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External validation of the CHEDDAR score for suspected pulmonary embolism in patients with SARS-CoV-2 infection in an independent cohort

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Abstract

The accuracy of the classic scores that help stratify the pretest clinical probability of pulmonary embolism (PE) in SARS-CoV-2 infection (COVID-19) is low. Therefore, to estimate the risk of PE in these patients, a new set of guidelines must be established. The recently published CHEDDAR score proposes a new diagnostic strategy to reduce the use of computed tomography pulmonary angiography (CTPA) in non-critically ill SARS-COV-2 patients with suspected PE. According to the nomogram, patients are segregated into low-risk (< 182 points) or high-risk (≥ 182 points) based on the best cut-off value to discard PE in the original cohort. We aimed to externally validate this diagnostic strategy in an independent cohort. We analyzed data from two retrospective cohorts of hospitalized non-critically ill COVID-19 patients who underwent a CTPA due to suspicion for PE. CHEDDAR score was applied. As per the CHEDDAR nomogram, patients were classified as having a low or high clinical pre-test probability. Of the 270 patients included, 69 (25.5%) had PE. Applying the CHEDDAR score, 182 (67.4%) patients could have had PE excluded without imaging. Among 58 patients classified as having high clinical pre-test probability, 39 (67.2%) had PE. Sensitivity, specificity, positive and negative predictive values, and AUC were 56%, 90%, 67%, 85%, and 0.783 (95% CI 0.71–0.85), respectively. We provide external validation of the CHEDDAR score in an independent cohort. Even though the CHEDDAR score showed good discrimination capacity, caution is required in patients classified as having low clinical pre-test probability with a D-dimer value > 3000 ng/mL, and a RALE score ≥ 4.

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Abbreviations

AUC:

Area under the receiver operating characteristic curve

CRP:

C-reactive protein

CTPA:

Computed tomography pulmonary angiogram

NPV:

Negative predictive value

PE:

Pulmonary embolism

PPV:

Positive predictive value

RALE:

Radiographic assessment of lung edema

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Acknowledgements

CHEDDAR Research Group: David Brown-Lavalle, Nuria Muñoz-Rivas, Eva Moya-Mateo, María Teresa Bellver-Álvarez, Ana Bustamante-Fermosel, Carmen Campos-Rebollo, María García-Lorente, Idoia Pagai-Valcárcel, Roberto Pedrero-Tomé.

Funding

No specific funding was received from any bodies in the public, commercial or not-for-profit sectors to carry out the work described in this manuscript.

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Authors and Affiliations

  1. Internal Medicine Department, Hospital Universitario Infanta Leonor–Virgen de la Torre, Gran Via del Este Avenue, 80, 28031, Madrid, Spain

    Anabel Franco-Moreno, Elena Palma-Huerta, Elisa Fernández-Vidal, Juan Torres-Macho, David Brown-Lavalle, Nuria Muñoz-Rivas, Eva Moya-Mateo, María Teresa Bellver-Álvarez & Ana Bustamante-Fermosel

  2. Internal Medicine Department, Hospital Universitario de Fuenlabrada, Madrid, Spain

    Elena Madroñal-Cerezo, Aida Izquierdo-Martínez, Lorena Carpintero-García, José Manuel Ruiz-Giardín, Cristina Lucía de Ancos-Aracil, Carmen Campos-Rebollo, María García-Lorente & Idoia Pagai-Valcárcel

  3. Hospital de Emergencias Enfermera Isabel Zendal, Madrid, Spain

    Javier Marco-Martínez & Rodolfo Romero-Pareja

  4. Internal Medicine Department, Hospital Universitario de Fuenlabrada, CiberInfect, Madrid, Spain

    José Manuel Ruiz-Giardín

  5. EPINUT-UCM (Ref. 920325) Investigation Group, Universidad Complutense de Madrid, Madrid, Spain

    Roberto Pedrero-Tomé

  6. Fundación para la Investigación e Innovación Biomédica de los Hospitales Universitarios Infanta Leonor y del Sureste, Madrid, Spain

    Roberto Pedrero-Tomé

Authors
  1. Anabel Franco-Moreno
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  2. Elena Palma-Huerta
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  3. Elisa Fernández-Vidal
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  4. Elena Madroñal-Cerezo
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  5. Javier Marco-Martínez
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  6. Rodolfo Romero-Pareja
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  7. Aida Izquierdo-Martínez
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  8. Lorena Carpintero-García
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  9. José Manuel Ruiz-Giardín
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  10. Juan Torres-Macho
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  11. Cristina Lucía de Ancos-Aracil
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Consortia

CHEDDAR Research Group

  • David Brown-Lavalle
  • , Nuria Muñoz-Rivas
  • , Eva Moya-Mateo
  • , María Teresa Bellver-Álvarez
  • , Ana Bustamante-Fermosel
  • , Carmen Campos-Rebollo
  • , María García-Lorente
  • , Idoia Pagai-Valcárcel
  •  & Roberto Pedrero-Tomé

Corresponding author

Correspondence to Anabel Franco-Moreno.

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Conflict of interest

The authors have declared no conflicts of interest.

Ethical approval

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. Ethics approval was obtained from the Hospital Universitario Clínico San Carlos (code 22/569-E). The need for Informed Consent was waived by the Ethics Committee of the Hospital Universitario Clínico San Carlos due to the retrospective nature of the study.

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The members of the CHEDDAR Research Group has been included in “Acknowledgements” section.

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Franco-Moreno, A., Palma-Huerta, E., Fernández-Vidal, E. et al. External validation of the CHEDDAR score for suspected pulmonary embolism in patients with SARS-CoV-2 infection in an independent cohort. J Thromb Thrombolysis 57, 352–357 (2024). https://doi.org/10.1007/s11239-023-02918-3

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