Bleeding risk by intensity of anticoagulation in critically ill patients with COVID‐19: A retrospective cohort study

Abstract

Background: Studies report hypercoagulability in coronavirus disease 2019 , leading many institutions to escalate anticoagulation intensity for thrombosis prophylaxis.Objective: To determine the bleeding risk with various intensities of anticoagulation in critically ill patients with COVID-19 compared with other respiratory viral illnesses (ORVI).Patients/Methods: This retrospective cohort study compared the incidence of major bleeding in patients admitted to an intensive care unit (ICU) within a single health system with COVID-19 versus ORVI. In the COVID-19 cohort, we assessed the effect of anticoagulation intensity received on ICU admission on bleeding risk. We performed a secondary analysis with anticoagulation intensity as a time-varying covariate to reflect dose changes after ICU admission.Results: Four hundred and forty-three and 387 patients were included in the COVID-19 and ORVI cohorts, respectively. The hazard ratio of major bleeding for the COVID-19 cohort relative to the ORVI cohort was 1.26 (95% confidence interval [CI]: 0.86-1.86). In COVID-19 patients, an inverse-probability treatment weighted model found therapeutic-intensity anticoagulation on ICU admission had an adjusted hazard ratio of bleeding of 1.55 (95% CI: 0.88-2.73) compared with standard prophylacticintensity anticoagulation. However, when anticoagulation was assessed as a timevarying covariate and adjusted for other risk factors for bleeding, the adjusted hazard ratio for bleeding on therapeutic-intensity anticoagulation compared with standard thromboprophylaxis was 2.59 (95% CI: 1.20-5.57). Conclusions:Critically ill patients with COVID-19 had a similar bleeding risk as ORVI patients. When accounting for changes in anticoagulation that occurred in COVID-19 patients, therapeutic-intensity anticoagulation was associated with a greater risk of major bleeding compared with standard thromboprophylaxis.

Prevention of venous thromboembolism and haemostasis monitoring in patients with COVID-19: Updated proposals (April 2021)

“…In a retrospective cohort of ICU patients, Halaby and al. reported an incidence of major bleeding of 14.8%, although the bleeding risk did not differ from other severe viral infections (HR 1.26; 95% CI 0.86–1.86) [39] .…”

“…The use of therapeutic dose anticoagulation might increase the rate of bleeding [5] , [39] , although the global bleeding risk remains low in prospective studies [17] , [19] . This could limit the benefit of therapeutic dose prophylactic anticoagulation in unselected patients.…”

Bleeding risk in hospitalized patients with COVID‐19 receiving intermediate‐ or therapeutic doses of thromboprophylaxis

“…Another study found that the rate of bleeding events was high in patients receiving (sub)therapeutic doses of anticoagulants, 18 and the doses of anticoagulants were the strongest determinant of the risk for bleeding. A recent study comparing the bleeding risk in patients with critical COVID‐19 and other respiratory viral illnesses found that therapeutic‐intensity anticoagulation was associated with a higher risk for major bleeding than standard VTE prophylaxis 23 …”

“…A recent study comparing the bleeding risk in patients with critical COVID-19 and other respiratory viral illnesses found that therapeutic-intensity anticoagulation was associated with a higher risk for major bleeding than standard VTE prophylaxis. 23 TA B L E 3 Clinical characteristics of the patients, according to the development of bleeding events One in every 3 patients (38%) in our cohort had D-dimer levels above 10 times the upper normal range, and their rate of major bleeding was high (74 of 719 patients, 10%). Because patients with COVID-19 and raised levels of D-dimer also are at increased risk for VTE, 24 we suggest that these patients should be carefully evaluated to decide what doses of anticoagulants would be optimal.…”

Covid-19 E Trombose

“…Estudos mostraram grande incidência de eventos trombóticos, apesar da dose profilática de anticoagulação 33 . Isso levou ao uso de doses profiláticas mais altas, chamadas de intermediárias, por não atingirem a dose terapêutica de anticoagulação plena 34 . Dados observacionais mostraram que a dose intermediária não teve impacto significativo na mortalidade quando comparada com a dose profilática tradicional e apresentou maior taxa de complicações por sangramento 33,35,36 .…”