Association of D-dimer and fibrinogen magnitude with hypercoagulability by thromboelastography in severe COVID-19

Abstract

Introduction: D-dimer concentration has been used to identify candidates for intensified anticoagulant treatment for both venous thromboembolism prevention and mitigation of the microthrombotic complications associated with COVID-19. Thromboelastography (TEG) maximum amplitude (MA) has been validated as an indicator of hypercoagulability and MA ≥ 68 mm has been utilized as a marker of hypercoagulability in other conditions. We evaluated the relationship between coagulation, inflammatory, and TEG parameters in patients with COVID-19 on extracorporeal membrane oxygenation (ECMO). Methods: We performed a single center retrospective analysis of consecutive patients that received ECMO for the treatment of COVID-19. TEG, inflammatory, and coagulation markers were compared in patients with and without thrombotic complications. Correlation tests were performed to identify the coagulation and inflammatory markers that best predict hypercoagulability as defined by an elevated TEG MA. Results: 168 TEGs were available in 24 patients. C-reactive protein and fibrinogen were significantly higher in patients that developed a thrombotic event versus those that did not (p=0.038 and p=0.043 respectively). D-dimer was negatively correlated with TEG MA (p<0.001) while fibrinogen was positively correlated (p<0.001). A fibrinogen > 441 mg/dL had a sensitivity of 91.2% and specificity of 85.7% for the detection of MA ≥ 68 mm. Conclusions: In critically ill patients with COVID-19, D-dimer concentration had an inverse relationship with hypercoagulability as measured by TEG MA. D-dimer elevation may reflect severity of COVID-19 related sepsis rather than designate patients likely to benefit from anticoagulation. Fibrinogen concentration may represent a more useful marker of hypercoagulability in this population.

The Role of TEG Analysis in Patients with COVID-19-Associated Coagulopathy: A Systematic Review

“…A LY30 value of 0% combined with elevated D-dimer levels was also found to predict the need for dialysis treatment for acute renal failure in 80% of patients [25]. Chandel et al (2020) found that D-dimer results were less consistent for assessing hypercoagulability in patients treated with extracorporeal membrane oxygenation (ECMO), which plays a key role in COVID-19 management and treatment, reporting a significant negative correlation between thromboelastography identified hypercoagulability in patients with and without macrothrombosis [16]. This is in line with results from research that suggest that ECMO support, with TEG measurements used for ensuring ECMO maintenance, can be an integral part of critical care for patients with COVID-19 [27].…”

Predictive ability of viscoelastic testing using ClotPro® for short-term outcome in patients with severe Covid-19 ARDS with or without ECMO therapy: a retrospective study

“…Evidence suggests that even increased markers of coagulation and fibrinolytic activation can be found in septic patients without correlation with impaired fibrinolytic activity measured by VET or other global fibrinolysis tests [63]. Equally, patients under ECMO showed onlya poor correlation of D-dimer values and hypercoagulability measured by VET [72]. In the study by Bachler et al D-dimer levels were useful in predicting impaired fibrinolysis in contrast to VET [40].…”

Early management of severe COVID-19 coagulopathy should be guided by TEG®, microclot and platelet mapping

“…Recently, various papers have shown the significance of TEG ® and the levels of coagulopathy in COVID-19 (an important measurement value of the TEG ® ) in managing COVID-19 patients is also getting more traction (Chandel, et al 2021, Görlinger and Levy 2021, Hranjec, et al 2020) (Smolarz, et al 2021). Hranjec and co-workers in 2020 also noted that TEG ® with platelet mapping, better characterizes the spectrum of COVID-19 coagulation-related abnormalities and may guide more tailored, patient-specific therapies these patients (Hranjec, et al 2020).…”