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      Clinical prediction model for pulmonary thrombosis diagnosis in hospitalized patients with SARS-CoV-2 infection

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          Abstract

          Background and Aim:

          We aimed to develop a clinical prediction model for pulmonary thrombosis (PT) diagnosis in hospitalized COVID-19 patients.

          Methods:

          Non-intensive care unit hospitalized COVID-19 patients who underwent a computed tomography pulmonary angiogram (CTPA) for suspected PT were included in the study. Demographic, clinical, analytical, and radiological variables as potential factors associated with the presence of PT were selected. Multivariable Cox regression analysis to develop a score for estimating the pre-test probability of PT was performed. The score was internally validated by bootstrap analysis.

          Results:

          Among the 271 patients who underwent a CTPA, 132 patients (48.7%) had PT. Heart rate >100 bpm (OR = 4.63 [95% CI: 2.30–9.34]; P < 0.001), respiratory rate >22 bpm (OR = 5.21 [95% CI: 2.00–13.54]; P < 0.001), RALE score ≥4 (OR = 3.24 [95% CI: 1.66–6.32]; P < 0.001), C-reactive protein (CRP) >100 mg/L (OR = 2.10 [95% CI: 0.95–4.63]; P = 0.067), and D-dimer >3.000 ng/mL (OR = 6.86 [95% CI: 3.54–13.28]; P < 0.001) at the time of suspected PT were independent predictors of thrombosis. Using these variables, we constructed a nomogram (CRP, Heart rate, D-dimer, RALE score, and respiratory rate [CHEDDAR score]) for estimating the pre-test probability of PT. The score showed a high predictive accuracy (area under the receiver–operating characteristics curve = 0.877; 95% CI: 0.83−0.92). A score lower than 182 points on the nomogram confers a low probability for PT with a negative predictive value of 92%.

          Conclusions:

          CHEDDAR score can be used to estimate the pre-test probability of PT in hospitalized COVID-19 patients outside the intensive care unit.

          Relevance for Patients:

          Developing a new clinical prediction model for PT diagnosis in COVID-19 may help in the triage of patients, and limit unnecessary exposure to radiation and the risk of nephrotoxicity due to iodinated contrast.

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          Most cited references47

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          Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

          Fei Zhou, Ting Yu, Ronghui Du … (2020)
          Summary Background Since December, 2019, Wuhan, China, has experienced an outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Epidemiological and clinical characteristics of patients with COVID-19 have been reported but risk factors for mortality and a detailed clinical course of illness, including viral shedding, have not been well described. Methods In this retrospective, multicentre cohort study, we included all adult inpatients (≥18 years old) with laboratory-confirmed COVID-19 from Jinyintan Hospital and Wuhan Pulmonary Hospital (Wuhan, China) who had been discharged or had died by Jan 31, 2020. Demographic, clinical, treatment, and laboratory data, including serial samples for viral RNA detection, were extracted from electronic medical records and compared between survivors and non-survivors. We used univariable and multivariable logistic regression methods to explore the risk factors associated with in-hospital death. Findings 191 patients (135 from Jinyintan Hospital and 56 from Wuhan Pulmonary Hospital) were included in this study, of whom 137 were discharged and 54 died in hospital. 91 (48%) patients had a comorbidity, with hypertension being the most common (58 [30%] patients), followed by diabetes (36 [19%] patients) and coronary heart disease (15 [8%] patients). Multivariable regression showed increasing odds of in-hospital death associated with older age (odds ratio 1·10, 95% CI 1·03–1·17, per year increase; p=0·0043), higher Sequential Organ Failure Assessment (SOFA) score (5·65, 2·61–12·23; p<0·0001), and d-dimer greater than 1 μg/mL (18·42, 2·64–128·55; p=0·0033) on admission. Median duration of viral shedding was 20·0 days (IQR 17·0–24·0) in survivors, but SARS-CoV-2 was detectable until death in non-survivors. The longest observed duration of viral shedding in survivors was 37 days. Interpretation The potential risk factors of older age, high SOFA score, and d-dimer greater than 1 μg/mL could help clinicians to identify patients with poor prognosis at an early stage. Prolonged viral shedding provides the rationale for a strategy of isolation of infected patients and optimal antiviral interventions in the future. Funding Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences; National Science Grant for Distinguished Young Scholars; National Key Research and Development Program of China; The Beijing Science and Technology Project; and Major Projects of National Science and Technology on New Drug Creation and Development.
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            Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.

            Erik von Elm, Douglas G. Altman, Matthias Egger … (2008)
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              Confirmation of the high cumulative incidence of thrombotic complications in critically ill ICU patients with COVID-19: An updated analysis

              F.A. Klok, Kruip MJHA, N.J.M. van der Meer … (2020)
              Introduction We recently reported a high cumulative incidence of thrombotic complications in critically ill patients with COVID-19 admitted to the intensive care units (ICUs) of three Dutch hospitals. In answering questions raised regarding our study, we updated our database and repeated all analyses. Methods We re-evaluated the incidence of the composite outcome of symptomatic acute pulmonary embolism (PE), deep-vein thrombosis, ischemic stroke, myocardial infarction and/or systemic arterial embolism in all COVID-19 patients admitted to the ICUs of 2 Dutch university hospitals and 1 Dutch teaching hospital from ICU admission to death, ICU discharge or April 22nd 2020, whichever came first. Results We studied the same 184 ICU patients as reported on previously, of whom a total of 41 died (22%) and 78 were discharged alive (43%). The median follow-up duration increased from 7 to 14 days. All patients received pharmacological thromboprophylaxis. The cumulative incidence of the composite outcome, adjusted for competing risk of death, was 49% (95% confidence interval [CI] 41–57%). The majority of thrombotic events were PE (65/75; 87%). In the competing risk model, chronic anticoagulation therapy at admission was associated with a lower risk of the composite outcome (Hazard Ratio [HR] 0.29, 95%CI 0.091–0.92). Patients diagnosed with thrombotic complications were at higher risk of all-cause death (HR 5.4; 95%CI 2.4–12). Use of therapeutic anticoagulation was not associated with all-cause death (HR 0.79, 95%CI 0.35–1.8). Conclusion In this updated analysis, we confirm the very high cumulative incidence of thrombotic complications in critically ill patients with COVID-19 pneumonia.
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                Author and article information

                Journal
                Journal ID (nlm-ta): J Clin Transl Res
                Journal ID (iso-abbrev): J Clin Transl Res
                Journal ID (publisher-id): Whioce Publishing Pte. Ltd.
                Title: Journal of Clinical and Translational Research
                Publisher: Whioce Publishing Pte. Ltd.
                ISSN (Print): 2382-6533
                ISSN (Electronic): 2424-810X
                Publication date Collection: 28 April 2023
                Publication date (Electronic): 06 February 2023
                Volume: 9
                Issue: 2
                Pages: 59-68
                Affiliations
                [1 ]Department of Internal Medicine, Hospital Universitario Infanta Leonor–Virgen de la Torre, Madrid, Spain
                [2 ]Department of Radiology, Hospital Universitario Infanta Leonor–Virgen de la Torre, Madrid, Spain
                [3 ]Department of Internal Medicine, Hospital Universitario de Fuenlabrada, Madrid, Spain
                [4 ]EPINUT-UCM (Ref. 920325) Investigation Group, Universidad Complutense de Madrid, Madrid, Spain
                [5 ]Fundación para la Investigación e Innovación Biomédica de los Hospitales Universitarios Infanta Leonor y del Sureste, Madrid, Spain
                Author notes
                [* ] Corresponding author: Anabel Franco-Moreno Department of Internal Medicine, Hospital Universitario Infanta Leonor–Virgen de la Torre. Gran Via del Este Avenue, 80, 28031, Madrid, Spain. Email: afranco278@ 123456hotmail.com
                [†]

                These authors contributed equally to this work.

                Article
                Publisher ID: jctres.09.202302.002
                PMC ID: 10075091
                SO-VID: 73778718-84b4-47da-92b4-5d45bf2777af
                Copyright © Copyright: © 2023 Author(s).
                License:

                This is an Open-Access article distributed under the terms of the Creative Commons Attribution-Noncommercial License, permitting all noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 19 November 2022
                Date revision received : 14 December 2022
                Date accepted : 12 January 2023
                Categories
                Subject: Original Article

                Keywords: covid-19,clinical prediction model,computed tomography pulmonary angiogram,diagnosis,pretest probability,pulmonary thrombosis,thromboinflammation
                Data availability:
                Keywords: covid-19, clinical prediction model, computed tomography pulmonary angiogram, diagnosis, pretest probability, pulmonary thrombosis, thromboinflammation

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