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Yang L, Tang S, Guo J, Gabriel N, Gellad WF, Essien UR, Magnani JW, Hernandez I. COVID-19 Diagnosis, Oral Anticoagulation, and Stroke Risk in Patients with Atrial Fibrillation. Am J Cardiovasc Drugs 2024; 24:693-702. [PMID: 39136872 DOI: 10.1007/s40256-024-00671-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/31/2024] [Indexed: 08/26/2024]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) has been associated with an increased risk of stroke. It remains unclear whether the risk of stroke associated with a diagnosis of COVID-19 differed with oral anticoagulation (OAC) use. The aim of this study was to evaluate the association between COVID-19 infection, OAC use, and stroke in patients with atrial fibrillation (AF). METHODS A retrospective cohort study was conducted in individuals with established AF using data from Optum's deidentified Clinformatics® Data Mart Database. Cox proportional hazard models with time-dependent variables were employed to assess the association between possession of OAC, COVID-19 diagnosis in both inpatient and outpatient setting, and time to ischemic stroke. RESULTS A total of 561,758 individuals aged 77 ± 10 were included in the study, with a mean follow up time of 1.3 years. OAC use was associated with a reduced stroke risk [hazard ratio (HR) 0.85, 95% confidence interval (CI) 0.82-0.88]. COVID-19 infection was associated with an increased risk of stroke (HR 2.11, 95% CI 1.87-2.38); this increased risk was particularly pronounced for patients diagnosed with an inpatient diagnosis of COVID-19 (HR 3.95, 95% CI 3.33-4.68). There was no significant interaction between OAC use and COVID-19 diagnosis (p value = 0.96). As a result, the relative increase in stroke risk associated with COVID-19 did not differ between patients on OAC (HR 2.12; 95% CI 1.71-2.62) and those not on OAC (HR 2.11; 95% CI 1.83-2.43). CONCLUSION In a nationwide sample of patients with established AF, we found the relative increase in stroke risk associated with COVID-19 was independent of OAC use.
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Affiliation(s)
- Lanting Yang
- Division of Clinical Pharmacy, University of California San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences, 9500 Gilman Dr, Room 2244, La Jolla, CA, 92093, USA
| | - Shangbin Tang
- Division of Clinical Pharmacy, University of California San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences, 9500 Gilman Dr, Room 2244, La Jolla, CA, 92093, USA
| | - Jingchuan Guo
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Nico Gabriel
- Division of Clinical Pharmacy, University of California San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences, 9500 Gilman Dr, Room 2244, La Jolla, CA, 92093, USA
| | - Walid F Gellad
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Utibe R Essien
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
- Center for the Study of Healthcare Innovation, Implementation and Policy, Greater Los Angeles VA Healthcare System, Los Angeles, CA, USA
| | - Jared W Magnani
- Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Inmaculada Hernandez
- Division of Clinical Pharmacy, University of California San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences, 9500 Gilman Dr, Room 2244, La Jolla, CA, 92093, USA.
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de Barros E Silva PGM, Furtado RHM, de Alcântara Chaud MS, Macedo AVS, Bronhara B, Damiani LP, Barbosa LM, Suiama MA, Ramacciotti E, de Aquino Martins P, de Oliveira AL, Nunes VS, Ritt LEF, Rocha AT, Tramujas L, Santos SV, Diaz DRA, Viana LS, Melro LMG, Figueiredo EL, Neuenschwander FC, Dracoulakis MDA, Lima RGSD, de Souza Dantas VC, Fernandes ACS, Gebara OCE, Hernandes ME, Queiroz DAR, Veiga VC, Canesin MF, de Faria LM, Feitosa-Filho GS, Gazzana MB, Liporace IL, de Oliveira Twardowsky A, Maia LN, Machado FR, de Matos Soeiro A, Conceição-Souza GE, Armaganijan L, Guimarães PO, Rosa RG, Azevedo LCP, Alexander JH, Avezum A, Berwanger O, Cavalcanti AB, Lopes RD. Predictors of bleeding and thrombotic events among patients admitted to the hospital with COVID-19 and elevated D-dimer: insights from the ACTION randomized clinical trial. J Thromb Thrombolysis 2024; 57:1031-1039. [PMID: 38762708 DOI: 10.1007/s11239-024-02995-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2024] [Indexed: 05/20/2024]
Abstract
Therapeutic anticoagulation showed inconsistent results in hospitalized patients with COVID-19 and selection of the best patients to use this strategy still a challenge balancing the risk of thrombotic and hemorrhagic outcomes. The present post-hoc analysis of the ACTION trial evaluated the variables independently associated with both bleeding events (major bleeding or clinically relevant non-major bleeding) and the composite outcomes thrombotic events (venous thromboembolism, myocardial infarction, stroke, systemic embolism, or major adverse limb events). Variables were assessed one by one with independent logistic regressions and final models were chosen based on Akaike information criteria. The model for bleeding events showed an area under the curve of 0.63 (95% confidence interval [CI] 0.53 to 0.73), while the model for thrombotic events had an area under the curve of 0.72 (95% CI 0.65 to 0.79). Non-invasive respiratory support was associated with thrombotic but not bleeding events, while invasive ventilation was associated with both outcomes (Odds Ratio of 7.03 [95 CI% 1.95 to 25.18] for thrombotic and 3.14 [95% CI 1.11 to 8.84] for bleeding events). Beyond respiratory support, creatinine level (Odds Ratio [OR] 1.01 95% CI 1.00 to 1.02 for every 1.0 mg/dL) and history of coronary disease (OR 3.67; 95% CI 1.32 to 10.29) were also independently associated to the risk of thrombotic events. Non-invasive respiratory support, history of coronary disease, and creatinine level may help to identify hospitalized COVID-19 patients at higher risk of thrombotic complications.ClinicalTrials.gov: NCT04394377.
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Affiliation(s)
- Pedro Gabriel Melo de Barros E Silva
- Brazilian Clinical Research Institute, São Paulo, Brazil
- Hcor Research Institute, São Paulo, Brazil
- Hospital Samaritano Paulista, São Paulo, Brazil
- Centro Universitario São Camilo, São Paulo, Brazil
| | - Remo H M Furtado
- Brazilian Clinical Research Institute, São Paulo, Brazil
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Instituto Do Coração (InCor), Hospital das Clinicas da Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | | | - Bruna Bronhara
- Brazilian Clinical Research Institute, São Paulo, Brazil
| | | | | | | | | | | | | | | | - Luiz Eduardo Fonteles Ritt
- Instituto D'Or de Pesquisa E Ensino, Hospital Cárdio Pulmonar, Salvador, Brazil
- Escola Bahiana de Medicina, Salvador, Brazil
| | - Ana Thereza Rocha
- Instituto D'Or de Pesquisa E Ensino, Hospital Cárdio Pulmonar, Salvador, Brazil
- Escola Bahiana de Medicina, Salvador, Brazil
- Universidade Federal da Bahia, Salvador, Brazil
| | | | | | | | - Lorena Souza Viana
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | | | | | | | | | | | | | | | | | - Viviane C Veiga
- BP-A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
- Hospital Universitário da Universidade Estadual de Londrina, Londrina, Brazil
| | | | | | | | | | | | | | - Lilia Nigro Maia
- Pain and Intensive Care Department, Federal University of Sao Paulo (UNIFESP), São Paulo, Brazil
| | - Flávia Ribeiro Machado
- BP-A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
- Instituto Socrates Guanaes, São Paulo, Brazil
| | - Alexandre de Matos Soeiro
- Instituto Do Coração (InCor), Hospital das Clinicas da Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | | | - Patrícia O Guimarães
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Regis G Rosa
- BP-A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
- Instituto Dante Pazzanese de Cardiologia, São Paulo, Brazil
| | - Luciano C P Azevedo
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil
- BP-A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | - John H Alexander
- Duke Clinical Research Institute, Duke University Medical Center, 2400 Pratt Street, Box 3850, Durham, NC, 27705, USA
| | | | - Otávio Berwanger
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Imperial College London, London, UK
- The George Institute for Global Health UK, London, UK
| | - Alexandre B Cavalcanti
- Hcor Research Institute, São Paulo, Brazil
- BP-A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | - Renato D Lopes
- Brazilian Clinical Research Institute, São Paulo, Brazil.
- Duke Clinical Research Institute, Duke University Medical Center, 2400 Pratt Street, Box 3850, Durham, NC, 27705, USA.
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Kietaibl S, Ahmed A, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, De Robertis E, Faraoni D, Filipescu DC, Fries D, Godier A, Haas T, Jacob M, Lancé MD, Llau JV, Meier J, Molnar Z, Mora L, Rahe-Meyer N, Samama CM, Scarlatescu E, Schlimp C, Wikkelsø AJ, Zacharowski K. Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022. Eur J Anaesthesiol 2023; 40:226-304. [PMID: 36855941 DOI: 10.1097/eja.0000000000001803] [Citation(s) in RCA: 72] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management. DESIGN A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline. RESULTS These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%. DISCUSSION Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality. CONCLUSION All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.
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Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesiology & Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University Vienna, Austria (SK), Department of Anaesthesia and Critical Care, University Hospitals of Leicester NHS Trust (AAh), Department of Cardiovascular Sciences, University of Leicester, UK (AAh), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (AAf), Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark (AAf), Department of Anaesthesiology & Critical Care, CNRS/TIMC-IMAG UMR 5525/Themas, Grenoble-Alpes University Hospital, Grenoble, France (PA), Department of Anaesthesiology & Intensive Care, Hospital Universitario Rio Hortega, Valladolid, Spain (CA), Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania (GB), Division of Anaesthesia, Analgesia, and Intensive Care - Department of Medicine and Surgery, University of Perugia, Italy (EDR), Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA (DFa), University of Medicine and Pharmacy Carol Davila, Department of Anaesthesiology & Intensive Care, Emergency Institute for Cardiovascular Disease, Bucharest, Romania (DCF), Department of Anaesthesia and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria (DFr), Department of Anaesthesiology & Critical Care, APHP, Université Paris Cité, Paris, France (AG), Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida, USA (TH), Department of Anaesthesiology, Intensive Care and Pain Medicine, St.-Elisabeth-Hospital Straubing, Straubing, Germany (MJ), Department of Anaesthesiology, Medical College East Africa, The Aga Khan University, Nairobi, Kenya (MDL), Department of Anaesthesiology & Post-Surgical Intensive Care, University Hospital Doctor Peset, Valencia, Spain (JVL), Department of Anaesthesiology & Intensive Care, Johannes Kepler University, Linz, Austria (JM), Department of Anesthesiology & Intensive Care, Semmelweis University, Budapest, Hungary (ZM), Department of Anaesthesiology & Post-Surgical Intensive Care, University Trauma Hospital Vall d'Hebron, Barcelona, Spain (LM), Department of Anaesthesiology & Intensive Care, Franziskus Hospital, Bielefeld, Germany (NRM), Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP. Centre - Université Paris Cité - Cochin Hospital, Paris, France (CMS), Department of Anaesthesiology and Intensive Care, Fundeni Clinical Institute, Bucharest and University of Medicine and Pharmacy Carol Davila, Bucharest, Romania (ES), Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Linz and Ludwig Boltzmann-Institute for Traumatology, The Research Centre in Co-operation with AUVA, Vienna, Austria (CS), Department of Anaesthesia and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark (AW) and Department of Anaesthesiology, Intensive Care Medicine & Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany (KZ)
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Lei S, Chen X, Wu J, Duan X, Men K. Small molecules in the treatment of COVID-19. Signal Transduct Target Ther 2022; 7:387. [PMID: 36464706 PMCID: PMC9719906 DOI: 10.1038/s41392-022-01249-8] [Citation(s) in RCA: 52] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 11/02/2022] [Accepted: 11/08/2022] [Indexed: 12/11/2022] Open
Abstract
The outbreak of COVID-19 has become a global crisis, and brought severe disruptions to societies and economies. Until now, effective therapeutics against COVID-19 are in high demand. Along with our improved understanding of the structure, function, and pathogenic process of SARS-CoV-2, many small molecules with potential anti-COVID-19 effects have been developed. So far, several antiviral strategies were explored. Besides directly inhibition of viral proteins such as RdRp and Mpro, interference of host enzymes including ACE2 and proteases, and blocking relevant immunoregulatory pathways represented by JAK/STAT, BTK, NF-κB, and NLRP3 pathways, are regarded feasible in drug development. The development of small molecules to treat COVID-19 has been achieved by several strategies, including computer-aided lead compound design and screening, natural product discovery, drug repurposing, and combination therapy. Several small molecules representative by remdesivir and paxlovid have been proved or authorized emergency use in many countries. And many candidates have entered clinical-trial stage. Nevertheless, due to the epidemiological features and variability issues of SARS-CoV-2, it is necessary to continue exploring novel strategies against COVID-19. This review discusses the current findings in the development of small molecules for COVID-19 treatment. Moreover, their detailed mechanism of action, chemical structures, and preclinical and clinical efficacies are discussed.
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Affiliation(s)
- Sibei Lei
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Xiaohua Chen
- Department of Pharmacy, Personalized Drug Therapy Key Laboratory of Sichuan Province Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Jieping Wu
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Xingmei Duan
- Department of Pharmacy, Personalized Drug Therapy Key Laboratory of Sichuan Province Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072, China.
| | - Ke Men
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China.
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Jing H, Wu X, Xiang M, Liu L, Novakovic VA, Shi J. Pathophysiological mechanisms of thrombosis in acute and long COVID-19. Front Immunol 2022; 13:992384. [PMID: 36466841 PMCID: PMC9709252 DOI: 10.3389/fimmu.2022.992384] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 10/27/2022] [Indexed: 08/02/2023] Open
Abstract
COVID-19 patients have a high incidence of thrombosis, and thromboembolic complications are associated with severe COVID-19 and high mortality. COVID-19 disease is associated with a hyper-inflammatory response (cytokine storm) mediated by the immune system. However, the role of the inflammatory response in thrombosis remains incompletely understood. In this review, we investigate the crosstalk between inflammation and thrombosis in the context of COVID-19, focusing on the contributions of inflammation to the pathogenesis of thrombosis, and propose combined use of anti-inflammatory and anticoagulant therapeutics. Under inflammatory conditions, the interactions between neutrophils and platelets, platelet activation, monocyte tissue factor expression, microparticle release, and phosphatidylserine (PS) externalization as well as complement activation are collectively involved in immune-thrombosis. Inflammation results in the activation and apoptosis of blood cells, leading to microparticle release and PS externalization on blood cells and microparticles, which significantly enhances the catalytic efficiency of the tenase and prothrombinase complexes, and promotes thrombin-mediated fibrin generation and local blood clot formation. Given the risk of thrombosis in the COVID-19, the importance of antithrombotic therapies has been generally recognized, but certain deficiencies and treatment gaps in remain. Antiplatelet drugs are not in combination with anticoagulant treatments, thus fail to dampen platelet procoagulant activity. Current treatments also do not propose an optimal time for anticoagulation. The efficacy of anticoagulant treatments depends on the time of therapy initiation. The best time for antithrombotic therapy is as early as possible after diagnosis, ideally in the early stage of the disease. We also elaborate on the possible mechanisms of long COVID thromboembolic complications, including persistent inflammation, endothelial injury and dysfunction, and coagulation abnormalities. The above-mentioned contents provide therapeutic strategies for COVID-19 patients and further improve patient outcomes.
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Affiliation(s)
- Haijiao Jing
- Department of Hematology, The First Hospital, Harbin Medical University, Harbin, China
| | - Xiaoming Wu
- Department of Hematology, The First Hospital, Harbin Medical University, Harbin, China
| | - Mengqi Xiang
- Department of Hematology, The First Hospital, Harbin Medical University, Harbin, China
| | - Langjiao Liu
- Department of Hematology, The First Hospital, Harbin Medical University, Harbin, China
| | - Valerie A. Novakovic
- Department of Research, VA Boston Healthcare System, Harvard Medical School, Boston, MA, United States
| | - Jialan Shi
- Department of Hematology, The First Hospital, Harbin Medical University, Harbin, China
- Department of Research, VA Boston Healthcare System, Harvard Medical School, Boston, MA, United States
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States
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Venous Thromboembolic Disease in COVID-19, Pathophysiology, Therapy and Prophylaxis. Int J Mol Sci 2022; 23:ijms231810372. [PMID: 36142282 PMCID: PMC9499629 DOI: 10.3390/ijms231810372] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/05/2022] [Accepted: 09/06/2022] [Indexed: 01/08/2023] Open
Abstract
For over two years, the world has been facing the epidemiological and health challenge of the coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Growing problems are also complications after the development of COVID-19 in the form of post and long- COVID syndromes, posing a challenge for the medical community, both for clinicians and the scientific world. SARS-CoV-2 infection is associated with an increased risk of cardiovascular complications, especially thromboembolic complications, which are associated with both thrombosis of small and very small vessels due to immunothrombosis, and the development of venous thromboembolism. Low molecular wight heparin (LMHW) are the basic agents used in the prevention and treatment of thromboembolic complications in COVID-19. There is still a great deal of controversy regarding both the prevention and treatment of thromboembolic complications, including the prophylaxis dose or the optimal duration of anticoagulant treatment in patients with an episode of venous thromboembolism.
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Increased Susceptibility for Thromboembolic Events versus High Bleeding Risk Associated with COVID-19. Microorganisms 2022; 10:microorganisms10091738. [PMID: 36144340 PMCID: PMC9505654 DOI: 10.3390/microorganisms10091738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 08/19/2022] [Accepted: 08/25/2022] [Indexed: 11/16/2022] Open
Abstract
The infection with the SARS-CoV-2 virus is associated with numerous systemic involvements. Besides the severe respiratory injuries and cardiovascular complications, it became obvious early on that this disease carries an increased risk of thromboembolic events, but a higher propensity for bleedings as well. We researched the medical literature over significant PubMed published articles debating on the prevalence, category of patients, the moment of occurrence, and evolution of venous thromboembolism (VTE), but also of venous and arterial “in situ” thrombosis (AT), and hemorrhagic events as well. Most researchers agree on an increased prevalence of thromboembolic events, ranging between 25 and 31% for VTE, depending on the analyzed population. For AT and hemorrhagic complications lower rates were reported, namely, about 2–3%, respectively, between 4.8 and 8%, occurring mostly in older patients, suffering from moderate/severe forms of COVID-19, with associated comorbidities. It is important to mention that patients suffering from hemorrhages frequently received thromboprophylaxis with anticoagulant drugs. As a consequence of thromboembolic and hemorrhagic complications which are both important negative prognostic factors, the evolution of patients infected with the SARS-CoV-2 virus is aggravated, determining an augmented morbidity and mortality of this population.
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Eman A, Balaban O, Süner KÖ, Cırdı Y, Şahin F, Demir G, Pekşen Ö, Musmul A, Erdem AF. The effect of low-dose and high-dose low-molecular-weight-heparin and aspirin thromboprophylaxis on clinical outcome and mortality in critical ill patients with COVID-19: A retrospective cohort study. Saudi Med J 2022; 43:715-722. [PMID: 35830988 PMCID: PMC9749692 DOI: 10.15537/smj.2022.43.7.20220038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 05/28/2022] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES To assess the effect of different thromboprophylaxis regimens on clinical outcomes and mortality of critical ill patients with coronavirus disease -19 (COVID-19). METHODS We investigated the medical records of patients with positive COVID-19 (using polymerase chain reaction test) who were admitted to the intensive care unit (ICU) at Sakarya University Hospital, Sakarya, Turkey, from March 2020 to January 2021. We included patients under anticoagulant therapy in the clinical course. The patients were allocated to 3 groups: Group A - low-dose (prophylactic) low-molecular-weight-heparin (LMWH) therapy, Group B - high-dose (therapeutic) LMWH therapy, and patients that received aspirin additional to the high-dose (therapeutic) LMWH as Group C. Primary outcomes were overall mortality rates and length of stay (LOS) in ICU. Secondary outcomes were rates of major hemorrhagic and thrombotic events. RESULTS Records of 475 patients were reviewed and 164 patients were included. No significant difference was detected in mortality rates between groups (p=0.135). Intensive care unit stay was 13 (9-24.5) days in Group A, 11 (8.75-23) days in Group B, and 13 (9-17) days in Group C without a significant difference (p=0.547). No significant difference was detected between groups in terms of thrombotic (p=0.565) and hemorrhagic events (p=0.615). CONCLUSION A high-dose anticoagulation therapy and addition of aspirin to LMWH therapy did not decrease the mortality rates and LOS in ICU in critical ill COVİD-19 patients. In addition, it did not increase the incidence of major hemorrhage and major thrombotic events.
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Affiliation(s)
- Ali Eman
- From the Department of Anesthesiology and Reanimation (Eman, Balaban, Şahin, Demir, Pekşen, Erdem); from the Department of Intensive Care (Süner), Sakarya Training and Research Hospital; from the Department of Intensive Care (Cırdı), faculty of Medicine, Sakarya University, Sakarya; and from the Department of Medical Services and Techniques (Musmul), Eskisehir Osmangazi University Vocational School of Health Services, Eskisehir, Turkey
| | - Onur Balaban
- From the Department of Anesthesiology and Reanimation (Eman, Balaban, Şahin, Demir, Pekşen, Erdem); from the Department of Intensive Care (Süner), Sakarya Training and Research Hospital; from the Department of Intensive Care (Cırdı), faculty of Medicine, Sakarya University, Sakarya; and from the Department of Medical Services and Techniques (Musmul), Eskisehir Osmangazi University Vocational School of Health Services, Eskisehir, Turkey
| | - Kezban Ö. Süner
- From the Department of Anesthesiology and Reanimation (Eman, Balaban, Şahin, Demir, Pekşen, Erdem); from the Department of Intensive Care (Süner), Sakarya Training and Research Hospital; from the Department of Intensive Care (Cırdı), faculty of Medicine, Sakarya University, Sakarya; and from the Department of Medical Services and Techniques (Musmul), Eskisehir Osmangazi University Vocational School of Health Services, Eskisehir, Turkey
| | - Yaşar Cırdı
- From the Department of Anesthesiology and Reanimation (Eman, Balaban, Şahin, Demir, Pekşen, Erdem); from the Department of Intensive Care (Süner), Sakarya Training and Research Hospital; from the Department of Intensive Care (Cırdı), faculty of Medicine, Sakarya University, Sakarya; and from the Department of Medical Services and Techniques (Musmul), Eskisehir Osmangazi University Vocational School of Health Services, Eskisehir, Turkey
| | - Fatih Şahin
- From the Department of Anesthesiology and Reanimation (Eman, Balaban, Şahin, Demir, Pekşen, Erdem); from the Department of Intensive Care (Süner), Sakarya Training and Research Hospital; from the Department of Intensive Care (Cırdı), faculty of Medicine, Sakarya University, Sakarya; and from the Department of Medical Services and Techniques (Musmul), Eskisehir Osmangazi University Vocational School of Health Services, Eskisehir, Turkey
- Address correspondence and reprint request to: Dr. Fatih Şahin, Department of Anesthesiology and Reanimation, Sakarya University Training and Research Hospital, Sakarya, Turkey. E-mail: ORCID ID: https://orcid.org/0000-0002-8501-0675
| | - Gürkan Demir
- From the Department of Anesthesiology and Reanimation (Eman, Balaban, Şahin, Demir, Pekşen, Erdem); from the Department of Intensive Care (Süner), Sakarya Training and Research Hospital; from the Department of Intensive Care (Cırdı), faculty of Medicine, Sakarya University, Sakarya; and from the Department of Medical Services and Techniques (Musmul), Eskisehir Osmangazi University Vocational School of Health Services, Eskisehir, Turkey
| | - Özge Pekşen
- From the Department of Anesthesiology and Reanimation (Eman, Balaban, Şahin, Demir, Pekşen, Erdem); from the Department of Intensive Care (Süner), Sakarya Training and Research Hospital; from the Department of Intensive Care (Cırdı), faculty of Medicine, Sakarya University, Sakarya; and from the Department of Medical Services and Techniques (Musmul), Eskisehir Osmangazi University Vocational School of Health Services, Eskisehir, Turkey
| | - Ahmet Musmul
- From the Department of Anesthesiology and Reanimation (Eman, Balaban, Şahin, Demir, Pekşen, Erdem); from the Department of Intensive Care (Süner), Sakarya Training and Research Hospital; from the Department of Intensive Care (Cırdı), faculty of Medicine, Sakarya University, Sakarya; and from the Department of Medical Services and Techniques (Musmul), Eskisehir Osmangazi University Vocational School of Health Services, Eskisehir, Turkey
| | - Ali F. Erdem
- From the Department of Anesthesiology and Reanimation (Eman, Balaban, Şahin, Demir, Pekşen, Erdem); from the Department of Intensive Care (Süner), Sakarya Training and Research Hospital; from the Department of Intensive Care (Cırdı), faculty of Medicine, Sakarya University, Sakarya; and from the Department of Medical Services and Techniques (Musmul), Eskisehir Osmangazi University Vocational School of Health Services, Eskisehir, Turkey
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Flumignan RL, Civile VT, Tinôco JDDS, Pascoal PI, Areias LL, Matar CF, Tendal B, Trevisani VF, Atallah ÁN, Nakano LC. Anticoagulants for people hospitalised with COVID-19. Cochrane Database Syst Rev 2022; 3:CD013739. [PMID: 35244208 PMCID: PMC8895460 DOI: 10.1002/14651858.cd013739.pub2] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND The primary manifestation of coronavirus disease 2019 (COVID-19) is respiratory insufficiency that can also be related to diffuse pulmonary microthrombosis and thromboembolic events, such as pulmonary embolism, deep vein thrombosis, or arterial thrombosis. People with COVID-19 who develop thromboembolism have a worse prognosis. Anticoagulants such as heparinoids (heparins or pentasaccharides), vitamin K antagonists and direct anticoagulants are used for the prevention and treatment of venous or arterial thromboembolism. Besides their anticoagulant properties, heparinoids have an additional anti-inflammatory potential. However, the benefit of anticoagulants for people with COVID-19 is still under debate. OBJECTIVES To assess the benefits and harms of anticoagulants versus active comparator, placebo or no intervention in people hospitalised with COVID-19. SEARCH METHODS We searched the CENTRAL, MEDLINE, Embase, LILACS and IBECS databases, the Cochrane COVID-19 Study Register and medRxiv preprint database from their inception to 14 April 2021. We also checked the reference lists of any relevant systematic reviews identified, and contacted specialists in the field for additional references to trials. SELECTION CRITERIA Eligible studies were randomised controlled trials (RCTs), quasi-RCTs, cluster-RCTs and cohort studies that compared prophylactic anticoagulants versus active comparator, placebo or no intervention for the management of people hospitalised with COVID-19. We excluded studies without a comparator group and with a retrospective design (all previously included studies) as we were able to include better study designs. Primary outcomes were all-cause mortality and necessity for additional respiratory support. Secondary outcomes were mortality related to COVID-19, deep vein thrombosis, pulmonary embolism, major bleeding, adverse events, length of hospital stay and quality of life. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. We used Cochrane RoB 1 to assess the risk of bias for RCTs, ROBINS-I to assess risk of bias for non-randomised studies (NRS) and GRADE to assess the certainty of evidence. We meta-analysed data when appropriate. MAIN RESULTS We included seven studies (16,185 participants) with participants hospitalised with COVID-19, in either intensive care units, hospital wards or emergency departments. Studies were from Brazil (2), Iran (1), Italy (1), and the USA (1), and two involved more than country. The mean age of participants was 55 to 68 years and the follow-up period ranged from 15 to 90 days. The studies assessed the effects of heparinoids, direct anticoagulants or vitamin K antagonists, and reported sparse data or did not report some of our outcomes of interest: necessity for additional respiratory support, mortality related to COVID-19, and quality of life. Higher-dose versus lower-dose anticoagulants (4 RCTs, 4647 participants) Higher-dose anticoagulants result in little or no difference in all-cause mortality (risk ratio (RR) 1.03, 95% CI 0.92 to 1.16, 4489 participants; 4 RCTs) and increase minor bleeding (RR 3.28, 95% CI 1.75 to 6.14, 1196 participants; 3 RCTs) compared to lower-dose anticoagulants up to 30 days (high-certainty evidence). Higher-dose anticoagulants probably reduce pulmonary embolism (RR 0.46, 95% CI 0.31 to 0.70, 4360 participants; 4 RCTs), and slightly increase major bleeding (RR 1.78, 95% CI 1.13 to 2.80, 4400 participants; 4 RCTs) compared to lower-dose anticoagulants up to 30 days (moderate-certainty evidence). Higher-dose anticoagulants may result in little or no difference in deep vein thrombosis (RR 1.08, 95% CI 0.57 to 2.03, 3422 participants; 4 RCTs), stroke (RR 0.91, 95% CI 0.40 to 2.03, 4349 participants; 3 RCTs), major adverse limb events (RR 0.33, 95% CI 0.01 to 7.99, 1176 participants; 2 RCTs), myocardial infarction (RR 0.86, 95% CI 0.48 to 1.55, 4349 participants; 3 RCTs), atrial fibrillation (RR 0.35, 95% CI 0.07 to 1.70, 562 participants; 1 study), or thrombocytopenia (RR 0.94, 95% CI 0.71 to 1.24, 2789 participants; 2 RCTs) compared to lower-dose anticoagulants up to 30 days (low-certainty evidence). It is unclear whether higher-dose anticoagulants have any effect on necessity for additional respiratory support, mortality related to COVID-19, and quality of life (very low-certainty evidence or no data). Anticoagulants versus no treatment (3 prospective NRS, 11,538 participants) Anticoagulants may reduce all-cause mortality but the evidence is very uncertain due to two study results being at critical and serious risk of bias (RR 0.64, 95% CI 0.55 to 0.74, 8395 participants; 3 NRS; very low-certainty evidence). It is uncertain if anticoagulants have any effect on necessity for additional respiratory support, mortality related to COVID-19, deep vein thrombosis, pulmonary embolism, major bleeding, stroke, myocardial infarction and quality of life (very low-certainty evidence or no data). Ongoing studies We found 62 ongoing studies in hospital settings (60 RCTs, 35,470 participants; 2 prospective NRS, 120 participants) in 20 different countries. Thirty-five ongoing studies plan to report mortality and 26 plan to report necessity for additional respiratory support. We expect 58 studies to be completed in December 2021, and four in July 2022. From 60 RCTs, 28 are comparing different doses of anticoagulants, 24 are comparing anticoagulants versus no anticoagulants, seven are comparing different types of anticoagulants, and one did not report detail of the comparator group. AUTHORS' CONCLUSIONS When compared to a lower-dose regimen, higher-dose anticoagulants result in little to no difference in all-cause mortality and increase minor bleeding in people hospitalised with COVID-19 up to 30 days. Higher-dose anticoagulants possibly reduce pulmonary embolism, slightly increase major bleeding, may result in little to no difference in hospitalisation time, and may result in little to no difference in deep vein thrombosis, stroke, major adverse limb events, myocardial infarction, atrial fibrillation, or thrombocytopenia. Compared with no treatment, anticoagulants may reduce all-cause mortality but the evidence comes from non-randomised studies and is very uncertain. It is unclear whether anticoagulants have any effect on the remaining outcomes compared to no anticoagulants (very low-certainty evidence or no data). Although we are very confident that new RCTs will not change the effects of different doses of anticoagulants on mortality and minor bleeding, high-quality RCTs are still needed, mainly for the other primary outcome (necessity for additional respiratory support), the comparison with no anticoagulation, when comparing the types of anticoagulants and giving anticoagulants for a prolonged period of time.
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Affiliation(s)
- Ronald Lg Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
- Cochrane Brazil, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Vinicius T Civile
- Cochrane Brazil, Universidade Federal de São Paulo, São Paulo, Brazil
- Department of Physiotherapy, Universidade Paulista, São Paulo, Brazil
| | | | - Patricia If Pascoal
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Libnah L Areias
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Charbel F Matar
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Britta Tendal
- Living Guidelines Program, Cochrane Australia, Melbourne, Australia
| | - Virginia Fm Trevisani
- Cochrane Brazil, Universidade Federal de São Paulo, São Paulo, Brazil
- Medicina de Urgência, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Álvaro N Atallah
- Cochrane Brazil, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Luis Cu Nakano
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
- Cochrane Brazil, Universidade Federal de São Paulo, São Paulo, Brazil
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10
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Kuno T, Miyamoto Y, Iwagami M, Ishimaru M, So M, Takahashi M, Egorova NN. The association of hemoglobin drop with in-hospital outcomes in COVID-19 patients. QJM 2022; 114:789-794. [PMID: 34597401 PMCID: PMC8500138 DOI: 10.1093/qjmed/hcab251] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/16/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Bleeding events can be critical in hospitalized patients with COVID-19, especially those with aggressive anticoagulation therapy. AIM We aimed to investigate whether hemoglobin drop was associated with increased risk of acute kidney injury (AKI) and in-hospital mortality among patients with COVID-19. DESIGN Retrospective cohort study. METHODS This retrospective study was conducted by review of the medical records of 6683 patients with laboratory-confirmed COVID-19 hospitalized in the Mount Sinai Health system between 1st March 2020 and 30th March 2021. We compared patients with and without hemoglobin drop >3 g/dl during hospitalization within a week after admissions, using inverse probability treatment weighted analysis (IPTW). Outcomes of interest were in-hospital mortality and AKI which was defined as serum creatine change of 0.3 mg/dl increase or 1.5 times baseline. RESULTS Of the 6683 patients admitted due to COVID-19, 750 (11.2%) patients presented with a marked hemoglobin drop. Patients with hemoglobin drop were more likely to receive therapeutic anticoagulation within 2 days after admissions. Patients with hemoglobin drop had higher crude in-hospital mortality (40.8% vs. 20.0%, P < 0.001) as well as AKI (51.4% vs. 23.9%, P < 0.001) compared to those without. IPTW analysis showed that hemoglobin drop was associated with higher in-hospital mortality compared to those without (odds ratio (OR) [95% confidential interval (CI)]: 2.21 [1.54-2.88], P < 0.001) as well as AKI (OR [95% CI]: 2.79 [2.08-3.73], P < 0.001). CONCLUSIONS Hemoglobin drop during COVID-19 related hospitalizations was associated with a higher risk of AKI and in-hospital mortality.
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Affiliation(s)
- Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, NY, USA
- Address for correspondence: Toshiki Kuno, MD, PhD, Division of Cardiology, Montefiore Medical Center, Albert Einsten College of Medicine, 111 East 210th St, Bronx, NY 10467-2401,
| | | | - Masao Iwagami
- Department of Health Services Research, University of Tsukuba, Tsukuba, Japan
| | - Miho Ishimaru
- Department of Health Services Research, University of Tsukuba, Tsukuba, Japan
| | - Matsuo So
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, NY, USA
| | - Mai Takahashi
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, NY, USA
| | - Natalia N Egorova
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, NY, USA
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11
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Oba S, Hosoya T, Amamiya M, Mitsumura T, Kawata D, Sasaki H, Kamiya M, Yamamoto A, Ando T, Shimada S, Shirai T, Okamoto T, Tateishi T, Endo A, Aiboshi J, Nosaka N, Yamanouchi H, Ugawa T, Nagaoka E, Oi K, Tao S, Maejima Y, Tanaka Y, Tanimoto K, Takeuchi H, Tohda S, Hirakawa A, Sasano T, Arai H, Otomo Y, Miyazaki Y, Yasuda S. Arterial and Venous Thrombosis Complicated in COVID-19: A Retrospective Single Center Analysis in Japan. Front Cardiovasc Med 2021; 8:767074. [PMID: 34869681 PMCID: PMC8639692 DOI: 10.3389/fcvm.2021.767074] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 10/18/2021] [Indexed: 12/24/2022] Open
Abstract
Background: Thrombosis is a characteristic complication in coronavirus disease 2019 (COVID-19). Since coagulopathy has been observed over the entire clinical course, thrombosis might be a clue to understanding the specific pathology in COVID-19. Currently, there is limited epidemiological data of COVID-19-associated thrombosis in the Japanese population and none regarding variant strains of SARS-CoV-2. Here, we elucidate the risk factors and the pattern of thrombosis in COVID-19 patients. Methods: The patients consecutively admitted to Tokyo Medical and Dental University Hospital with COVID-19 were retrospectively analyzed. SARS-CoV-2 variants of concern/interest (VOC/VOI) carrying the spike protein mutants E484K, N501Y, or L452R were identified by PCR-based analysis. All thrombotic events were diagnosed by clinical symptoms, ultrasonography, and/or radiological tests. Results: Among the 516 patients, 32 patients experienced 42 thromboembolic events. Advanced age, severe respiratory conditions, and several abnormal laboratory markers were associated with the development of thrombosis. While thrombotic events occurred in 13% of the patients with a severe respiratory condition, those events still occurred in 2.5% of the patients who did not require oxygen therapy. Elevated D-dimer and ferritin levels on admission were independent risk factors of thrombosis (adjusted odds ratio 9.39 and 3.11, 95% confidence interval 2.08-42.3, and 1.06-9.17, respectively). Of the thrombotic events, 22 were venous, whereas 20 were arterial. While patients with thrombosis received anticoagulation and antiinflammatory therapies with a higher proportion, the mortality rate, organ dysfunctions, and bleeding complications in these patients were higher than those without thrombosis. The incidence of thrombosis in COVID-19 became less frequent over time, such as during the replacement of the earlier strains of SARS-CoV-2 by VOC/VOI and during increased use of anticoagulatory therapeutics. Conclusion: This study elucidated that elevated D-dimer and ferritin levels are useful biomarkers of thrombosis in COVID-19 patients. The comparable incidence of arterial thrombosis with venous thrombosis and the development of thrombosis in less severe patients required further considerations for the management of Japanese patients with COVID-19. Further studies would be required to identify high-risk populations and establish appropriate interventions for thrombotic complications in COVID-19.
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Affiliation(s)
- Seiya Oba
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Tadashi Hosoya
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Miki Amamiya
- Department of Cardiovascular Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Takahiro Mitsumura
- Department of Respiratory Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Daisuke Kawata
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Hirokazu Sasaki
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Mari Kamiya
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Akio Yamamoto
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Takahiro Ando
- Department of Respiratory Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Sho Shimada
- Department of Respiratory Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Tsuyoshi Shirai
- Department of Respiratory Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Tsukasa Okamoto
- Department of Respiratory Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Tomoya Tateishi
- Department of Respiratory Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Akira Endo
- Trauma and Acute Critical Care Medical Center, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Junichi Aiboshi
- Trauma and Acute Critical Care Medical Center, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Nobuyuki Nosaka
- Department of Intensive Care Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Hideo Yamanouchi
- Department of Intensive Care Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Toyomu Ugawa
- Department of Intensive Care Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Eiki Nagaoka
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Keiji Oi
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Susumu Tao
- Department of Cardiovascular Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Yasuhiro Maejima
- Department of Cardiovascular Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Yukie Tanaka
- Research Core, Institute of Research, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Kousuke Tanimoto
- Research Core, Institute of Research, Tokyo Medical and Dental University (TMDU), Tokyo, Japan.,Genome Laboratory, Medical Research Institute, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Hiroaki Takeuchi
- Department of Molecular Virology, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Shuji Tohda
- Clinical Laboratory, Tokyo Medical and Dental University (TMDU) Hospital, Tokyo, Japan
| | - Akihiro Hirakawa
- Department of Clinical Biostatistics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Tetsuo Sasano
- Department of Cardiovascular Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Hirokuni Arai
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Medical Center, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Yasunari Miyazaki
- Department of Respiratory Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Shinsuke Yasuda
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
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12
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Natarelli L, Virgili F, Weber C. SARS-CoV-2, Cardiovascular Diseases, and Noncoding RNAs: A Connected Triad. Int J Mol Sci 2021; 22:12243. [PMID: 34830125 PMCID: PMC8620514 DOI: 10.3390/ijms222212243] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 11/10/2021] [Accepted: 11/11/2021] [Indexed: 12/23/2022] Open
Abstract
Coronavirus Disease 2019 (COVID-19), caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), is characterized by important respiratory impairments frequently associated with severe cardiovascular damages. Moreover, patients with pre-existing comorbidity for cardiovascular diseases (CVD) often present a dramatic increase in inflammatory cytokines release, which increases the severity and adverse outcomes of the infection and, finally, mortality risk. Despite this evident association at the clinical level, the mechanisms linking CVD and COVID-19 are still blurry and unresolved. Noncoding RNAs (ncRNAs) are functional RNA molecules transcribed from DNA but usually not translated into proteins. They play an important role in the regulation of gene expression, either in relatively stable conditions or as a response to different stimuli, including viral infection, and are therefore considered a possible important target in the design of specific drugs. In this review, we introduce known associations and interactions between COVID-19 and CVD, discussing the role of ncRNAs within SARS-CoV-2 infection from the perspective of the development of efficient pharmacological tools to treat COVID-19 patients and taking into account the equally dramatic associated consequences, such as those affecting the cardiovascular system.
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Affiliation(s)
- Lucia Natarelli
- Institute for Cardiovascular Prevention (IPEK), Ludwig-Maximilians-Universität (LMU), 800336 Munich, Germany;
| | - Fabio Virgili
- Research Center for Food and Nutrition, Council for Agricultural Research and Economics, 00178 Rome, Italy;
| | - Christian Weber
- Institute for Cardiovascular Prevention (IPEK), Ludwig-Maximilians-Universität (LMU), 800336 Munich, Germany;
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, 80336 Munich, Germany
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6229 HX Maastricht, The Netherlands
- Munich Cluster for Systems Neurology (SyNergy), Institute for Stroke and Dementia Research, 81377 Munich, Germany
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13
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Lerch S. Schlaganfall und SARS-CoV-2. CARDIOVASC 2021. [PMCID: PMC8528558 DOI: 10.1007/s15027-021-3571-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Sven Lerch
- Abt. Neurologie, Bundeswehr-KH Berlin, Scharnhorststr. 13, 10115 Berlin, Germany
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14
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Rivera-Caravaca JM, Harrison SL, Buckley BJR, Fazio-Eynullayeva E, Underhill P, Marín F, Lip GYH. Efficacy and safety of direct-acting oral anticoagulants compared to vitamin K antagonists in COVID-19 outpatients with cardiometabolic diseases. Cardiovasc Diabetol 2021; 20:176. [PMID: 34481513 PMCID: PMC8417638 DOI: 10.1186/s12933-021-01368-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 08/23/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND It remains uncertain if prior use of oral anticoagulants (OACs) in COVID-19 outpatients with multimorbidity impacts prognosis, especially if cardiometabolic diseases are present. Clinical outcomes 30-days after COVID-19 diagnosis were compared between outpatients with cardiometabolic disease receiving vitamin K antagonist (VKA) or direct-acting OAC (DOAC) therapy at time of COVID-19 diagnosis. METHODS A study was conducted using TriNetX, a global federated health research network. Adult outpatients with cardiometabolic disease (i.e. diabetes mellitus and any disease of the circulatory system) treated with VKAs or DOACs at time of COVID-19 diagnosis between 20-Jan-2020 and 15-Feb-2021 were included. Propensity score matching (PSM) was used to balance cohorts receiving VKAs and DOACs. The primary outcomes were all-cause mortality, intensive care unit (ICU) admission/mechanical ventilation (MV) necessity, intracranial haemorrhage (ICH)/gastrointestinal bleeding, and the composite of any arterial or venous thrombotic event(s) at 30-days after COVID-19 diagnosis. RESULTS 2275 patients were included. After PSM, 1270 patients remained in the study (635 on VKAs; 635 on DOACs). VKA-treated patients had similar risks and 30-day event-free survival than patients on DOACs regarding all-cause mortality, ICU admission/MV necessity, and ICH/gastrointestinal bleeding. The risk of any arterial or venous thrombotic event was 43% higher in the VKA cohort (hazard ratio 1.43, 95% confidence interval 1.03-1.98; Log-Rank test p = 0.029). CONCLUSION In COVID-19 outpatients with cardiometabolic diseases, prior use of DOAC therapy compared to VKA therapy at the time of COVID-19 diagnosis demonstrated lower risk of arterial or venous thrombotic outcomes, without increasing the risk of bleeding.
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Affiliation(s)
- José Miguel Rivera-Caravaca
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Hospital Clínico Universitario Virgen de La Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Stephanie L Harrison
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Benjamin J R Buckley
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | | | | | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de La Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.
- Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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15
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Lopes RD, de Barros E Silva PGM, Furtado RHM, Macedo AVS, Bronhara B, Damiani LP, Barbosa LM, de Aveiro Morata J, Ramacciotti E, de Aquino Martins P, de Oliveira AL, Nunes VS, Ritt LEF, Rocha AT, Tramujas L, Santos SV, Diaz DRA, Viana LS, Melro LMG, de Alcântara Chaud MS, Figueiredo EL, Neuenschwander FC, Dracoulakis MDA, Lima RGSD, de Souza Dantas VC, Fernandes ACS, Gebara OCE, Hernandes ME, Queiroz DAR, Veiga VC, Canesin MF, de Faria LM, Feitosa-Filho GS, Gazzana MB, Liporace IL, de Oliveira Twardowsky A, Maia LN, Machado FR, de Matos Soeiro A, Conceição-Souza GE, Armaganijan L, Guimarães PO, Rosa RG, Azevedo LCP, Alexander JH, Avezum A, Cavalcanti AB, Berwanger O. Therapeutic versus prophylactic anticoagulation for patients admitted to hospital with COVID-19 and elevated D-dimer concentration (ACTION): an open-label, multicentre, randomised, controlled trial. Lancet 2021; 397:2253-2263. [PMID: 34097856 PMCID: PMC8177770 DOI: 10.1016/s0140-6736(21)01203-4] [Citation(s) in RCA: 317] [Impact Index Per Article: 105.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 05/12/2021] [Accepted: 05/13/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND COVID-19 is associated with a prothrombotic state leading to adverse clinical outcomes. Whether therapeutic anticoagulation improves outcomes in patients hospitalised with COVID-19 is unknown. We aimed to compare the efficacy and safety of therapeutic versus prophylactic anticoagulation in this population. METHODS We did a pragmatic, open-label (with blinded adjudication), multicentre, randomised, controlled trial, at 31 sites in Brazil. Patients (aged ≥18 years) hospitalised with COVID-19 and elevated D-dimer concentration, and who had COVID-19 symptoms for up to 14 days before randomisation, were randomly assigned (1:1) to receive either therapeutic or prophylactic anticoagulation. Therapeutic anticoagulation was in-hospital oral rivaroxaban (20 mg or 15 mg daily) for stable patients, or initial subcutaneous enoxaparin (1 mg/kg twice per day) or intravenous unfractionated heparin (to achieve a 0·3-0·7 IU/mL anti-Xa concentration) for clinically unstable patients, followed by rivaroxaban to day 30. Prophylactic anticoagulation was standard in-hospital enoxaparin or unfractionated heparin. The primary efficacy outcome was a hierarchical analysis of time to death, duration of hospitalisation, or duration of supplemental oxygen to day 30, analysed with the win ratio method (a ratio >1 reflects a better outcome in the therapeutic anticoagulation group) in the intention-to-treat population. The primary safety outcome was major or clinically relevant non-major bleeding through 30 days. This study is registered with ClinicalTrials.gov (NCT04394377) and is completed. FINDINGS From June 24, 2020, to Feb 26, 2021, 3331 patients were screened and 615 were randomly allocated (311 [50%] to the therapeutic anticoagulation group and 304 [50%] to the prophylactic anticoagulation group). 576 (94%) were clinically stable and 39 (6%) clinically unstable. One patient, in the therapeutic group, was lost to follow-up because of withdrawal of consent and was not included in the primary analysis. The primary efficacy outcome was not different between patients assigned therapeutic or prophylactic anticoagulation, with 28 899 (34·8%) wins in the therapeutic group and 34 288 (41·3%) in the prophylactic group (win ratio 0·86 [95% CI 0·59-1·22], p=0·40). Consistent results were seen in clinically stable and clinically unstable patients. The primary safety outcome of major or clinically relevant non-major bleeding occurred in 26 (8%) patients assigned therapeutic anticoagulation and seven (2%) assigned prophylactic anticoagulation (relative risk 3·64 [95% CI 1·61-8·27], p=0·0010). Allergic reaction to the study medication occurred in two (1%) patients in the therapeutic anticoagulation group and three (1%) in the prophylactic anticoagulation group. INTERPRETATION In patients hospitalised with COVID-19 and elevated D-dimer concentration, in-hospital therapeutic anticoagulation with rivaroxaban or enoxaparin followed by rivaroxaban to day 30 did not improve clinical outcomes and increased bleeding compared with prophylactic anticoagulation. Therefore, use of therapeutic-dose rivaroxaban, and other direct oral anticoagulants, should be avoided in these patients in the absence of an evidence-based indication for oral anticoagulation. FUNDING Coalition COVID-19 Brazil, Bayer SA.
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Affiliation(s)
- Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA; Brazilian Clinical Research Institute, São Paulo, Brazil.
| | - Pedro Gabriel Melo de Barros E Silva
- Brazilian Clinical Research Institute, São Paulo, Brazil; HCor Research Institute, São Paulo, Brazil; Hospital Samaritano Paulista, São Paulo, Brazil
| | - Remo H M Furtado
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil; Instituto do Coração, Universidade de São Paulo, São Paulo, Brazil
| | | | - Bruna Bronhara
- Brazilian Clinical Research Institute, São Paulo, Brazil
| | - Lucas Petri Damiani
- Brazilian Clinical Research Institute, São Paulo, Brazil; HCor Research Institute, São Paulo, Brazil
| | | | | | - Eduardo Ramacciotti
- Brazilian Clinical Research Institute, São Paulo, Brazil; Science Valley Research Institute, São Paulo, Brazil; Hemostasis & Thrombosis Research Laboratories at Loyola University Medical Center, Maywood, IL, USA
| | | | | | | | | | - Ana Thereza Rocha
- Hospital Cárdio Pulmonar, Salvador, Brazil; Escola Bahiana de Medicina, Salvador, Brazil; Universidade Federal da Bahia, Salvador, Brazil
| | | | | | | | - Lorena Souza Viana
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil; Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | | | | | | | | | | | | | | | | | | | | | - Viviane C Veiga
- Brazilian Research in Intensive Care Network, São Paulo, Brazil; BP-A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | | | | | - Gilson Soares Feitosa-Filho
- Escola Bahiana de Medicina, Salvador, Brazil; Santa Casa de Misericórdia da Bahia-Hospital Santa Izabel, Salvador, Brazil; Centro Universitário Faculdade de Tecnologia e Ciências, Salvador, Brazil
| | | | | | | | - Lilia Nigro Maia
- Hospital de Base de São José do Rio Preto, São José do Rio Preto, Brazil
| | - Flávia Ribeiro Machado
- Brazilian Research in Intensive Care Network, São Paulo, Brazil; Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, São Paulo, Brazil
| | | | | | | | | | - Regis G Rosa
- Brazilian Research in Intensive Care Network, São Paulo, Brazil; Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Luciano C P Azevedo
- Brazilian Research in Intensive Care Network, São Paulo, Brazil; Hospital Sírio Libanês Research and Education Institute, São Paulo, Brazil
| | - John H Alexander
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Alexandre B Cavalcanti
- HCor Research Institute, São Paulo, Brazil; Brazilian Research in Intensive Care Network, São Paulo, Brazil
| | - Otavio Berwanger
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil
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Nappi F, Iervolino A, Avtaar Singh SS. Thromboembolic Complications of SARS-CoV-2 and Metabolic Derangements: Suggestions from Clinical Practice Evidence to Causative Agents. Metabolites 2021; 11:341. [PMID: 34070672 PMCID: PMC8229698 DOI: 10.3390/metabo11060341] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/18/2021] [Accepted: 05/22/2021] [Indexed: 01/08/2023] Open
Abstract
Severe Acute Respiratory Syndrome (SARS) Coronavirus (CoV)-2 is a recently identified positive sense single-strand RNA (ssRNA) β-coronavirus. The viral spike proteins infect human hosts by binding to the cellular receptor angiotensin-converting enzyme 2 (ACE2). The infection causes a systemic illness involving cell metabolism. This widespread involvement is implicated in the pathophysiology of the illness which ranges from mild to severe, requiring multi organ support, ranging from oxygen supplementation to full cardiovascular and respiratory support. Patients with multiple co-existing comorbidities are also at a higher risk. The aim of this review is to explore the exact mechanisms by which COVID-19 affects patients systemically with a primary focus on the bleeding and thrombotic complications linked with the disease. Issues surrounding the thrombotic complications following administration of the ChAdOx1 nCoV-19 (Astra-Zeneca-Oxford) vaccine have also been illustrated. Risk stratification and treatment options in these patients should be tailored according to clinical severity with input from a multidisciplinary team.
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Affiliation(s)
- Francesco Nappi
- Centre Cardiologique du Nord de Saint-Denis, Department of Cardiac Surgery, 93200 Saint-Denis, France
| | - Adelaide Iervolino
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy;
| | - Sanjeet Singh Avtaar Singh
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Agamemnon St, Clydebank G81 4DY, UK;
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17
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Flumignan RL, Tinôco JDDS, Pascoal PI, Areias LL, Cossi MS, Fernandes MI, Costa IK, Souza L, Matar CF, Tendal B, Trevisani VF, Atallah ÁN, Nakano LC. Prophylactic anticoagulants for people hospitalised with COVID-19. Cochrane Database Syst Rev 2020; 10:CD013739. [PMID: 33502773 PMCID: PMC8166900 DOI: 10.1002/14651858.cd013739] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) is a serious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The primary manifestation is respiratory insufficiency that can also be related to diffuse pulmonary microthrombosis in people with COVID-19. This disease also causes thromboembolic events, such as pulmonary embolism, deep venous thrombosis, arterial thrombosis, catheter thrombosis, and disseminated intravascular coagulopathy. Recent studies have indicated a worse prognosis for people with COVID-19 who developed thromboembolism. Anticoagulants are medications used in the prevention and treatment of venous or arterial thromboembolic events. Several drugs are used in the prophylaxis and treatment of thromboembolic events, such as heparinoids (heparins or pentasaccharides), vitamin K antagonists and direct anticoagulants. Besides their anticoagulant properties, heparinoids have an additional anti-inflammatory potential, that may affect the clinical evolution of people with COVID-19. Some practical guidelines address the use of anticoagulants for thromboprophylaxis in people with COVID-19, however, the benefit of anticoagulants for people with COVID-19 is still under debate. OBJECTIVES To assess the effects of prophylactic anticoagulants versus active comparator, placebo or no intervention, on mortality and the need for respiratory support in people hospitalised with COVID-19. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, LILACS and IBECS databases, the Cochrane COVID-19 Study Register and medRxiv preprint database from their inception to 20 June 2020. We also checked reference lists of any relevant systematic reviews identified and contacted specialists in the field for additional references to trials. SELECTION CRITERIA Randomised controlled trials (RCTs), quasi-RCTs, cluster-RCTs and cohort studies that compared prophylactic anticoagulants (heparin, vitamin K antagonists, direct anticoagulants, and pentasaccharides) versus active comparator, placebo or no intervention for the management of people hospitalised with COVID-19. We excluded studies without a comparator group. Primary outcomes were all-cause mortality and need for additional respiratory support. Secondary outcomes were mortality related to COVID-19, deep vein thrombosis (DVT), pulmonary embolism, major bleeding, adverse events, length of hospital stay and quality of life. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. We used ROBINS-I to assess risk of bias for non-randomised studies (NRS) and GRADE to assess the certainty of evidence. We reported results narratively. MAIN RESULTS We identified no RCTs or quasi-RCTs that met the inclusion criteria. We included seven retrospective NRS (5929 participants), three of which were available as preprints. Studies were conducted in China, Italy, Spain and the USA. All of the studies included people hospitalised with COVID-19, in either intensive care units, hospital wards or emergency departments. The mean age of participants (reported in 6 studies) ranged from 59 to 72 years. Only three included studies reported the follow-up period, which varied from 8 to 35 days. The studies did not report on most of our outcomes of interest: need for additional respiratory support, mortality related to COVID-19, DVT, pulmonary embolism, adverse events, and quality of life. Anticoagulants (all types) versus no treatment (6 retrospective NRS, 5685 participants) One study reported a reduction in all-cause mortality (adjusted odds ratio (OR) 0.42, 95% confidence interval (CI) 0.26 to 0.66; 2075 participants). One study reported a reduction in mortality only in a subgroup of 395 people who required mechanical ventilation (hazard ratio (HR) 0.86, 95% CI 0.82 to 0.89). Three studies reported no differences in mortality (adjusted OR 1.64, 95% CI 0.92 to 2.92; 449 participants; unadjusted OR 1.66, 95% CI 0.76 to 3.64; 154 participants and adjusted risk ratio (RR) 1.15, 95% CI 0.29 to 2.57; 192 participants). One study reported zero events in both intervention groups (42 participants). The overall risk of bias for all-cause mortality was critical and the certainty of the evidence was very low. One NRS reported bleeding events in 3% of the intervention group and 1.9% of the control group (OR 1.62, 95% CI 0.96 to 2.71; 2773 participants; low-certainty evidence). Therapeutic-dose anticoagulants versus prophylactic-dose anticoagulants (1 retrospective NRS, 244 participants) The study reported a reduction in all-cause mortality (adjusted HR 0.21, 95% CI 0.10 to 0.46) and a lower absolute rate of death in the therapeutic group (34.2% versus 53%). The overall risk of bias for all-cause mortality was serious and the certainty of the evidence was low. The study also reported bleeding events in 31.7% of the intervention group and 20.5% of the control group (OR 1.8, 95% CI 0.96 to 3.37; low-certainty evidence). Ongoing studies We found 22 ongoing studies in hospital settings (20 RCTs, 14,730 participants; 2 NRS, 997 participants) in 10 different countries (Australia (1), Brazil (1), Canada (2), China (3), France (2), Germany (1), Italy (4), Switzerland (1), UK (1) and USA (6)). Twelve ongoing studies plan to report mortality and six plan to report additional respiratory support. Thirteen studies are expected to be completed in December 2020 (6959 participants), eight in July 2021 (8512 participants), and one in December 2021 (256 participants). Four of the studies plan to include 1000 participants or more. AUTHORS' CONCLUSIONS There is currently insufficient evidence to determine the risks and benefits of prophylactic anticoagulants for people hospitalised with COVID-19. Since there are 22 ongoing studies that plan to evaluate more than 15,000 participants in this setting, we will add more robust evidence to this review in future updates.
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Affiliation(s)
- Ronald Lg Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | - Patricia If Pascoal
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Libnah L Areias
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Marcelly S Cossi
- Department of Nursing, State University of Rio Grande do Norte, Natal, Brazil
| | - Maria Icd Fernandes
- Department of Nursing, State University of Rio Grande do Norte, Natal, Brazil
| | - Isabelle Kf Costa
- Department of Nursing, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Larissa Souza
- Department of Public Health, State University of Rio Grande do Norte, Natal, Brazil
| | - Charbel F Matar
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Britta Tendal
- Living Guidelines Program, Cochrane Australia, Melbourne, Australia
| | - Virginia Fm Trevisani
- Medicina de Urgência and Rheumatology, Escola Paulista de Medicina, Universidade Federal de São Paulo and Universidade de Santo Amaro, São Paulo, Brazil
| | - Álvaro N Atallah
- Cochrane Brazil, Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde, São Paulo, Brazil
| | - Luis Cu Nakano
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
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