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The Prevalence of Pulmonary Embolism in Acute Exacerbations of COPD FREE TO VIEW

Sami Simons, MD; Erik van der Heijden, MD, PhD; Yvonne Heijdra, MD, PhD
Author and Funding Information

Radboud University Medical Centre Nijmegen, the Netherlands

Sami Simons, MD, Radboud University Medical Centre, Department of Pulmonary Diseases (454), PO Box 9101, 6500 HB Nijmegen, the Netherlands; e-mail: S.Simons@long.umcn.nl


The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2009 American College of Chest Physicians


Chest. 2009;136(2):645. doi:10.1378/chest.08-2644
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To the Editor:

With great interest we read the systematic review by Rizkallah et al1 in CHEST reporting a high prevalence of pulmonary embolism (PE) during an acute exacerbation of COPD (AECOPD). The authors suggest that one of four COPD patients who require hospitalization for an acute exacerbation may have a PE. In our opinion however, the results of their study are skewed due to inadequate study sampling and a potential selection bias.

For their review, Rizkallah et al1 selected five studies.26 Two studies2,3 did not estimate the prevalence of PE during an AECOPD, but rather calculated the coexistence of COPD in patients with a PE. Assuming that every patient with a PE presents with a AECOPD is in our opinion not justified.

The three other studies selected46 display a high heterogeneity in PE prevalence. Rizkallah and colleagues1 argue that the higher prevalence is seen exclusively in hospitalized patients. However, all three studies also included patients from the emergency department. In our opinion, the discrepancy is due to a selection bias. In two studies,5,6 patients with an obvious infective cause of their AECOPD were excluded. Moreover, one of these studies6 only included patients with a d-dimer level > 500 ng/mL. The only study4 not excluding these patient categories showed a low PE prevalence of 3%.

We therefore argue that it may be both the exclusion of certain patient categories as well as the erroneous selection of studies that has artificially augmented the result presented by Rizkallah and colleagues.1 The prevalence of PE in AECOPD remains open to debate.

Rizkallah J, Man SFP, Sin DD. Prevalence of pulmonary embolism in acute exacerbations of chronic obstructive pulmonary disease: a systematic review and metaanalysis. Chest. 2009;135:786-793. [PubMed] [CrossRef]
 
Lesser BA, Leeper KV Jr, Stein PD, et al. The diagnosis of acute pulmonary embolism in patients with chronic obstructive pulmonary disease. Chest. 1992;102:17-22. [PubMed]
 
Hartmann IJ, Hagen PJ, Melissant CF, et al. Diagnosing acute pulmonary embolism: effect of chronic obstructive pulmonary disease on the performance of D-dimer testing, ventilation/perfusion scintigraphy, spiral computed tomographic angiography, and conventional angiography; ANTELOPE study group—Advances in New Technologies Evaluating the Localization of Pulmonary Embolism. Am J Respir Crit Care Med. 2000;162:2232-2237. [PubMed]
 
Rutschmann OT, Cornuz J, Poletti PA, et al. Should pulmonary embolism be suspected in exacerbation of chronic obstructive pulmonary disease? Thorax. 2007;62:121-125. [PubMed]
 
Tillie-Leblond I, Marquette CH, Perez T, et al. Pulmonary embolism in patients with unexplained exacerbation of chronic obstructive pulmonary disease: prevalence and risk factors. Ann Intern Med. 2006;144:390-396. [PubMed]
 
Mispelaere D, Glerant JC, Audebert M, et al. Embolie pulmonaire et forms sibilantes des décompensations de bronchopneumopathie chronique obstructive. Rev Mal Respir. 2002;19:415-423. [PubMed]
 

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References

Rizkallah J, Man SFP, Sin DD. Prevalence of pulmonary embolism in acute exacerbations of chronic obstructive pulmonary disease: a systematic review and metaanalysis. Chest. 2009;135:786-793. [PubMed] [CrossRef]
 
Lesser BA, Leeper KV Jr, Stein PD, et al. The diagnosis of acute pulmonary embolism in patients with chronic obstructive pulmonary disease. Chest. 1992;102:17-22. [PubMed]
 
Hartmann IJ, Hagen PJ, Melissant CF, et al. Diagnosing acute pulmonary embolism: effect of chronic obstructive pulmonary disease on the performance of D-dimer testing, ventilation/perfusion scintigraphy, spiral computed tomographic angiography, and conventional angiography; ANTELOPE study group—Advances in New Technologies Evaluating the Localization of Pulmonary Embolism. Am J Respir Crit Care Med. 2000;162:2232-2237. [PubMed]
 
Rutschmann OT, Cornuz J, Poletti PA, et al. Should pulmonary embolism be suspected in exacerbation of chronic obstructive pulmonary disease? Thorax. 2007;62:121-125. [PubMed]
 
Tillie-Leblond I, Marquette CH, Perez T, et al. Pulmonary embolism in patients with unexplained exacerbation of chronic obstructive pulmonary disease: prevalence and risk factors. Ann Intern Med. 2006;144:390-396. [PubMed]
 
Mispelaere D, Glerant JC, Audebert M, et al. Embolie pulmonaire et forms sibilantes des décompensations de bronchopneumopathie chronique obstructive. Rev Mal Respir. 2002;19:415-423. [PubMed]
 
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