Clinical question: How common are venous thromboembolisms (VTEs) in patients presenting with acute exacerbation of chronic obstructive pulmonary disease (AE-COPD) and what is the effect on prognosis, hospital length of stay (LOS), and one-year mortality?
Background: Worldwide, COPD is a leading cause of mortality, and many COPD patients will suffer from exacerbations. Many times, infections or environmental triggers are to blame, but the etiology remains elusive in up to one-third of patients. It is known that COPD patients are twice as likely to develop VTE compared to those without, and prior studies have shown variable prevalence of VTE during AE-COPD (2.1 to 29.1%). Missing this diagnosis contributes significantly to long-term morbidity and mortality.
Study design: Multicenter, prospective cohort study
Setting: Patients admitted to 11 participating hospitals in China from January 2017 to January 2021
Synopsis: 1,580 patients older than 40 years who had a diagnosis of COPD based on GOLD criteria and were admitted for acute exacerbation (worsening cough, dyspnea, or sputum production) were included in the analysis. Wells and revised Geneva Scores were calculated for each patient. All received computed tomography pulmonary angiogram (CTPA), lower extremity duplex ultrasounds, and cardiac ultrasounds within 48 hours of admission. Prevalence of VTE was 24.5% and of these 16.8% had pulmonary embolisms, which is consistent with prior studies. Of those with VTE, Wells and revised Geneva scoring classified 7.4% and 11.6% of patients, respectively, as a low probability. Patients with VTE were older, had COPD for a longer period, had more VTE risk factors, and had more chronic medical comorbidities. Their LOS was longer (13.7 versus 11.4 days, P <0.01) and 1-year mortality was higher (12.9% versus 4.5%, P <0.001). Patients presenting with purulent sputum had lower odds of having VTE (odds ratio [OR], 0.43) while patients with a history of VTE, cor pulmonale, tachypnea, elevated D-dimer, and elevated B-type natriuretic peptide had increased odds of having VTE (ORs, 15.2, 2.0, 1.1, 1.1, and 1.4, respectively). Limitations include patients from a single country, lack of data from outpatients, and interrater variability with risk scores.
Bottom line: There is an increased prevalence of VTE in patients presenting with AE-COPD which increases LOS and one-year mortality. In patients who present with AE-COPD where there is no apparent infectious or environmental cause, consider screening for VTE, especially if patients do not have purulent sputum or if they have a history of VTE.
Citation: Liu X, et al. Prevalence, risk factor and clinical characteristics of venous thrombus embolism in patients with acute exacerbation of COPD: A prospective multicenter study. Int J Chron Obstruct Pulmon Dis. 2023;18:907-17.
Dr. Dang
Dr. Dang is a hospitalist at Atrium Health in Charlotte, N.C