Systemic thrombosis in a large cohort of COVID-19 patients despite thromboprophylaxis: A retrospective study

Abstract

Background: Incidence of thrombotic events associated to Coronavirus disease-2019 (COVID-19) is difficult to assess and reported rates differ significantly. Optimal thromboprophylaxis is unclear.Objectives: We aimed to analyze the characteristics of patients with a confirmed thrombotic complication including inflammatory and hemostatic parameters, compare patients affected by arterial vs venous events and examine differences between survivors and non-survivors. We reviewed compliance with thromboprophylaxis and explored how the implementation of a severity-adjusted protocol could have influenced outcome. Methods: Single-cohort retrospective study of COVID-19 patients admitted, from March 3 to May 3 2020, to the Infanta Leonor University Hospital in Madrid, epicenter of the Spanish outbreak. Results: Among 1127 patients, 80 thrombotic events were diagnosed in 69 patients (6.1% of the entire cohort). Forty-three patients (62%) suffered venous thromboembolism, 18 (26%) arterial episodes and 6 (9%) concurrent venous and arterial thrombosis. Most patients (90%) with a confirmed thrombotic complication where under low-molecular-weight heparin treatment. Overt disseminated intravascular coagulation (DIC) was rare. Initial ISTH DIC score and pre-event CRP were significantly higher among non-survivors. In multivariate analysis, arterial localization was an independent predictor of mortality (OR = 18, 95% CI: 2.4-142, p < .05). Conclusions: Despite quasi-universal thromboprophylaxis, COVID-19 lead to a myriad of arterial and venous thrombotic events. Considering the subgroup of patients with thrombotic episodes, arterial events appeared earlier in the course of disease and conferred very poor prognosis, and an ISTH DIC score ≥ 3 at presentation was identified as a potential predictor of mortality. Severity-adjusted thromboprophylaxis seemed to decrease the number of events and could have influenced mortality. Randomized controlled trials are eagerly awaited.

Are Reduced Levels of Coagulation Proteins Upon Admission Linked to COVID-19 Severity and Mortality?

“…In this sense, several mechanisms of coagulation activation have been postulated (4) and large dynamic fluctuations in coagulation and fibrinolysis laboratory parameters have been described during disease course (5). Development of overt disseminated intravascular coagulation (DIC) seems to be rare and to follow a different pattern from other infection-derived DIC (5)(6)(7), but it has been reported in up to 71% of fatal cases as a late and ominous sign (8).…”

Concomitant Acute Limb Ischemia and Pulmonary Embolism in the Course of SARS-CoV-2 Infection: Case Report

“…Our patient had both arterial and venous thromboembolic events despite thromboprophylaxis regime. There are some few cases reported in the literature, the incidence of concomitant arterial and venous thrombosis was up 0.5% in a Spanish study [14]. Through this report case we highlighted the possibility to develop thromboembolic events far from hospitalization for mild COVID-19 pneumonia.…”

Hospitalized Children With Familial Hypercholesterolemia and COVID-19: A Case for Preventive Anticoagulation

“…The pathophysiological mechanisms include, among others, cytokine-initiated inflammatory activation of coagulation and insufficient control of anticoagulant pathways, which together lead to endothelial dysfunction and microvascular thrombosis (19). The usefulness of the ISTH DIC score was shown in a retrospective large cohort study of 1,127 adult COVID-19 patients in Spain (20). In this study, the initial ISTH DIC score was significantly higher among the ultimately non-surviving patients.…”