Thromboprophylaxis and laboratory monitoring for in-hospital patients with Covid-19 - a Swiss consensus statement by the Working Party Hemostasis

Casini, Alessandro; Alberio, Lorenzo; Angelillo‐Scherrer, Anne; Fontana, Pierre; Gerber, Bernhard; Graf, Laura; Hegemann, Inga; Korte, Wolfgang; Hovinga, Johanna Kremer; Lecompte, Thomas; Martínez, María Dolores Jiménez; Nagler, Michael; Studt, Jan‐Dirk; Tsakiris, Dimitrios Α.; Wuillemin, Walter A.; Asmis, Lars M.

doi:10.4414/smw.2020.20247

Cited by 84 publications

(120 citation statements)

References 3 publications

(3 reference statements)

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“…We agree with the reservations about the use of tAC in severe COVID-19 voiced by professional societies, 4,16 given the potential for serious adverse events, chiefly bleeding. It is important to note, however, that in our cohort the rates of all types of bleeding were similar among those who received tAC and those who did not, suggesting that this therapeutic strategy can be relatively safe.…”

Section: Discussionsupporting

confidence: 72%

Therapeutic Anticoagulation Delays Death in COVID-19 Patients: Cross-Sectional Analysis of a Prospective Cohort

Ionescu

Grasso-Knight

Castillo

et al. 2020

TH Open

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A hypercoagulable state has been described in coronavirus disease 2019 (COVID-19) patients. Others have reported a survival advantage with prophylactic anticoagulation (pAC) and therapeutic anticoagulation (tAC), but these retrospective analyses have important limitations such as confounding by indication. We studied the impact of tAC and pAC compared with no anticoagulation (AC) on time to death in COVID-19. We performed a cross-sectional analysis of 127 deceased COVID-19 patients and compared time to death in those who received tAC (n = 67), pAC (n = 47), and no AC (n = 13). Median time to death was longer with higher doses of AC (11 days for tAC, 8 days for pAC, and 4 days for no AC, p < 0.001). In multivariate analysis, AC was associated with longer time to death, both at prophylactic (hazard ratio [HR] = 0.29; 95% confidence interval [CI]: 0.15 to 0.58; p < 0.001) and therapeutic doses (HR = 0.15; 95% CI: 0.07 to 0.32; p < 0.001) compared with no AC. Bleeding rates were similar among tAC and remaining patients (19 vs. 18%; p = 0.877). In deceased COVID-19 patients, AC was associated with a delay in death in a dose-dependent manner. Randomized trials are required to prospectively investigate the benefit and safety of higher doses of AC in this population.

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Section: Discussionsupporting

confidence: 72%

Therapeutic Anticoagulation Delays Death in COVID-19 Patients: Cross-Sectional Analysis of a Prospective Cohort

Ionescu

Grasso-Knight

Castillo

et al. 2020

TH Open

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“…Recent data from severely affected patients suggest the coagulopathy is not consistent with acute disseminated intravascular coagulation (DIC) and instead supports hypercoagulability together with a severe inflammatory state [16]. Additionally, autopsy series published in recent weeks highlight particularly the thrombosis of small vessels [17,18], and multiple groupings are now advising on how best to manage anticoagulation in COVID-positive patients [19][20][21][22][23]. Recognising evidence of microvascular injury [17,18], it is plausible that early, stratified intermediate prophylactic or full therapeutic anticoagulation, where appropriate, with heparin may have modified the disease process and led to improved outomes in our protocolised case series compared to all series [4-7; 12] , and low overall admission mortality rates for a cohort already at an advanced stage of disease.…”

Section: Discussionmentioning

confidence: 99%

Early detection of severe COVID-19 disease patterns define near real-time personalised care, bioseverity in males, and decelerating mortality rates

Vizcaychipi

Shovlin

Hayes

et al. 2020

Preprint

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Background: COVID-19 is a global health emergency. Recent data indicate a 50% mortality rate across UK intensive care units.Methods: A single institution, two-centre retrospective analysis following implementation of a Decision Support tool and real-time data dashboard for early detection of patients requiring personalised enhanced care, focussing on respiratory rate, diastolic blood pressure, oxygenation indices, C-reactive protein, D-dimer and ferritin. Protocols differing from conventional practice included high-dose prophylactic anticoagulation for all COVID-19 positive patients and prescription of antioxidants.Results: By 22/04/2020, 923 patients tested COVID-19 positive. 569 patients (61.7%) were male. The majority presented with advanced disease: interquartile ranges were C-reactive protein 44.9-179mg/L, D-dimer 1070-3802ng/mL, and ferritin 261-1208μg/L. Completed case fatality rates were 25.1% [95% CI 20.0, 30.0] in females, 40.5% [95% CI 35.9, 45.0] in males. 139 patients were admitted to intensive care where current death rates are 16.2% [95% CI 3.8, 28.7] in females, 38.2% [95% CI 28.6, 47.8] inmales with no trends for differences based on ethnicity. A real-time traffic lights dashboard enabled rapid assessment of patients using critical parameters to accelerate adjustments to management protocols. In total 513 (55.6%) of patients were flagged as high risk for thromboembolic disease, exceeding the numbers flagged for respiratory deteriorations (N=391, 42.4%), or cytokine storm (N=68, 7.4%). There was minimal evidence that age was associated with disease severity, but males had higher levels of all dashboard indices, particularly C-reactive protein and ferritin (p<0.0001) which displayed no relationship with age.Conclusions: Survival rates are encouraging. Protocols employed (traffic light-driven personalised care, protocolised early therapeutic anticoagulation based on D-dimer >1,000ng/mL and/or CRP>200 mg/L, personalised ventilatory strategies and antioxidants) are recommended to other units. Males are at greater risk of severe disease, most likely as the obligate SARS-CoV-2 receptor is encoded by the Xchromosome, and require especially close, and early attention.

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“…Standard dose thromboprophylaxis in hospitalized COVID-19 patients has been advocated by Chinese (CMDA), 14 ISTH, 15 and Thrombosis-UK 16 recommendations. However, intensified anticoagulation varying with disease severity (clinically/ hematological or other biological parameters) has been recommended by CCS, 17 GIHP, GFHT, 18 NIPHN, 19 GTH, 20 SSC 21 and Swiss Haematology 22 Society.…”

Section: Synopsis Of Guidelines and Position Papers On Venous Thrombomentioning

confidence: 99%

Venous Thromboembolism in COVID-19: Are Women Different?

Chhabra

Goyal

2020

Indian Journal of Cardiovascular Disease in Women WINCARS

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The epidemiological data suggests predominant male prevalence, morbidity and mortality with SARS COVID-2. Similarly, venous thromboembolic (VTE) events have a male sex predilection with variant mechanisms involving angiotensin-converting enzyme 2 (ACE-2) expression and pathways in women. COVID-19 could directly affect or it could be an indirect action of the disease via critical ailment hypoxemia, or hemostatic abnormalities might be the underlying mechanisms of VTE in a COVID-19 patient with baseline risk factor profile. VTE diagnosis in a COVID scenario has issues of a prone positioned patient, exposure of health workers and minimal therapeutic benefits in a critically ill patient with acute respiratory distress syndrome (ARDS). Anticoagulation with low-molecular weight heparin (LMWH) can be chosen over unfractionated heparin (UFH) with less monitoring requirements and thereby low exposure to healthcare workers. Variant guidelines for thromboprophylaxis (in hospital/extended postdischarge) have come up, stating anticoagulant administration, according to baseline risk profile and hemostatic biomarkers. Catheter-directed interventions should be reserved only for life-threatening situations. In women, hormonal milieu (for e.g., 17 β-estradiol) might influence occurrence of favorable ACE 2 polymorphisms with less VTE events. The management strategies in a female patient with VTE would be more or less similar to males. Combined oral contraceptives (COC) and estrogen replacement therapies (ERT) may be curtailed in COVID-19 positive patients, given their thrombogenic potential. Pregnancy and postpartum state in COVID-19 positive patient need VTE prophylaxis all the more in the presence of risk profile favoring VTE. Also, VTE prophylaxis when indicated should be continued in women in a normal menstrual cycle. Bleeding risks specific to women (menorrhagia secondary to dysfunctional uterine bleeding [DUB], fibroids, adnexal malignancies and masses, hypothyroidism, etc.) need to be weighed while taking a decision for indicated anticoagulation regimen.

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Thromboprophylaxis and laboratory monitoring for in-hospital patients with Covid-19 - a Swiss consensus statement by the Working Party Hemostasis

Cited by 84 publications

References 3 publications

Therapeutic Anticoagulation Delays Death in COVID-19 Patients: Cross-Sectional Analysis of a Prospective Cohort

Therapeutic Anticoagulation Delays Death in COVID-19 Patients: Cross-Sectional Analysis of a Prospective Cohort

Early detection of severe COVID-19 disease patterns define near real-time personalised care, bioseverity in males, and decelerating mortality rates

Venous Thromboembolism in COVID-19: Are Women Different?

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