Abstract | Uvod: Potreba za MSCT angiografijom plućne arterije kako bi se isključila PE temelji se na bodovnim sustavima u kombinaciji s mjerenjima D-dimera. Cilj ovog istraživanja je bio analizirati nove kliničke i laboratorijske parametre, usporediti postojeće te predložiti novi bodovni sustav za kliničko predviđanje PE u hospitaliziranih COVID-19 bolesnika. Također smo analizirali kliničke i laboratorijske parametre te usporedili tri bodovna sustava koji se trenutno koriste (BOVA, PESI i sPESI bodovni sustav) za predviđanje smrtnosti povezane s PE. Metode: Provedeno je retrospektivno opservacijsko istraživanje koje je uključivalo 270 hospitaliziranih COVID-19 bolesnika kojima je urađena MSCT angiografija plućne arterije zbog kliničke sumnje na PE. Izračunati su modificirani Wellsov, revidirani Ženevski, pojednostavljeni Ženevski, YEARS, 4PEPS i PERC bodovni sustavi te je izračunata površina ispod ROC (AuROC, eng. area under the receiver operating curve) za svaki od spomenutnih bodovnih sustava. Podatci o mortalitetu uključenih bolesnika dobiveni su iz matičnog ureda. Rezultati: Ukupna incidencija PE među među hospitaliziranim COVID-19 bolesnicima bila je 28,1%. Grupa pacijenata s PE imala je značajno dulje trajanje bolesti prilikom hospitalizacije, (10 naspram 8 dana, p = 0,006); više razine D-dimera, (10,2 naspram 5,3 µg/L, p < 0,001); te veći udio kroničnog bubrežnog zatajivanja, (16% prema 7%, p = 0,041). Samo su 4PEPS i modificirani Wellsov bodovni sustav postigli statističku značajnost u predviđanju PE među hospitaliziranim COVID-19 bolesnicima. Predložili smo novi CDD 10 bodovni sustav koji uključuje tri varijable i to kronično bubrežno zatajivanje, D-dimere i 10 dana trajanja bolesti prije hospitalizacije: C kao kronično bubrežno zatajivanje (0,5 bodova ako je prisutno), D kao D-dimeri (negativni, 1,5 boda ako su uredne vrijednosti, 2 boda ako su vrijednosti iznad 10,0 µg/L) i D-10 kao 10. dan bolesti koji nosi 2 boda ako bolest traje više od 10 dana prije hospitalizacije ili 1 bod ako bolest traje dulje od 8 dana. CDD-10 bodovni sustav bio je u rasponu od –1,5 do 4,5 i pokazao je AuROC od 0,672, p < 0,001 na graničnoj vrijednosti od 0,5, dok je bodovni sustav 4PEPS pokazao AuROC od 0,638, a modificirani Wellsov bodovni sustav 0,611. Klinička vjerojatnost PE bila je niska (0%) kada je vrijednost CDD-10 bodovnog sustava bila negativna, umjerena (24%) za CDD-10 u rasponu 0-2,5 i visoka (43%) kada je bila veća od 2,5. Tijekom razdoblja praćenja umrlo je 57 od 270 bolesnika. Unatoč većem postotku preživjelih pacijenata s PE (82,7%) u odnosu na one koji nemaju PE (77,1%), nije pronađena statistička značajnost (P=0,337). Novopredloženi NAP dijagnostički model koji uključuje NT-proBNP (1 bod ako je >572 pg/mL, 2 boda ako je >982 pg/mL), dob (1 bod ako je >73 godine) i protrombinsko vrijeme (1 bod ako je ≤ 0,89 ) pokazao se kao bolji prediktor mortaliteta povezanog s PE, nadmašivši prethodno korištene BOVA i PESI bodovne sustave s površinom ispod ROC od 0,86. Zaključci: Iz navedenih rezultata je vidljivo da je potrebna bolja stratifikacija rizika među hospitaliziranim COVID-19 bolesnicima koji zahtijevaju MSCT angiografiju plućne arterije zbog kliničke sumnje na PE. Naš novi predloženi CDD-10 bodovni sustav je pokazao najveću točnost u predviđanju PE kod hospitaliziranih COVID-19 bolesnika. NAP dijagnostički model, koji uključuje tri lako dostupne varijable, pokazo je najveću točnost u predviđanju smrtnosti povezane s PE među hospitaliziranim COVID-19 bolesnicima. |
Abstract (english) | Introduction: The need for performing computed tomography pulmonary angiography (CTPA) to rule out pulmonary embolism (PE) in hospitalized COVID-19 patients (HCP) is determined by a combination of clinical scores and D-dimer values. This study aimed to evaluate the effectiveness of existing and proposed scoring models for detecting PE in HCP, while also examining unique clinical and laboratory features. Furthermore, it involved the evaluation of new clinical and laboratory data, as well as comparison among three established scoring systems (BOVA score, PESI score, and sPESI score) used to predict mortality associated with PE. Methods: A retrospective study was conducted on 270 hospitalized COVID-19 patients (HCPs) who received CT pulmonary angiography (CTPA) for suspected pulmonary embolism (PE). Various scoring systems including Modified Wells, Revised Geneva, Simplified Geneva, YEARS, 4-Level Pulmonary Embolism Clinical Probability Score (4PEPS), and PE rule-out criteria (PERC) were utilized to assess the patients. The area under the receiver operating characteristic curve (AuROC) was determined as part of the analysis. Mortality data for the observed patients was obtained from the Registrar's office. Results: In our analysis of HCPs, the overall prevalence of pulmonary embolism (PE) was determined to be 28.1%. The PE group exhibited elevated D-dimer levels (10.2 versus 5.3 µg/L, p < 0.001), a higher incidence of preexisting chronic renal failure (16% vs 7%, p = 0.041), and a notably longer duration of COVID-19 symptoms upon hospital admission (10 vs 8 days, p = 0.006). Notably, only the modified Wells score and the 4PEPS score were found to be statistically significant in differentiating between HCPs with and without PE. To enhance predictive accuracy, we introduced a novel (CDD-10) scoring system. This composite score incorporates three key parameters: The scoring system includes C for chronic kidney failure (0.5 points if detected), D for D-dimers (-1.5 points if within normal range, 2 points if above 10.0 µg/L), and D-10 representing the duration of illness prior to hospital admission (2 points for over 10 days or 1 point for more than 8 days). The CDD-10 scoring system spans from -1.5 to 4.5 and exhibited an area under the curve (AuROC) of 0.672 at a threshold of 0.5, surpassing the AuROC values of both the 4PEPS score (0.638) and Modified Wells score (0.611). The probability of pulmonary embolism (PE) was categorized as minimal (0%) for negative CDD-10 scores, medium (24%) for scores between 0 and 2.5, and elevated (43%) for scores above 2.5. During the monitoring period, there were recorded 57 deaths among a total of 270 patients; however, survival rates showed no statistically significant difference between those with PE (82.7%) compared to those without PE (77.1%), with a p-value of P=0.337. Furthermore, we proposed a new risk assessment model named NAP that integrates NT-proBNP levels (>572 pg/mL contributing one point or >982 pg/mL adding two points), Age (>73 years counting one point), and Prothrombin time ratio (>0.89 receiving one point). The NAP model emerged as a superior predictor with an area under the curve (AUC) value of 0.86, surpassing existing BOVA and PESI scores in predictive accuracy. Conclusions: Hospitalized COVID-19 patients (HCPs) requiring CTPA for suspected PE necessitate enhanced risk stratification. Our recently introduced CDD-10 assessment exhibits enhanced precision in forecasting pulmonary embolism in patients admitted with SARS-CoV-2 infection. The NAP scoring system, encompassing three readily available criteria, exhibits heightened precision in forecasting mortality resulting from PE. |