Role of repeat pulmonary angiography and D-dimer testing in pulmonary thromboembolism evaluation among COVID-19 patients

Abstract

Aims: Pulmonary thromboembolism (PE) is a life-threatening condition in pulmonary medicine. It is commonly diagnosed in emergency medicine via computed tomography pulmonary angiography (CTPA). D-dimer is a well-established diagnostic marker for PE, and repeated imaging and testing are often part of follow-up protocols. This study investigates whether the presence or severity of PE influences the need for repeated imaging and D-dimer testing among patients diagnosed with coronavirus disease 2019 (COVID-2019). Methods: The study included patients evaluated in the emergency department for PE and were then on routine follow-up at one week, one month, three months, and six months. PE diagnoses were confirmed by CTPA and categorized by severity. Results: Of the 149 patients, 55.7% were diagnosed with PE, with most cases being severe. Over six months, the mortality rate was 6.7%. Repeat CTPA was done in 67.1% of patients, but severity did not correlate with repeat imaging frequency. D-dimer levels decreased over time except in patients with recurrent PE. High initial D-dimer was associated with PE diagnosis but did not influence subsequent imaging requests. Conclusion: D-dimer levels are reduced over time in patients without confirmed PE, implying a reduced need for repeat imaging if levels are low. Variations in repeat testing practices suggest over-testing may occur, influenced by clinical judgment rather than guidelines. D-dimer levels did not significantly impact repeat CTPA requests, and severe PE cases did not require more frequent imaging among patients diagnosed with COVID-19. Routine repeat imaging may not be necessary in patients with declining D-dimer levels post-initial evaluation.

Keywords

• Computed tomography pulmonary angiography
• D-dimer
• emergency medicine
• pulmonary embolism

COVID-19 hastalarında pulmoner tromboemboli değerlendirilmesinde tekrarlayan pulmoner anjiyografi ve D-dimer testinin rolü

Abstract

Giriş Pulmoner tromboemboli (PTE), göğüs hastalıklarında yaşamı tehdit eden bir durumdur. Acil serviste genellikle bilgisayarlı tomografi pulmoner anjiyografi (BTPA) ile tanı konur. D-dimer, PTE için iyi tanımlanmış bir tanı belirtecidir ve takip protokollerinde tekrarlayan görüntüleme ve testler sıkça yer almaktadır. Bu çalışma, Koronavirüs Hastalığı 2019 (COVID-2019) tanısı almış hastalarda PTE varlığı veya şiddetinin tekrarlayan görüntüleme ve D-dimer testine duyulan ihtiyacı etkileyip etkilemediğini araştırmaktadır. Gereç ve Yöntemler Çalışmaya acil serviste PTE açısından değerlendirilen ve ardından birinci hafta, birinci ay, üçüncü ay ve altıncı ayda rutin takipleri yapılan hastalar dahil edildi. PTE tanıları BTPA ile doğrulandı ve şiddetine göre sınıflandırıldı. Bulgular 149 hastanın %55,7’sine PTE tanısı konuldu ve vakaların çoğu ağırdı. Altı aylık süreçte mortalite oranı %6,7 idi. Hastaların %67,1’ine tekrar BTPA yapıldı, ancak şiddet ile tekrarlayan görüntüleme sıklığı arasında ilişki saptanmadı. D-dimer düzeyleri, tekrarlayan PTE’si olanlar dışında, zamanla azalma gösterdi. Yüksek başlangıç D-dimer düzeyleri PTE tanısı ile ilişkiliydi ancak sonraki görüntüleme taleplerini etkilemedi. Tartışma Doğrulanmış PTE’si olmayan hastalarda D-dimer düzeyleri zamanla azalmakta, bu da düşük düzeylerde tekrar görüntülemeye duyulan ihtiyacın azaldığını göstermektedir. Tekrarlayan test uygulamalarındaki farklılıklar, kılavuzlardan ziyade klinik yargıya bağlı olarak ek test yapılabileceğini düşündürmektedir. Sonuç D-dimer düzeyleri, tekrar BTPA taleplerini anlamlı şekilde etkilememiştir ve ağır PTE vakaları, COVID-19 tanılı hastalarda daha sık görüntüleme gerektirmemiştir. İlk değerlendirme sonrası D-dimer düzeyleri düşen hastalarda rutin tekrarlayan görüntülemeye gerek olmayabilir.

Keywords

• Bilgisayarlı Tomografi Pulmoner Anjiyografi
• D-Dimer
• Acil Tıp
• Pulmoner Emboli

References

1. Freund Y, Cohen-Aubart F, Bloom B. Acute pulmonary embolism. JAMA. 2022;328(13):1336. doi:10.1001/jama.2022.16815
2. Kline JA, Kabrhel C. Emergency evaluation for pulmonary embolism, part 1: clinical factors that ıncrease risk. J Emerg Med. 2015;48(6):771-780. doi:10.1016/j.jemermed.2014.12.040
3. Chen S, Mouratidis B. Comparison of lung scintigraphy and CT angiography in the diagnosis of pulmonary embolism. Australas Radiol. 2002;46(1):47-51. doi:10.1046/j.1440-1673.2001.00993.x
4. Wittram C, Maher MM, Yoo AJ, Kalra MK, Shepard JAO, McLoud TC. CT angiography of pulmonary embolism: diagnostic criteria and causes of misdiagnosis. RadioGraphics. 2004;24(5):1219-1238. doi:10.1148/rg. 245045008
5. Perrier A, Desmarais S, Goehring C, et al. D-dimer testing for suspected pulmonary embolism in outpatients. Am J Respir Crit Care Med. 1997; 156(2):492-496. doi:10.1164/ajrccm.156.2.9702032
6. Wolf SJ, McCubbin TR, Feldhaus KM, Faragher JP, Adcock DM. Prospective validation of wells criteria in the evaluation of patients with suspected pulmonary embolism. Ann Emerg Med. 2004;44(5):503-510. doi:10.1016/j.annemergmed.2004.04.002
7. Jakubiak GK, Starzak M, Gmyrek J, Pietrzak M, Cieślar G, Stanek A. Large hiatal hernia as a risk factor for recurrent pulmonary embolism in a 76-year-old female patient. Acta Angiologica. 2024;30(3):121-125. doi: 10.5603/aa.100555
8. Tan BK, Mainbourg S, Friggeri A, et al. Arterial and venous thromboembolism in COVID-19: a study-level meta-analysis. Thorax. 2021;76(10):970-979. doi:10.1136/thoraxjnl-2020-215383

9. Knight R, Walker V, Ip S, et al. Association of COVID-19 with major arterial and venous thrombotic diseases: a population-wide cohort study of 48 million adults in England and wales. Circulation. 2022;146(12):892-906. doi:10.1161/CIRCULATIONAHA.122.060785
10. Nemec HM, Ferenczy A, Christie BD, Ashley DW, Montgomery A. Correlation of D-dimer and outcomes in COVID-19 patients. Am Surg. 2022;88(9):2115-2118. doi:10.1177/00031348221091940
11. Rivera-Lebron B, McDaniel M, Ahrar K, et al. Diagnosis, treatment and follow up of acute pulmonary embolism: consensus practice from the PERT consortium. Clin Appl Thromb Hemost. 2019;25: 1076029619853037. 2019;25. doi:10.1177/1076029619853037
12. Klok FA, Ageno W, Ay C, et al. Optimal follow-up after acute pulmonary embolism: a position paper of the European Society of Cardiology Working Group on Pulmonary Circulation and Right Ventricular Function, in collaboration with the European Society of Cardiology Working Group on Atherosclerosis and Vascular Biology, endorsed by the European Respiratory Society. Eur Heart J. 2022;43(3):183-189. doi: 10.1093/eurheartj/ehab816
13. Boon GJAM, Bogaard HJ, Klok FA. Essential aspects of the follow-up after acute pulmonary embolism: an illustrated review. Res Pract Thromb Haemost. 2020;4(6):958-968. doi:10.1002/rth2.12404
14. Konstantinides SV, Meyer G, Galié N, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J. 2020;41(4):543-603. doi:10.1183/13993003.01647-2019
15. Tapson VF, Platt DM, Xia F, et al. Monitoring for pulmonary hypertension following pulmonary embolism: the INFORM study. Am J Med. 2016;129(9):978-985.e2. doi:10.1016/j.amjmed.2016.03.006
16. Ma KA, Kahn SR, Akaberi A, et al. Serial imaging after pulmonary embolism and correlation with functional limitation at 12 months: results of the ELOPE study. Res Pract Thromb Haemost. 2018;2(4):670-677. doi:10.1002/rth2.12123
17. Kline JA, Courtney DM, Beam DM, King MC, Steuerwald M. Incidence and predictors of repeated computed tomographic pulmonary angiography in emergency department patients. Ann Emerg Med. 2009; 54(1):41-48. doi:10.1016/j.annemergmed.2008.08.015
18. Kline JA, Garrett JS, Sarmiento EJ, Strachan CC, Courtney DM. Over-testing for suspected pulmonary embolism in American Emergency Departments. Circ Cardiovasc Qual Outcomes. 2020;13(1):e005753. doi: 10.1161/CIRCOUTCOMES.119.005753
19. Ooi MWX, Rajai A, Patel R, Gerova N, Godhamgaonkar V, Liong SY. Pulmonary thromboembolic disease in COVID-19 patients on CT pulmonary angiography–prevalence, pattern of disease and relationship to D-dimer. Eur J Radiol. 2020;132:109336. doi:10.1016/j.ejrad.2020. 109336
20. Ljungqvist M, Söderberg M, Moritz P, Ahlgren A, Lärfars G. Evaluation of Wells score and repeated D-dimer in diagnosing venous thromboembolism. Eur J Intern Med. 2008;19(4):285-288. doi:10.1016/j.ejim.2007.08.007
21. Gegin S, Karakaya T, Arslan Aksu E, Özdemir B, Özdemir L, Pazarlı AC. The distribution of hereditary risk factors in patients with pulmonary thromboembolism without identifiable acquired risk factors. Duzce Medical Journal. 2025;27(1):69-74. doi:10.18678/dtfd.1583292