Incidence of VTE and Bleeding Among Hospitalized Patients With Coronavirus Disease 2019

Abstract

Background Individual studies have reported widely variable rates for venous thromboembolism ( VTE ) and bleeding among hospitalized patients with coronavirus disease 2019 ( COVID-19 ). Research question What is the incidence of VTE and bleeding among hospitalized patients with COVID-19? Methods In this systematic review and meta-analysis we searched 15 standard and COVID-19 specific sources between January 1, 2020 and July 31, 2020, with no restriction by language. We pooled incidence estimates using random-effects meta-analyses. We evaluated heterogeneity using the I 2 statistic. We assessed publication bias using Begg's and Egger's tests. Results The pooled incidence was 17.0% (95% confidence interval [ CI ], 13.4%-20.9%) for VTE, 12.1% (95% CI, 8.4%-16.4%) for DVT, 7.1% (95% CI, 5.3%-9.1%) for PE, 7.8% (95% CI, 2.6%-15.3%) for bleeding, and 3.9% (95% CI, 1.2%-7.9%) for major bleeding. In subgroup meta-analyses, the incidence of VTE was higher when assessed by screening (33.1% vs. 9.8% by clinical diagnosis), among patients in the ICU (27.9% vs. 7.1% in the ward), in prospective studies (25.5% vs. 12.4% in retrospective studies), and with the inclusion of catheter-associated thrombosis/isolated distal DVTs and isolated subsegmental PEs. The highest pooled incidence estimate of bleeding was reported for patients receiving intermediate- or full-dose anticoagulation (21.4%) and the lowest in the only prospective study that assessed bleeding events (2.7%). Interpretation Among hospitalized patients with COVID-19, the overall estimated pooled incidence of VTE was 17.0%, with higher rates with routine screening, inclusion of distal DVT and subsegmental PE, in critically ill patients, and in prospective studies. Bleeding events were observed in 7.8% of patients and were sensitive to use of escalated doses of anticoagulants, and nature of data collection. Additional studies are required to ascertain the significance of various thrombotic events and to identify strategies to improve patient outcomes.

COVID-19–associated Coagulopathy

“…Beyond respiratory and renal failure, COVID-19–associated coagulopathy is a major challenge with a very high incidence of thromboembolic complications. 1 In contrast to bacterial sepsis and disseminated intravascular coagulation, standard coagulation tests such as activated partial thromboplastin time, prothrombin time, and antithrombin level do not significantly change in most COVID-19 patients, despite a high incidence of thrombotic events. 2 This important finding further emphasizes that the classical cascade model of hemostasis and standard coagulation tests that focus on plasmatic clotting times do not reflect the pathophysiology of thromboinflammatory response/immunothrombosis as it occurs in COVID-19.…”

“…These changes on the cellular level are not reflected by plasmatic coagulation tests but by whole blood viscoelastic testing and are characterized by decreased coagulation times in nonactivated viscoelastic tests, increased clot firmness in viscoelastic tests with and without platelet contribution, as well as hypofibrinolysis/fibrinolysis shutdown (thromboelastometry triad of thrombosis and COVID-19). 1 , 2 , 8 – 10 , 19 Notably, the systemic inflammatory response syndrome of acute infections, sepsis, disseminated intravascular coagulation, and COVID-19 are characterized by different viscoelastic and platelet function patterns. 3 , 18 We believe that differentiation and outcome management strategies can be improved by multimodal testing that includes the combination of viscoelastic, platelet function, and conventional biomarkers such as D-dimers.…”

Incidence, risk factors, and thrombotic load of pulmonary embolism in patients hospitalized for COVID-19 infection

“…According to the current literature, the expected incidence of PE in hemodynamically stable (mainly non-ICU) patients with elevated D-dimer and routine thrombosis prophylaxis (as similar as possible to our patients) is 10%. 43 Assuming a calculation error of 6%, a confidence level of 95%, 73 patients with a valid reading of CTPA scan were needed. Agreement between radiologists on the diagnosis of PE was assessed via the Kappa index.…”

EACTA/SCA Recommendations for the Cardiac Anesthesia Management of Patients With Suspected or Confirmed COVID-19 Infection: An Expert Consensus From the European Association of Cardiothoracic Anesthesiology and Society of Cardiovascular Anesthesiologists With Endorsement From the Chinese Society of Cardiothoracic and Vascular Anesthesiology

“…Caution should be exercised when the platelets fall below 30,000/μml for prophylaxis or below 50,000/μml for therapeutic heparin. Bleeding events are observed in 7.8% of patients with COVID-19 infection, which are sensitive to the use of escalated doses of anticoagulants ( 19 ). Point-of-care monitoring of coagulation, including thromboelastography ( 20 ) can be considered to manage hemostasis in the perioperative period.…”