Pulmonary embolism diagnostic strategies in patients with COPD exacerbation: Post-hoc analysis of the PEP trial.

Background: The prevalence of pulmonary embolism (PE) is approximately 11-17 % in patients with an acute exacerbation of chronic obstructive pulmonary disease (AE-COPD). The optimal diagnostic strategy for PE in these patients remains undetermined.
Aims: To evaluate the safety and efficacy of standard (revised Geneva and Wells PE scores combined with fixed D-dimer cut-off) and computed tomography pulmonary angiogram (CTPA)-sparing diagnostic strategies (ADJUST-PE, YEARS, PEGeD, 4PEPS) in patients with AE-COPD.
Method: Post-hoc analyses of data from the multicenter prospective PEP study were performed. The primary outcome was the diagnostic failure rate of venous thromboembolism (VTE) during the entire study period. Secondary outcomes included diagnostic failure rate of PE and deep venous thrombosis (DVT), respectively, during the entire study period and the number of CTPA needed per diagnostic strategy.
Results: 740 patients were included. The revised Geneva and Wells PE scores combined with fixed D-dimer cut-off had a diagnostic failure rate of VTE of 0.7 % (95%CI 0.3 %-1.7 %), but >70.0 % of the patients needed imaging. All CTPA-sparing diagnostic algorithms reduced the need for CTPAs (-10.1 % to -32.4 %, depending on the algorithm), at the cost of an increased VTE diagnosis failure rate of up to 2.1 % (95%CI 1.2 %-3.4 %).
Conclusion: Revised Geneva and Wells PE scores combined with fixed D-dimer cut-off were safe, but a high number of CTPA remained needed. CTPA-sparing algorithms would reduce imaging, at the cost of an increased VTE diagnosis failure rate that exceeds the safety threshold. Further studies are needed to improve diagnostic management in this population.
Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr. Couturaud reports having received research grant support from Bristol-Myers Squibb/Pfizer and Bayer and fees for board memberships or symposia from Bayer, Bristol-Myers Squibb/Pfizer, Merck Sharp and Dohme, Merck Sharp and Dohme, Sanofi, Leo Pharma, Janssen and Astra Zeneca and having received travel support from Bayer, Bristol-Myers Squibb/Pfizer, Leo Pharma, Pfizer. Dr. Bertoletti reports having received research grant support from Bayer and fees for board memberships or symposia from Actelion, Aspen, Bayer, Bristol-Myers Squibb/Pfizer and MSD, and having received travel support from Aspen, Bayer, Bristol-Myers Squibb/Pfizer, Daiichi Sankyo, Leo Pharma, MSD and Actelion. Dr. Pastre declares he has no conflict of interest related to this research. Dr. Roy declares he has no conflict of interest related to this research. Dr. Rambaud declares he has no conflict of interest related to this research. Dr. Mai declares she has no conflict of interest related to this research. Dr. Motreff declares she has no conflict of interest related to this research. Dr. Auffret declares he has no conflict of interest related to this research. Dr. Le Mao declares he has no conflict of interest related to this research. Dr. Gagnadoux declares he has no conflict of interest related to this research. Dr. Paleiron declares he has no conflict of interest related to this research. Dr. Schmidt declares he has no conflict of interest related to this research. Dr. Schmidt declares he has no conflict of interest related to this research. Dr. Sanchez reports having received research grant support from Bayer, Daiichi-Sankyo and Portola Pharmaceuticals, and fees or non-financial support for consultancy activities from Actelion, GlaxoSmithKline, Boehringer Ingelheim and Chiesi. Dr. Bressollette declares he has no conflict of interest related to this research. Dr. Nonent declares he has no conflict of interest related to this research. Dr. Tromeur declares she has no conflict of interest related to this research. Dr. Salaun declares he has no conflict of interest related to this research. Dr. Mismetti reports having received research grants from Bayer, fees for board memberships from Bayer, Bristol-Myers Squibb/Pfizer and Daiichi Sankyo, for lectures from Bayer, Boehringer Ingelheim, Bristol-Myers Squibb/Pfizer, Daiichi Sankyo and Sanofi, and for development of educational presentations from Bayer and Bristol-Myers Squibb/Pfizer. Dr. Girard reports having received personal fees and non-financial support from Bayer and Leo Pharma. Dr. Lacut reports having received personal fees from Bayer-Health Care, Bristol-Myers Squibb and Boehringer Ingelheim. Dr. Lemarie declares she has no conflict of interest related to this research. Dr. Meyer reports having received research grant support from Bayer, Boehringer Ingelheim, LEO Pharma Research Foundation and Sanofi, having been an uncompensated board member and a consultant for Bayer, Boehringer-Ingelheim, Bristol-Myers Squibb, Leo Pharma and Pfizer, and having received travel support from Bayer, Boehringer Ingelheim, Daiichi Sankyo, Leo Pharma and Sanofi. Dr. Leroyer reports having received research grant support from Pfizer and fees for board memberships or symposia from Bayer and Astra Zeneca and having received travel support from Bayer, Leo Pharma. No other potential conflict of interest relevant to this article was reported.
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