Abstract

Accumulating studies on COVID-19 patients report high incidences of thrombotic complications, but guidance on the best diagnostic approach for suspected pulmonary embolism (PE) in COVID-19 patients is lacking. Diagnosing PE in these patients is challenging as signs and symptoms of PE and COVID-19 show wide overlap, D-dimer levels are often elevated in the absence of thrombosis and computed tomography pulmonary angiography (CTPA) may be unfeasible in the case of severe renal impairment and/or hemodynamic instability.

This narrative review discusses available literature and guidelines on current diagnostic algorithms for suspected PE in special patient populations, in particular COVID-19. A special focus is on reviewing the literature aimed at identifying symptoms with a high suspicion for PE and on the diagnostic performance of diagnostic algorithms for suspected PE in the setting of COVID-19.

Based on available literature, the index of suspicion for PE should be high in the case of unexplained abrupt worsening of respiratory status, typical symptoms of deep-vein thrombosis and/or acute unexplained right ventricular dysfunction. Despite the lack of prospective diagnostic management studies, we propose to adhere to current diagnostic algorithms applying assessment of pre-test probability and D-dimer testing as available evidence suggests that these might be considered safe. Preferably, algorithms using adjusted D-dimer thresholds are recommended as it likely improves the yield of the clinical decision rule/D-dimer combination.

摘要

对 COVID-19 患者的累积研究报告血栓并发症的发生率很高，但缺乏对 COVID-19 患者疑似肺栓塞 (PE) 的最佳诊断方法的指导。在这些患者中诊断 PE 具有挑战性，因为 PE 和 COVID-19 的体征和症状显示出广泛的重叠，在没有血栓形成的情况下 D-二聚体水平通常升高，并且计算机断层扫描肺血管造影 (CTPA) 在严重肾病的情况下可能不可行损伤和/或血流动力学不稳定。

这篇叙述性评论讨论了有关特殊患者人群（尤其是 COVID-19）中疑似 PE 的当前诊断算法的可用文献和指南。一个特别的重点是回顾旨在识别高度怀疑 PE 的症状的文献，以及在 COVID-19 环境中疑似 PE 的诊断算法的诊断性能。

根据现有文献，在不明原因的呼吸状态突然恶化、深静脉血栓形成的典型症状和/或不明原因的急性右心室功能障碍的情况下，应高度怀疑 PE。尽管缺乏前瞻性诊断管理研究，我们建议坚持当前的诊断算法，应用测试前概率评估和 D-二聚体测试，因为现有证据表明这些可能被认为是安全的。优选地，推荐使用调整的 D-二聚体阈值的算法，因为它可能提高临床决策规则/D-二聚体组合的产量。