Prevention, Diagnosis, and Treatment of VTE in Patients With Coronavirus Disease 2019

Moores, Lisa K.; Tritschler, Tobias; Brosnahan, Shari B.; Carrier, Marc; Collen, Jacob; Doerschug, Kevin C.; Holley, Aaron B.; Jiménez, David; Gal, Grégoire Le; Rali, Parth; Wells, Philip S.

doi:10.1016/j.chest.2020.05.559

Cited by 601 publications

(767 citation statements)

References 76 publications

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“…The ISTH Guidance 21 suggested thromboprophylaxis with a prophylactic-dose UFH or LMWH with the possibility to escalate to an Intermediate-dose for high risk and a 50% increase in the dose for obese patients. The CHEST guidelines 22 suggested the current standard dose anticoagulant thromboprophylaxis over intensifying the dose to intermediate or full treatment dosing. In addition to an accurate estimate of the risk of thrombosis, there are areas requiring further investigation.…”

Section: Discussionmentioning

confidence: 99%

High Rate of Bleeding and Arterial Thrombosis in COVID-19: Saudi Multicenter Study

Raizah

Alaskar

Shaheen

et al. 2020

Preprint

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Background: Coronavirus disease 2019 (COVID-19) is a global pandemic with a substantial impact on mortality, the health system and the economy8,9. Several observational studies reported the rate of venous and arterial thrombotic events in patients infected with COVID-19, with conflicting results . The aim of this multicentre study was to estimate the rate of thrombotic and bleeding events in hospitalized patients diagnosed with COVID-19 in Saudi Arabia. Method: multicenter study of 636 hospitalized patients with COVID-19.Result: Twelve patients were diagnosed with VTE 1.89% (95% CI, 1.18–3). The rate in the non-ICU group was 0.19% (95% CI, 0.04–0.84) compared to 10.38% (95% CI, 6.45–16.27) in the ICU group. Fourteen patients were diagnosed with an arterial event with an overall rate of 2.20% (95% CI, 1.43–3.38). The rate in the non-ICU group was 0.94% (95% CI, 0.46–0.1.93) and 8.49% (95% CI, 5.01–14.04) in the ICU group. The overall composite events rate was 2.99% (95% CI, 2.06–4.31). The composite events rate in the non-ICU group was 0.94% (95% CI, 0.46–0.1.93) and 13.21% (95% CI, 8.7–19.54) in the ICU group. Eleven patients developed bleeding with an overall rate of 1.73% (95% CI, 1.06–2.81). The bleeding rate in the non-ICU group was 0.19% (95% CI, 0.04–0.84), and 9.43% (95% CI, 5.72–15.16) in the ICU group. Of the selected risk factors, the only risk factor that predicted VTE and the composite outcome, was the baseline D-dimer. (OR 1.31, 95% CI, 1.084-1.573, p=0.005) and composite events (OR 1.32, 95% CI, 1.126-1.555, p=0.0007).Conclusion: Of 636 adults with COVID-19, the rate of VTE was similar to the rate of hospitalized patients with a similar degree of critical illness. In contrast to the risk of VTE, we found a high rate of arterial and bleeding complications in patients admitted to ICU. An elevated D-dimer at baseline could predict a thrombotic complication in the COVID-19 patients, which may assist in the identification of these patients. Given the high rate of bleeding, the current study suggests that the intensification of anticoagulation in COVID-19 patients beyond the standard of care, should be pursued with caution and is best evaluated in a randomised controlled study.

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Section: Discussionmentioning

confidence: 99%

High Rate of Bleeding and Arterial Thrombosis in COVID-19: Saudi Multicenter Study

Raizah

Alaskar

Shaheen

et al. 2020

Preprint

View full text Add to dashboard Cite

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“…Therefore, special attention should be paid to severe patients with long-term bed rest, advanced age, and complicated underlying diseases, especially in the presence of coagulation abnormalities. Appropriate anticoagulant treatment might be considered in such patients in order to prevent the occurrence of deep vein thrombosis (DVT) and related complications [29][30][31]. In the present study, a reduction in OI was associated with increased mortality.…”

Section: Discussionmentioning

confidence: 63%

Association factors with severe cases and antiviral drug assessment in patients with COVID-19

Gong

Guo

Kang

et al. 2020

Preprint

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Background Due to the latent onset of novel coronavirus disease 2019 (COVID-19), it is important to identify patients with increased probabilities for disease progression early in order to implement timely medical strategies. This study aimed to identify the factors associated with severe COVID-19 and evaluate the current antiviral drugs, especially in severe patients. Methods This was a retrospective observational study performed at the No. 7 Hospital of Wuhan (Wuhan, China) with hospitalized patients confirmed with COVID-19 from January 11 to March 13, 2020. Multivariable logistic regression analysis was used to identify the associated factors of severe COVID. Treatment of antivirus drugs were collected and evaluated. Results Of the 550 patients, 292 (53.1%) were female and 277 (50.4%) were ≥ 60 years old. The most common symptom was fever (n = 372, 67.7%), followed by dry cough (n = 257, 46.7%), and dyspnea (n = 237, 43.1%), and fatigue (n = 224, 40.7%). Among the severe patients, 20.2% required invasive ventilator support and 18.0% required non-invasive ventilator. The identified risk factors for severe cases were: age ≥ 60 years (odds ratio (OR) = 3.02, 95% confidence interval (CI): 1.13–8.08, P = 0.028), D-dimer > 0.243 µg/ml (OR = 2.734, 95%CI: 1.012–7.387, P = 0.047), and low oxygenation index (OR = 0.984, 95%CI: 0.980–0.989, P < 0.001). In severe cases, the benefits of arbidol alone was 73.3%, which was better than ribavirin (7/17, 41.2%, P = 0.029). Conclusions Age ≥ 60 years, D-dimer > 0.243 µg/ml, and lower oxygenation index were associated with severe cases. Arbidol might provide more clinical benefits in treating patients with severe COVID-19 compared with other antiviral drugs.

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“…Most importantly, the majority of patients with COVID-19 (89.5%) in this study were started on fulldose anticoagulation per our internal protocol due to elevated D-dimer levels (most commonly unfractionated heparin) for prevention of thrombotic complications associated with COVID-19 that are increasingly being reported [11,13,14]. Multiple societal guidelines, which were developed after our study period, specifically from the American Society of Hematology and American Society of CHEST Physicians do not recommend full-dose anticoagulation for prevention of thromboembolism in COVID-19 given the unclear benefits and potential high risk of bleeding in this vulnerable population [15,16]. Of note, majority of the COVD-19 patients in our study cohort were found to be supratherapeutic while on anticoagulation prior to hemorrhagic stroke diagnosis, suggesting inadvertent outcomes of being on full-dose therapy.…”

Section: Mechanisms Of Hemorrhagementioning

confidence: 99%

“…The presence of SARS-CoV-1 virus has been demonstrated in human brains, and there are multiple cases of central nervous system involvement of other similar coronaviruses, highlighting its neuro-invasive potential [17]. SARS-CoV-2 binds to ACE2 receptors, which are expressed by neurons and glial cells, raising the possibility of direct viral neurologic injury [15]. Additionally, ACE2 receptors are highly concentrated on the endothelial cells of blood vessels, and when attacked by SARS-CoV-2, may result in disruption of the blood brain barrier and abnormal cerebral autoregulation [19].…”

Section: Mechanisms Of Hemorrhagementioning

confidence: 99%

Anticoagulation use and Hemorrhagic Stroke in SARS-CoV-2 Patients Treated at a New York Healthcare System

et al. 2020

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Background and Purpose: While the thrombotic complications of COVID-19 have been well described, there are limited data on clinically significant bleeding complications including hemorrhagic stroke. The clinical characteristics, underlying stroke mechanism, and outcomes in this particular subset of patients are especially salient as therapeutic anticoagulation becomes increasingly common in the treatment and prevention of thrombotic complications of COVID-19. Methods: We conducted a retrospective cohort study of patients with hemorrhagic stroke (both non-traumatic intracerebral hemorrhage and spontaneous non-aneurysmal subarachnoid hemorrhage) who were hospitalized between March 1, 2020, and May 15, 2020, within a major healthcare system in New York, during the coronavirus pandemic. Patients with hemorrhagic stroke on admission and who developed hemorrhage during hospitalization were both included. We compared the clinical characteristics of patients with hemorrhagic stroke and COVID-19 to those without COVID-19 admitted to our hospital system between March 1, 2020, and May 15, 2020 (contemporary controls), and March 1, 2019, and May 15, 2019 (historical controls). Demographic variables and clinical characteristics between the individual groups were compared using Fischer's exact test for categorical variables and nonparametric test for continuous variables. We adjusted for multiple comparisons using the Bonferroni method. Results: During the study period in 2020, out of 4071 patients who were hospitalized with COVID-19, we identified 19 (0.5%) with hemorrhagic stroke. Of all COVID-19 with hemorrhagic stroke, only three had isolated non-aneurysmal SAH with no associated intraparenchymal hemorrhage. Among hemorrhagic stroke in patients with COVID-19, coagulopathy was the most common etiology (73.7%); empiric anticoagulation was started in 89.5% of these patients versus 4.2% in contemporary controls (p ≤ .001) and 10.0% in historical controls (p ≤ .001). Compared to contemporary and historical controls, patients with COVID-19 had higher initial NIHSS scores, INR, PTT, and fibrinogen levels. Patients with COVID-19 also had higher rates of in-hospital mortality (84.6% vs. 4.6%, p ≤ 0.001). Sensitivity analyses excluding patients with strictly subarachnoid hemorrhage yielded similar results.

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Prevention, Diagnosis, and Treatment of VTE in Patients With Coronavirus Disease 2019

Cited by 601 publications

References 76 publications

High Rate of Bleeding and Arterial Thrombosis in COVID-19: Saudi Multicenter Study

High Rate of Bleeding and Arterial Thrombosis in COVID-19: Saudi Multicenter Study

Association factors with severe cases and antiviral drug assessment in patients with COVID-19

Anticoagulation use and Hemorrhagic Stroke in SARS-CoV-2 Patients Treated at a New York Healthcare System

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