Clinical profile and prognosis in patients on oral anticoagulation before admission for COVID‐19

Abstract

Background The coronavirus disease 2019 (COVID‐19) shows high morbidity and mortality, particularly in patients with concomitant cardiovascular diseases. Some of these patients are under oral anticoagulation (OAC) at admission, but to date, there are no data on the clinical profile, prognosis and risk factors of such patients during hospitalization for COVID‐19. Design Subanalysis of the international ‘real‐world’ HOPE COVID‐19 registry. All patients with prior OAC at hospital admission for COVID‐19 were suitable for the study. All‐cause mortality was the primary endpoint. Results From 1002 patients included, 110 (60.9% male, median age of 81.5 [IQR 75‐87] years, median Short‐Form Charlson Comorbidity Index [CCI] of 1 [IQR 1‐3]) were on OAC at admission, mainly for atrial fibrillation and venous thromboembolism. After propensity score matching, 67.9% of these patients died during hospitalization, which translated into a significantly higher mortality risk compared to patients without prior OAC (HR 1.53, 95% CI 1.08‐2.16). After multivariate Cox regression analysis, respiratory insufficiency during hospitalization (HR 6.02, 95% CI 2.18‐16.62), systemic inflammatory response syndrome (SIRS) during hospitalization (HR 2.29, 95% CI 1.34‐3.91) and the Short‐Form CCI (HR 1.24, 95% CI 1.03‐1.49) were the main risk factors for mortality in patients on prior OAC. Conclusions Compared to patients without prior OAC, COVID‐19 patients on OAC therapy at hospital admission showed lower survival and higher mortality risk. In these patients on OAC therapy, the prevalence of several comorbidities is high. Respiratory insufficiency and SIRS during hospitalization, as well as higher comorbidity, pointed out those anticoagulated patients with increased mortality risk.

Association of chronic anticoagulant and antiplatelet use on disease severity in SARS-COV-2 infected patients

“…Our study in a diverse group of SARS-CoV-2 infected patients in Northern California also did not show an association between chronic anticoagulant and antiplatelet use with mortality, invasive ventilator use or inpatient hospitalizations. A recent study of European patients found lower survival and increased mortality risk in patients on chronic anticoagulation at the time of hospital admission for SARS-CoV-2 infection, though the prevalence of several comorbidities was high in that cohort [ 8 ]. The conflicting results likely arise from differences in patient population with the New York and European patients being more severely ill with overall higher risk of hospitalization during the peak of illness in the spring of 2020.…”

“…Infection with SARS-CoV-2 can lead to a severe systemic inflammatory response, vascular endothelial dysfunction and hemostatic derangements, predisposing to microvascular and macrovascular thrombi and significant morbidity [1,4]. Efforts to mitigate the disease severity have generated discussions regarding empiric use of anticoagulants and antiplatelets in SARS-CoV-2 infected patients, though with little substantive data on benefit [1,5,6].…”

“…Infection with SARS-CoV-2 can lead to a severe systemic inflammatory response, vascular endothelial dysfunction and hemostatic derangements, predisposing to microvascular and macrovascular thrombi and significant morbidity [1,4]. Efforts to mitigate the disease severity have generated discussions regarding empiric use of anticoagulants and antiplatelets in SARS-CoV-2 infected patients, though with little substantive data on benefit [1,5,6]. A recent study in SARS-CoV-2 infected patients in a New York City health system showed no difference in survival, time to mechanical ventilation or hospital admission in those patients who were on anticoagulant or antiplatelet therapy at the time of SARS-CoV-2 diagnosis [7].…”

“…Emerging evidence suggests that SARS-CoV-2 coronavirus associated coagulopathy is associated with higher morbidity and mortality [1][2][3]. To mitigate this, there has been increased interest and clinical use of empiric anticoagulation and antiplatelet therapy.…”

Direct oral anticoagulant use and risk of severe COVID‐19

“…Preemptive anticoagulant treatment before or at the time of SARS-CoV-2 infection to protect against severe disease is theoretically appealing but real-world data have been lacking. Previously, only small studies of COVID-19 patient cohorts have been conducted showing mixed results [6][7][8][9][10][11][12][13]. An additional case-control study aimed at investigating the association between renin-angiotensin-aldosterone system blockers and COVID-19 reported also on oral anticoagulant use (odds ratio, 1.16; 95% CI 1.04-1.30) [19].…”