[Six cases of acute pulmonary embolism associated with COVID-19]

Rising from the province of Wuhan in China, the new coronavirus SARS-CoV-2 broke out in winter 2019, causing a global pandemic. In most cases reported, COVID-19 symptoms include cough, dyspnea, myalgia and asthenia. In some cases, the disease can also cause severe respiratory distress syndrome, requiring intensive care. Recent studies suggest that SARS-CoV-2 infection predisposes to thromboembolic event such as pulmonary embolism. Moreover, there is an overlap between signs and symptoms of pulmonary embolism and COVID-19, which brings a challenge for the diagnosis and could potentially be fatal. Nevertheless, the incidence rate of pulmonary embolism in cases of COVID-19 is currently not known. In this paper we describe six cases of pulmonary embolism associated with COVID-19.

[Coagulopathies, thrombotic risk and anticoagulation in COVID-19]

Clinical observations indicate that COVID-19 often provokes coagulopathies, which have been associated with high morbidity and mortality rates. These coagulopathies likely result from Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection-elicited systemic inflammation and endothelial damage. Patients with severe COVID-19 are at high risk of venous and arterial thromboembolic diseases; they can also develop disseminated intravascular coagulation in the most advanced stages of the disease. Medical Organisations on Thrombosis and Hemostasis, among which the Belgian Society on Thrombosis and Haemostasis (BSTH), have formulated recommendations for the prophylaxis and treatment of COVID-19-related venous thromboembolism in ambulatory and hospitalised patients, as well as for the anticoagulation of COVID-19 patients in need of long-term anticoagulation for unrelated cause.These recommendations provide every hospital and primary care physicians with an easy-to-use clinical guidance; they mainly rely on limited level of evidence and are likely to evolve with knowledge of COVID-19 pathophysiology and availability of data from ongoing clinical trials.

Ultrasound imaging obtained by emergency department physicians to diagnose deep vein thrombosis: accuracy, safety, and efficiency

OBJECTIVES

To assess the accuracy, safety, and efficiency of ultrasound images obtained by emergency physician to diagnose deep vein thrombosis (DVT). patients with acute heart failure (AHF) attended in a hospital emergency department (ED).

MATERIAL AND METHODS

Prospective multicenter cohort study. We assigned patients suspected of having DVT to an intervention or control group. Emergency physicians took ultrasound images that were later evaluated by a radiologist in the intervention group. In the control group, images were evaluated only by the radiologist. We analyzed patient, physician, and episode variables. Test results, times until imaging, and 30-day adverse events were also analyzed. Sensitivity, specificity, positive and negative likelihood ratios, and agreement between physicians and radiologists (κ statistic) were calculated.

RESULTS

A total of 304 patients (209 in the intervention group and 95 controls) were included. The groups were comparable. The overall prevalence of DVT was 35.5% (95% CI, 30.3-41.0). The sensitivity of ultrasound images obtained by emergency physicians was superior in relation to experience: 71.4 (95% CI, 50.0-86.0) for those in a training course, 75.0 (95% CI, 80.0-95.4) for those with at least 2 months' practical experience, and 94.7 (95% CI, 82.7-98.5) for routine users. Specificity statistics for the 3 levels of physician experience were 83.3 (95% CI 55.2- 95.2), 100 (95% CI 83.0-100), and 96.6 (95% CI 88.4-99.0), respectively. The positive and negative likelihood ratios for ultrasound imaging by physicians were 27.94 and 0.054, respectively. The κ statistic was 0.80. Mean (SD) time until a physician took ultrasound images was 1.81 (1.46) hours versus 4.39 (1.81) hours until a radiologist obtained images (P = .007). Three deaths occurred within 30 days. They were not attributable to recurrence or bleeding.

CONCLUSION

Ultrasound images taken by emergency physicians to diagnose DVT are accurate and safe and may be efficient. However, routine experience with ultrasound is necessary.

[Edoxaban (LIXIANA®) : new oral anticoagulant forthetreatment and secondary prevention of thromboembolic disease]

Edoxaban (Lixiana®) is a new oral anticoagulant that selectively inhibits Xa coagulation factor. It was carefully evaluated in the treatment and secondary prevention of deep venous thrombosis and pulmonary embolism in the Hokusai-VTE trial and in the prevention of systemic and cerebral embolisms in patients with non valvular atrial fibrillation in the ENGAGE AF-TIMI 48 trial. In both studies, edoxaban has proven its non-inferiority regarding its efficacy compared with warfarin as reference treatment while demonstrating a superiority regarding safety. Especially, it was associated with a significantly lower incidence of major and/or non-major but clinically relevant bleeding episodes compared with warfarin, and a significant reduction in cerebral and fatal hemorrhages was shown in ENGAGE AF-TIMI 48. Edoxaban is prescribed at a dose of 60 mg once daily, which should be reduced to 30 mg once daily in patients with renal impairment (creatinine clearance between 15 and 50 ml/min), a body weight below or equal 60 kg and/or a concomitant therapy with some strong P-glycoprotein inhibitors. Lixiana® is reimbursed for the treatment and secondary prevention of venous thromboembolic disease as well as in patients with non valvular atrial fibrillation and the presence of at least another risk factor.