Written by Bo Stubblefield
In patients hospitalized for a COPD exacerbation, addition of an active strategy for the diagnosis of pulmonary embolism (PE) plus usual care compared to usual care alone did not significantly improve the composite outcome of nonfatal new or recurrent venous thromboembolism (VTE), readmission for COPD, or death at 90 days.
Why does this matter?
In a recent cross-sectional, prospective study, the prevalence of PE was reported as 6% in patients admitted to the hospital with worsening respiratory symptoms in the setting of known COPD (1). This is believed to approximate the true prevalence in emergency department (ED) patients with COPD exacerbations. Prior studies have reported a higher prevalence of PE in patients with COPD ranging anywhere from 19 to 29% (2-4). A systematic review and meta-analysis in Chest (mostly non-ED patients) found a pooled prevalence of PE in unexplained COPD exacerbations to be 16% (95% CI 8.3%-25.8%) (5). Although observational studies and meta-analyses have assessed the prevalence of PE among patients with COPD exacerbations, does an active search strategy for PE improve clinical outcomes in patients hospitalized for COPD exacerbations?
“No, I did not order a Dimer on that pt with COPD”, “No, I’m not crazy”, “Yes, I do think that Sting did his best work with The Police in the early 80s…”
This randomized controlled trial enrolled 746 patients with COPD exacerbations requiring hospitalization in 18 academic hospitals across Spain. Nearly 99% of patients completed the trial. All patients in the intervention group received a D-dimer and a subsequent CTA of the chest if >500 ng/mL* as part of the active search strategy. The primary composite outcome occurred in about 29% of both the control group and the intervention group (p=0.86). This was a negative trial. An active search for thrombosis in patients with a COPD exacerbation requiring admission did not improve the composite outcome. However, patients were excluded if PE was the initial clinical suspicion, and the study was not powered to detect individual components of the composite outcome (i.e. nonfatal new or recurrent VTE).
Watch David Jiménez, the lead author discuss the manuscript here. Of note, a post hoc analysis revealed that an age-adjusted D-dimer would have reduced the need for CTA by 15%. See our JournalFeed on the nuances of D-dimer adjustment.
*Cutoff levels for defining elevated D-dimer established by department of clinical chemistry at each participating site – 500ng/mL for all, with exception of HemosIL assay.
Effect of a Pulmonary Embolism Diagnostic Strategy on Clinical Outcomes in Patients Hospitalized for COPD Exacerbation: A Randomized Clinical Trial. JAMA. 2021 Oct 5;326(13):1277-1285. doi: 10.1001/jama.2021.14846.
Reviewed by Clay Smith
Couturaud F, Bertoletti L, Pastre J, et al. Prevalence of Pulmonary Embolism Among Patients With COPD Hospitalized With Acutely Worsening Respiratory Symptoms. Jama 2021;325:59-68.
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.