Main Article Content
Venous thromboembolism; Chronic Obstructive Pulmonary Disease; Pulmonary embolism; In situ thrombosis
BACKGROUND. There are no studies investigating populations of patients with both pulmonary embolism and chronic obstructive pulmonary disease (PE-COPD) with and without deep venous thrombosis (DVT).
AIM OF THE STUDY. To define prevalence of DVT in COPD with PE and to compare characteristics of COPD patients who develop PE, with and without DVT. Secondly, we aimed to assess differences in the localization of PE among study groups.
METHODS. 116 patients with PE were enrolled in a retrospective study. Clinical data as well as echocardiographic and lower limb ultrasonography records were collected for all subjects.
Subjects were divided into two groups according to the presence of COPD: Group 1, 54 patients with diagnosis of PE without COPD and Group 2, 66 patients diagnosed of PE with COPD. Then, individuals of Group 2 were subdivided in two subgroups according to the presence (n=21) or absence (n=45) of DVT.
RESULTS. 33% of patients with COPD and PE showed DVT. These subjects had higher PaCO2 and ejection fraction (p<0.05 for all) and higher percentage of chronic renal failure and diabetes mellitus compared to those without DVT (p<0.05 for all). Moreover, in COPD-PE patients with DVT, the most frequent localization was proximal (54% of total), whereas COPD-PE patients without DVT showed a more frequent segmental localization (60% of total). No difference was found in clinical presentation and blood-chemistry tests.
CONCLUSIONS. DVT was non-common in PE-COPD patients. Chronic renal failure, and type 2 diabetes mellitus are more frequent in PE-COPD patients with DVT, that showed a higher frequency of proximal localization, thereby indicating a greater risk of more severe clinical implications. Conversely, PE- COPD subjects without DVT showed a more frequent segmental localization and were less hypercapnic. PE should be taken into account in COPD with worsening of respiratory symptoms, also in absence of DVT.
2. Schneider C. Bothner U, Jick SS, et al. Chronic obstructive pulmonary disease and the risk of cardiovascular diseases. European journal of epidemiology 2010;25: 253-260.
3. MacNee W. Systemic inflammatory biomarkers and co-morbidities of chronic obstructive pulmonary disease. Ann Med 2013;45:291–300.
4. Park SH. Pulmonary embolism is more prevalent than deep vein thrombosis in cases of chronic obstructive pulmonary disease and interstitial lung diseases. Springer Plus 2016; 5: 1777.
5. Rizkallah J, Man SFP, Sin DD. Prevalence of pulmonary embolism in acute exacerbations of COPD: a systematic review and metaanalysis. Chest 2009;135: 786-793.
6. Aleva FE, Voets LW, Simons SO, et al. Prevalence and localization of pulmonary embolism in unexplained acute exacerbations of COPD: a systematic review and meta-analysis. Chest 2017;151:544-554.
7. Monreal M, Munoz-Torreiro JF, Naraine VS, et al. Pulmonary embolism in patients with chronic obstructive pulmonary disease or congestive heart failure. The American journal of medicine 2006;119: 851-858.
8. Piazza G, Goldhaber SZ, Kroll A, et al. Venous thromboembolism in patients with chronic obstructive pulmonary disease. The American journal of medicine 2012;125:1010-1018.
9. Carson JL, Terrin ML, Duff A et al. Pulmonary embolism and mortality in patients with COPD. Chest 1996;110:1212-1219.
10. Zielinski J, Mac Nee N, Wedzicha J, et al. Causes of death in patients with COPD and chronic respiratory failure. Monaldi Arch Chest Dis 1997;52:43–47.
11. Konstantinides SV, Torbicki A, Agnelli G, et al. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 2014;35:3033–3069.
12 Stein PD, Beemath A, Meyers FA, et al. Pulmonary embolism and deep venous thrombosis in hospitalized adults with chronic obstructive pulmonary disease. Journal of Cardiovascular Medicine 2007;8:253-257.
13. Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. Available from: http://goldcopd.org.
14. Lensing AW, Prandoni P, Brandjes D, et al. Detection of deep-vein thrombosis by real-time b-mode ultrasonography. N Engl J Med 1989;320:342–345.
15. Yamaki T, Nozaki M, Sakurai H, et al. Presence of lower limb deep vein thrombosis and prognosis in patients with symptomatic pulmonary embolism: preliminary report. Eur J Vasc Endovasc Surg. 2009;37:225-231.
16. Girard P, Sanchez O, Leroyer C, et al. Deep venous thrombosis in patients with acute pulmonary embolism: prevalence, risk factors, and clinical significance. Chest 2005;128:1593-600
17. Erelel M., Ece T, Arseven O. The frequency of deep venous thrombosis and pulmonary embolus in acute exacerbation of chronic obstructive pulmonary disease. Respiratory Medicine 2002;96:515-518.
18. Gunen H, Gulbas G, In E, et al. Venous thromboemboli and exacerbations of COPD. Eur Respir J 2010;35:1243–1248
19. Akgun M, Meral M, Onbas O, et al. Comparison of clinical characteristics and outcomes of patients with COPD exacerbation with or without venous thromboembolism. Respiration 2006;73: 428-433.
20. Wattanakit K, Cushman M, Stehman-Breen, et al. Chronic kidney disease increases risk for venous thromboembolism. Journal of the American society of Nephrology 2008;19:135-140.
21. Daneschvar HL, Seddighzadeh A, Piazza G, et al. Deep vein thrombosis in patients with chronic kidney disease. Thrombosis and haemostasis 2008;99:1035-1039.
22. Petrauskiene V, Falk M, Waernbaum I, et al. The risk of venous thromboembolism is markedly elevated in patients with diabetes. Diabetologia 2005;48:1017–1021.
23. Ageno W, Becattini C, Brighton T, et al. Cardiovascular risk factors and venous thromboembolism: a meta-analysis. Circulation. 2008;117:93–102.
24. Van Gent JM, Zander AL, Olson EJ, et al. Pulmonary embolism without deep venous thrombosis: De novo or missed deep venous thrombosis?. Journal of Trauma and Acute Care Surgery 2014;76:1270-1274.
25. Schwartz T. Pulmonary embolism without deep venous thrombosis. Annals of vascular surgery 2012;26:973-976.
26. Barrios D, Rosa-Salazar V, Jiménez D, et al. Right heart thrombi in pulmonary embolism. European Respiratory Journal 2016: Nov;48(5):1377-1385.
27. Voelkel NF, Cool CD. Pulmonary vascular involvement in chronic obstructive pulmonary disease. Eur Respir J 2003; 22:28s–32s.
28 Levi M, van der Poll T, Schultz M. New insights into pathways that determine the link between infection and thrombosis. Neth J Med. 2012;70:114-20.
29. Shetty R, Seddighzadeh A, Piazza G, et al. Chronic obstructive pulmonary disease and deep vein thrombosis: a prevalent combination. Journal of thrombosis and thrombolysis, 2008;26: 35-40.
30. Biswas M, Prakash PK, Cossburn M, et al, Life threatening thrombotic complications of relative polycythaemia. J Intern Med. 2003;253:481–483.
31. Kim V, Goel N, Gangar J, et al. Risk factors for venous thromboembolism in chronic obstructive pulmonary disease. Chronic obstructive pulmonary diseases 2014;1:239.
32. Johannesdottir SA, Horvath-Puho E, Dekkers OM, et al. Use of glucocorticoids and risk of venous thromboembolism: a nationwide population-based case-control study. JAMA Intern Med. 2013;173:743-752.
33. Righini M, Goehring C, Bounameaux H, et al. Effects of age on the performance of common diagnostic tests for pulmonary embolism. Am J Med. 2000;109:357-361.
34. illie-Leblond I, Marquette CH, Perez T, et al. Pulmonary embolism in patients with unexplained exacerbation of chronic obstructive pulmonary disease: prevalence and risk factors. Annals of internal medicine 2006;144:390-396.
35. Akpinar EE, Hoşgün D, Akpinar S, et al. Incidence of pulmonary embolism during COPD exacerbation. Jornal Brasileiro de Pneumologia 2014;40:38-45
36. Kraaijpoel N, van Es N, Porreca E, et al. The diagnostic management of upper extremity deep vein thrombosis: A review of the literature. Thromb Res. 2017;156:54-59