Pulmonary embolism in patients with unexplained exacerbation of chronic obstructive pulmonary disease: prevalence and risk factors.
BACKGROUND
Diagnosis of pulmonary embolism (PE) is difficult in patients with chronic obstructive pulmonary disease (COPD) and exacerbation.


OBJECTIVE
To evaluate PE in patients with COPD and exacerbation of unknown origin and explore factors associated with PE.


METHODS
Prospective cohort study.


METHODS
University-affiliated hospital in France.


METHODS
211 consecutive patients, all current or former smokers with COPD, who were admitted to the hospital for severe exacerbation of unknown origin and did not require invasive mechanical ventilation.


METHODS
Spiral computed tomography angiography (CTA) and ultrasonography within 48 hours of admission and assessment of the Geneva score. Patients were classified as PE positive (positive results on CTA or negative results on CTA and positive results on ultrasonography) or PE negative (negative results on CTA and negative results on ultrasonography or negative results on CTA and no recurrence of PE at follow-up 3 months later).


RESULTS
49 of 197 patients (25% [95% CI, 19% to 32%]) met the diagnostic criteria for PE. Clinical factors associated with PE were previous thromboembolic disease (risk ratio, 2.43 [CI, 1.49 to 3.94]), malignant disease (risk ratio, 1.82 [CI, 1.13 to 2.92]), and decrease in PaCO2 of at least 5 mm Hg (risk ratio, 2.10 [CI, 1.23 to 3.58]). A total of 9.2% (CI, 4.7% to 15.9%) of patients with a low-probability Geneva score received a diagnosis of PE. An exploratory analysis suggested that substituting malignant disease for recent surgery in the Geneva score might improve its performance in excluding PE in this sample who were more likely to have malignant disease than to have had recent surgery. However, this improvement seems insufficient to exclude PE with enough certainty to withhold therapy for low-risk patients on the basis of the modified score.


CONCLUSIONS
This study was done in only 1 center. Patients with COPD requiring invasive mechanical ventilation in the intensive care unit were not included. The upper bound of the 95% CI for the low probability of PE according to the Geneva score is too high to rule out PE. The classification of COPD exacerbation of unknown origin was based on the clinician's assessment, not on a standard evaluation for all patients.


CONCLUSIONS
This study showed a 25% prevalence of PE in patients with COPD hospitalized for severe exacerbation of unknown origin. Three clinical factors are associated with the increased risk for PE. The Geneva score and the modified Geneva score should be prospectively evaluated in patients with COPD.
Tillie-Leblond
Isabelle
I
Lung Department, University Hospital A Calmette, Lille, France.
Marquette
Charles-Hugo
CH
Perez
Thierry
T
Scherpereel
Arnaud
A
Zanetti
Christophe
C
Tonnel
André-Bernard
AB
Remy-Jardin
Martine
M
D000368:Aged; D000792:Angiography / Q000379:methods; D002245:Carbon Dioxide / Q000097:blood; D006801:Humans; D007866:Leg / Q000000981:diagnostic imaging; D008875:Middle Aged; D009369:Neoplasms / Q000150:complications; D015995:Prevalence; D011446:Prospective Studies; D029424:Pulmonary Disease, Chronic Obstructive / Q000150:complications*; D011655:Pulmonary Embolism / Q000000981:diagnostic imaging / Q000453:epidemiology*; D012307:Risk Factors; D013923:Thromboembolism / Q000150:complications; D036542:Tomography, Spiral Computed; D018615:Ultrasonography, Doppler, Color
D002245:Carbon Dioxide