD who presents with acute shortness of breath, there is often the lingering question in the back of our minds: what about PE? Prior studies have reported a high prevenance of PE in patients with COPD ranging anywhere from 19 to 29% (1-3). A recent systematic review and meta-analysis in Chest and summarized by JF (880 patients) found a pooled prevalence of PE in unexplained COPD exacerbations to be 16% – albeit with wide 95% confidence intervals (8.3%-25.8%). Further, this prevalence matters given mortality and length of hospital admission seem to be increased in patients with acute COPD exacerbations and PE (4)
“Sure. It could all be the COPD, but what about PE?” – the voice in the back of your head (or maybe just my head. Is someone burning toast?)
This was a multicenter cross-sectional study of 740 patients with prospective follow-up at 3 months. Patients had confirmed COPD and were admitted to the hospital with worsening respiratory symptoms.
Overall, 5.9% of patients had confirmed pulmonary embolism at 48 hours of admission. Among those patients who did not have PE diagnosed at admission and who did not receive anticoagulation, 5 patients (0.7%) developed PE at 3-month follow-up. 3-month mortality was 6.8%, with patients diagnosed with PE within 48 hours of admission having higher mortality than those without PE on admission.
This study provides high quality, prospective evidence that the prevalence of PE in patients with COPD admitted for respiratory symptoms is lower than that reported in prior reviews but still an important consideration in this population. Authors note that further research is needed to risk-stratify and screen this specific population. In the interim, let’s continue to risk-stratify these patients with the tools available to us, and use our D-dimer when needed!
Prevalence of Pulmonary Embolism Among Patients With COPD Hospitalized With Acutely Worsening Respiratory Symptoms. JAMA. 2021 Jan 5;325(1):59-68. doi: 10.1001/jama.2020.23567.
Bonus reading on clinician gestalt and risk stratification used in this study
Initially, clinician judgment was used to classify patients as clinically suspected or not suspected of having a pulmonary embolism AND as having a diagnosis other than pulmonary embolism more or less likely. Clinical probability of PE was subsequently assessed in all patients using the Revised Geneva Score. Patients with high pre-test probability (n=17) were imaged. Patients with Low to intermediate pre-test probability had D-dimers ordered (n=723). Of those patients with +D-dimers (n=500), 95% underwent CTPA. The prevalence of PE reached 10% when suspected using clinician gestalt, but remained just above 3% in patients without clinical suspicion. Check out Table 3.
Reviewed by Clay Smith
Akpinar EE, Hoşgün D, Akpinar S, Ataç GK, Doğanay B, Gülhan M. Incidence of pulmonary embolism during COPD exacerbation. J Bras Pneumol 2014;40:38-45.
Tillie-Leblond I, Marquette CH, Perez T, et al. Pulmonary embolism in patients with unexplained exacerbation of chronic obstructive pulmonary disease: prevalence and risk factors. Ann Intern Med 2006;144:390-6.
Rizkallah J, Man SFP, Sin DD. Prevalence of pulmonary embolism in acute exacerbations of COPD: a systematic review and metaanalysis. Chest 2009;135:786-93.
Aleva FE, Voets L, Simons SO, de Mast Q, van der Ven A, Heijdra YF. Prevalence and Localization of Pulmonary Embolism in Unexplained Acute Exacerbations of COPD: A Systematic Review and Meta-analysis. Chest 2017;151:544-54.