The Role of Therapeutic Anticoagulation in COVID-19

Abstract

Coagulopathy has proven to be a common complication of the novel coronavirus SARS-CoV-2, with evidence of elevated D-dimers and fibrin degradation products associated with an increased incidence of thromboembolism. Despite emerging evidence describing the coagulopathy and its clinical relevance in COVID-19, fewer studies have addressed the potential role of empiric therapeutic anticoagulation in this setting. We report the case of a patient admitted to our intensive care unit (ICU) with severe acute respiratory distress syndrome (ARDS) secondary to COVID-19 whose clinical trajectory improved dramatically after initiation of a therapeutic dose of LMWH. The patient showed progressive elevation of fibrinogen and D-dimers despite a prophylactic dose of LMWH during her ICU stay. This was met with a moderate increase of troponin T-hs, an escalating need for vasopressors, and a progressive decrease in her P/F ratio despite preserved lung static compliance. Her platelet count was normal and had an elevated fibrinogen during the first week of ICU stay. The ECG was normal, and a bedside transthoracic echocardiogram showed no evidence of pulmonary embolism and a preserved EF with no regional wall motion abnormalities (RMWA). The chest X-ray was not dissimilar to previous exams, and the ABG showed hypoxia with normal pCO2 values. The decision was made to commence empiric therapeutic enoxaparin. The patient did not experience bleeding complications, and her clinical trajectory appeared to change dramatically. She was successfully extubated three days later and proceeded to clinical recovery and eventual discharge from the ICU. The available evidence shows that there is undoubtedly coagulopathy associated with COVID-19 with various subsequent forms of clinical manifestation described in the literature. Evidence also shows the benefits of heparin as an anticoagulant. From the discussion of this case report, however, it can be concluded that despite the plausible theoretical rationale, studies pertaining to the role of empiric therapeutic anticoagulation in this setting fall short of providing compelling evidence. Subsequently the role of empiric therapeutic anticoagulation in COVID-19 remains unclear with a pressing call for further research.

Efficacy and Safety of Anticoagulants for COVID-19 Patients in the Intensive Care Unit: A Systematic Review and Meta-Analysis

“…Besides, previous studies supported anticoagulant application as both therapy and prophylaxis. Anticoagulants potentially decrease coagulopathy, microthrombus, and organ damage ( 16), but there are still no general guidelines for their application in COVID-19 patients, and further studies are required to ensure effectiveness (17).…”

Low molecular weight heparin reduces arterial blood lactic acid content and increases estimated glomerular filtration rate in patients with moderate Covid-19 pneumonia

“…[ 22 ] Treatment with LMWH within the initial 7-day onset of acute respiratory distress syndrome significantly improved the PaO 2 /FiO 2 ratio and reduced the risk of 7-day mortality by 48% and the risk of 28-day mortality by 37%, particularly in the subgroup receiving high-dose LMWH (≥5000 U/day). [ 23 ] However, the largest available study to date evaluating anticoagulation was an analysis of 2773 patients with Covid-19 in the Mount Sinai Health System. Here, the authors found that patients who received anticoagulation were significantly more likely to require invasive mechanical ventilation.…”

“…A case series of postmortem autopsies found that PE was the direct cause of death (33%) [22] . Treatment with LMWH within the initial 7-day onset of acute respiratory distress syndrome significantly improved the PaO 2 /FiO 2 ratio and reduced the risk of 7-day mortality by 48% and the risk of 28-day mortality by 37%, particularly in the subgroup receiving high-dose LMWH (≥5000 U/day) [23] . However, the largest available study to date evaluating anticoagulation was an analysis of 2773 patients with Covid-19 in the Mount Sinai Health System.…”

Low Molecular Weight Heparin Protects Lung, Renal and Microcirculation Function in Patients with Covid-19 Pneumonia

“…A case series of post-mortem autopsies found that pulmonary embolism(PE) was the direct cause of death in 4 (33%) [17]. Treatment with LMWH within the initial 7-day onset of acute respiratory distress syndrome (ARDS) signi cantly improved the PaO2/FiO2 ratio and reduced the risk of 7-day mortality by 48% and the risk of 28-day mortality by 37%, particularly in the subgroup receiving high-dose LMWH of ≥ 5000U/day [18]. However, the largest available study evaluating anticoagulation was an analysis of 2,773 patients with COVID-19 in the Mount Sinai Health System found that patients who received anticoagulation were signi cantly more likely to require invasive mechanical ventilation [19].Our results showed that LMWH therapy could reduce PCO2, which was considered to be related to reduction of pulmonary vascular thrombosis and improvement in alveolar-capillary gas exchange.…”