Is Pulmonary Embolism Often a Result of Recurring COVID-19 Infections?
Pulmonary embolism is associated with acute COVID-19 infection, not recurring infections—the evidence addresses PE during active COVID-19 illness, with no data supporting PE as a consequence of multiple separate COVID-19 episodes. 1
PE Incidence During Acute COVID-19 Infection
The available evidence focuses exclusively on PE occurring during active COVID-19 hospitalization, not from recurring infections:
- PE occurs in approximately 25% of hospitalized COVID-19 patients who undergo imaging for suspected thromboembolism, with similar rates in ICU (29%) and non-ICU (24%) settings 2
- The incidence of VTE in COVID-19 patients is higher than in non-COVID hospitalized patients with similar degrees of illness, even with prophylactic anticoagulation 1
- PE develops at a median of 7.0 days after hospital admission during the acute infection phase 3
Pathophysiology: Why COVID-19 Causes PE During Acute Infection
COVID-19 creates a perfect thrombotic storm through all three components of Virchow's triad during active infection 1:
- Hypercoagulable state: Systemic cytokine storm (elevated IL-2, IL-7, granulocyte colony-stimulating factor, IP10, MCP1, MIP1A, TNF-α) triggers the coagulation system 1
- Endothelial injury: Significantly elevated von Willebrand factor and Factor VIII levels indicate direct vascular damage 1
- Stasis: Severe ARDS requiring positive-pressure ventilation with high PEEP and fluid restriction decreases pulmonary blood flow, leading to microthrombosis 1
Critical Evidence Gap: No Data on Recurring Infections
None of the available guidelines or research studies address PE risk from multiple separate COVID-19 infections [1 through 4]. The evidence exclusively examines:
- PE during a single acute COVID-19 hospitalization 1, 2
- Recurrent VTE during the same COVID-19 illness despite anticoagulation (not recurrent COVID infections) 1
- Post-discharge thromboprophylaxis following a single COVID-19 episode 1
Management of Recurrent VTE During Acute COVID-19 (Not Recurring Infections)
If PE recurs during the same COVID-19 illness despite therapeutic anticoagulation 1:
- With LMWH failure: Increase LMWH dose by 25-30% after confirming compliance 1
- With DOAC or warfarin failure: Switch to therapeutic weight-adjusted LMWH after confirming compliance and therapeutic range 1
- Minimum anticoagulation duration is 3 months for any COVID-19-associated PE 1
Clinical Pitfalls
- Do not confuse "recurrent VTE during COVID-19" with "PE from recurring COVID-19 infections"—the guidelines address breakthrough thrombosis during a single illness, not thrombotic risk from multiple separate infections 1
- D-dimer levels >1600 ng/mL (8.761 nmol/L) predict PE with 100% sensitivity during acute COVID-19 and should prompt CT pulmonary angiography 2
- Hemorrhagic events occur later than thrombotic events (median 11.4 days vs 7.0 days after admission), requiring careful temporal risk-benefit assessment 3
- Male sex, smoking, and elevated lactate dehydrogenase, ferritin, and IL-6 levels are associated with increased PE risk during acute COVID-19 2