Venous Thromboembolism in Hospitalized Critical and Noncritical COVID-19 Patients: A Systematic Review and Meta-analysis

Severely Ill COVID-19 Patients May Exhibit Hypercoagulability Despite Escalated Anticoagulation

Introduction: Severely ill COVID-19 patients receiving prophylactic-dose anticoagulation exhibit high rates of thrombosis and mortality. The escalation of anticoagulation also does not reduce mortality and has an uncertain impact on thrombosis rates. The reasons why escalated doses fail to outperform prophylactic doses in reducing risks of thrombosis and death in severely ill COVID-19 patients remain unclear. We hypothesized that escalated anticoagulation would not effectively prevent hypercoagulability and, consequently, would not reduce the risk of thrombosis and death in some severely ill patients. Methods: We conducted a prospective multicenter study that enrolled 3860 COVID-19 patients, including 1654 severely ill. They received different doses of low-molecular-weight or unfractionated heparin, and their blood coagulation was monitored with activated partial thromboplastin time, D-dimer, and Thrombodynamics. A primary outcome was hypercoagulability detected by Thrombodynamics. Blood samples were collected at the trough level of anticoagulation. Results: We found that escalated anticoagulation did not prevent hypercoagulability in 28.3% of severely ill patients at the trough level of the pharmacological activity. Severely ill patients with such hypercoagulability had higher levels of inflammation markers and better creatinine clearance compared to severely ill patients without it. Hypercoagulability detected by Thrombodynamics was associated with a 1.68-fold higher hazard rate for death and a 3.19-fold higher hazard rate for thrombosis. Elevated D-dimer levels were also associated with higher hazard rates for thrombosis and death, while shortened APTTs were not. The simultaneous use of Thrombodynamics and D-dimer data enhanced the accuracy for predicting thrombotic events and fatal outcomes in severely ill patients. Conclusions: Thrombodynamics reliably detects hypercoagulability in COVID-19 patients and can be used in conjunction with D-dimer to assess the risk of thrombosis and death in severely ill patients. The pharmacological effect of LMWH at the trough level might be too low to prevent thrombosis in some severely ill patients with severe inflammation and better creatinine clearance, even if escalated doses are used.

Development of venous thromboembolism and its impact on hospitalized adults with covid-19: rapid systematic review

The association between COVID-19 and coagulation disorders has been discussed since the onset of the pandemic. Four years into the pandemic, it is crucial to organize the findings and evidence accumulated thus far. The objective of this study was to review and synthesize the available scientific evidence regarding the relationship between COVID-19 and development of venous thromboembolism (VTE). A rapid systematic review was conducted by searching two electronic databases, selecting systematic review articles that assessed the association between COVID-19 and development of VTE, such as deep vein thrombosis (DVT) or pulmonary embolism (PE). The studies indicated that hospitalized COVID-19 patients are at greater risk of developing VTE, especially those admitted to intensive care units (ICUs). Elevated D-dimer levels and male gender were also associated with increased risks.

Trends in the Diagnosis of Pediatric Venous Thromboembolism and Arterial Ischemic Stroke during the COVID-19 Pandemic: An Administrative Database Study

OBJECTIVE

To investigate trends in the diagnosis of venous thromboembolism (VTE) and arterial ischemic stroke (AIS), and examine the use of pharmacological thromboprophylaxis during the COVID-19 pandemic.

STUDY DESIGN

This retrospective cohort study used the Pediatric Health Information Systems database to investigate patients admitted to a participating hospital between January 1, 2018, and December 31, 2021. International Classification of Diseases, 10th edition codes were used to identify VTE, AIS, and COVID-19. Pharmacy billing codes were used to investigate pharmacological thromboprophylaxis use.

RESULTS

1 759 701 unique patients underwent 2 234 135 inpatient admissions. Rate of VTE increased from 84 cases per 10 000 admissions in 2018-2019 to 108 cases per 10 000 admissions in 2020-2021, representing a 28.6% increase (P < .001). In contrast, the rate of AIS remained stable through the study period. When compared with 2018-2019, children diagnosed with VTE during 2020-2021 had longer hospitalizations and were more likely to be admitted to the intensive care unit. When analysis was limited to 2020-2021, a diagnosis code of COVID-19 was associated with a 1.35-fold (95% CI: 1.24-1.45) increase in the odds of VTE diagnosis, but not AIS. Use of pharmacologic thromboprophylaxis increased from 1.5% of hospitalizations in 2018-2019 to 3.0% of hospitalizations in 2020-2021 (P < .001). When evaluating thromboprophylaxis during 2020-2021, a diagnosis code for COVID-19 was associated with an 11-fold (95% CI: 10.86-11.49; P < .001) increase in the utilization of pharmacological thromboprophylaxis.

CONCLUSIONS

This study found an increase in the rate of VTE among hospitalized children during the pandemic. A diagnosis of COVID-19 was associated with a modest increase in odds of VTE diagnosis, which occurred despite increased use of pharmacological thromboprophylaxis.

Incidental venous thrombosis in oncology in a sub-Saharan tertiary hospital

The relationship between cancer and thrombosis was initially highlighted in the 19th century. Vascular complications in oncology can be arterial or venous thrombosis, and incidental pulmonary embolism is a growing challenge. We aimed to describe the frequency and clinical characteristics of cancer patients with incidental venous thromboembolism (iVTE). We conducted a descriptive study at the Yaounde General Hospital. We included patients with a confirmed diagnosis of cancer, followed up on an outpatient basis, in whom an iVTE was identified on a computed tomography scan performed to evaluate tumour status over a 6-month period. Of the 359 patients, 19 had venous thromboses, representing a frequency of 5.3%. The mean age was 51.2 years. The sex ratio was 1.1 in favour of males. Comorbidities found were diabetes, hypertension and obesity. Colon cancer (5), ovarian cancer (3) and lung cancer (3) were the most frequent diagnoses. All patients had advanced disease with 14 (73.7%) being naive to anticancer treatment. Pulmonary arteries were the most affected vessel (63.1%). The frequency of iVTE in a sub-Saharan context was around 5%.

Extracellular histones: a unifying mechanism driving platelet-dependent extracellular vesicle release and thrombus formation in COVID-19

BACKGROUND

COVID-19 can cause profound inflammation and coagulopathy, and while many mechanisms have been proposed, there is no known common pathway leading to a prothrombotic state.

OBJECTIVES

From the beginning of the COVID-19 pandemic, elevated levels of extracellular histones have been found in plasma of patients infected with SARS-CoV-2. We hypothesized that platelet activation triggered by extracellular histones might represent a unifying mechanism leading to increased thrombin generation and thrombosis.

METHODS

We utilized blood samples collected from an early clinical trial of hospitalized COVID-19 patients (NCT04360824) and recruited healthy subjects as controls. Using plasma samples, we measured the procoagulant and prothrombotic potential of circulating extracellular histones and extracellular vesicles (EVs). Platelet prothrombotic activity was assessed via thrombin generation potential and platelet thrombus growth. Circulating EVs were assessed for thrombin generation potential in vitro in plasma and enhancement of thrombotic susceptibility in vivo in mice.

RESULTS

Compared with controls, COVID-19 patients had elevated plasma levels of citrullinated histone H3, cell-free DNA, nucleosomes, and EVs. Plasma from COVID-19 patients promoted platelet activation, platelet-dependent thrombin generation, thrombus growth under venous shear stress, and release of platelet-derived EVs. These prothrombotic effects of COVID-19 plasma were inhibited by an RNA aptamer that neutralizes both free and DNA-bound histones. EVs isolated from COVID-19 plasma enhanced thrombin generation in vitro and potentiated venous thrombosis in mice in vivo.

CONCLUSION

We conclude that extracellular histones and procoagulant EVs drive the prothrombotic state in COVID-19 and that histone-targeted therapy may prove beneficial.

Perinatal outcomes among pregnant patients with peripartum coronavirus disease 2019 infection

PURPOSE

Evaluate maternal and neonatal outcomes in peripartum coronavirus disease 2019 (COVID-19) positive women.

METHODS

A retrospective cohort study was conducted, comparing outcomes between women with and without peripartum COVID-19. All singleton deliveries from June 2020 to January 2022 were included. Univariate analysis was followed by multivariate analysis.

RESULTS

Of 26,827 singleton deliveries, 563 women had peripartum COVID-19, associated with preterm deliveries both near-term and remote from term [adjusted odds ratio (aOR) 1.6 and 2.0, respectively, p = 0.007 and 0.003]. Women with peripartum COVID-19 had a significantly higher rate of disseminated intravascular coagulation (DIC) (aOR 23.0, p < 0.001). Conversely, peripartum COVID-19 peripartum COVID-19 was negatively associated with premature rupture of membranes and prolonged maternal length of stay (aOR 0.7 and 0.5, respectively, p = 0.006 and <0.001). In cesarean delivery (CDs), patients with COVID-19 had higher rate of urgent CDs (75.5 vs. 56.1%, p < 0.001), higher rate of regional anesthesia (74.5 vs. 64.9%, p = 0.049), and longer anesthesia duration (86.1 vs. 53.4 min, p < 0.001). CD rate due to non-reassuring fetal heart rate (NRFHR) was significantly higher in women with COVID-19 (29.6 vs. 17.4%, p = 0.002). Conversely, CDs rate due to history of previous single CD was significantly higher in patients without COVID-19 diagnosis (13.6 vs. 4.1%, p = 0.006). Concerning neonatal outcomes, an association has been observed between COVID-19 and low one-minute APGAR score <5, as well as neonatal COVID-19 infection (aOR 61.8 and 1.7 respectively, p < 0.001 and p = 0.037).

CONCLUSIONS

Peripartum COVID-19 is associated with preterm deliveries, urgent CDs and DIC, potentially aligning with the infection's pathophysiology and coagulation alterations.

Associations between prior COVID-19 infection and venous thromboembolism following common plastic surgery operations

INTRODUCTION

SARS-CoV-2 (COVID-19) infection has been described as a cause of systemic hypercoagulability and a risk factor for the development of venous thromboembolism (VTE). Whereas some multispecialty studies have proposed a link between COVID-19 and postoperative thrombosis, other single-specialty studies have found no such association. We utilized a large national database to determine whether prior COVID-19 infection was associated with the incidence of VTE following common plastic surgery operations.

METHODS

The Merative™ MarketScan® Research Databases were used to identify female patients who underwent index abdominal panniculectomy, breast reduction, autologous breast reconstruction, or implant-based breast reconstruction procedures between 2020 and 2021. International Classification of Disease, tenth edition (ICD-10) codes were used to identify patients diagnosed with COVID-19 preoperatively and those who experienced a VTE in the 90 days postoperatively. Propensity score matching and multivariable logistic regression were used to determine any independent association between COVID-19 and postoperative VTE.

RESULTS

Twenty-four thousand two hundred and twenty-eight patients met inclusion criteria. Mean age at time of surgery was 44 years. Six percent carried a preoperative COVID-19 diagnosis, and postoperative VTE occurred in 1.3%. In a propensity-score-matched analysis of 2754 patients, COVID-19 did not significantly correlate with incidence of postoperative VTE (P = 0.463). Compared with a matched prepandemic cohort (14,151 patients), the incidence of VTE did not increase following any of the four studied procedures during the COVID-19 pandemic.

CONCLUSION

This analysis of a national insurance claims database provides evidence against a link between resolved COVID-19 infection and VTE within 90 days of four common plastic surgery operations.

Venous thromboembolism in Black COVID-19 patients in a minority context compared to White, Asian and other racialized patients: A systematic review and meta-analysis

IMPORTANCE

COVID-19 has disproportionately affected racialized populations, with particular impact among individuals of Black individuals. However, it is unclear whether disparities in venous thromboembolic (VTE) complications exist between Black individuals and those belonging to other racial groups with confirmed SARS-CoV2 infections.

OBJECTIVE

To summarize the prevalence and moderators associated with VTE among Black COVID-19 patients in minoritized settings, and to compare this to White and Asian COVID-19 patients according to sex, age, and comorbid health conditions (heart failure, cancer, obesity, hypertension).

DESIGN SETTING, AND PARTICIPANTS

A systematic search of MEDLINE, Embase, CINAHL and CENTRAL for articles or reports published from inception to February 15, 2023.

STUDY SELECTION

Reports on VTE among Black individuals infected with SARS-CoV2, in countries where Black people are considered a minority population group.

DATA EXTRACTION AND SYNTHESIS

Study characteristics and results of eligible studies were independently extracted by 2 pairs of reviewers. VTE prevalence was extracted, and risk of bias was assessed. Prevalence estimates of VTE prevalence among Black individuals with COVID19 in each study were pooled. Where studies provided race-stratified VTE prevalence among COVID19 patients, odds ratios were generated using a random-effects model.

MAIN OUTCOMES AND MEASURES

Prevalence of VTE, comprising of deep vein thrombosis and pulmonary embolism.

RESULTS

Ten studies with 66,185 Black individuals reporting the prevalence of COVID-19 associated VTE were included. Weighted median age of included studies was 47.60. Pooled prevalence of COVID-19 associated VTE was 7.2 % (95 % CI, 3.8 % - 11.5 %) among Black individuals. Among individuals with SARS-CoV2 infections, Black population had higher risks of VTE compared to their White (OR = 1.79, [95 % CI 1.28-2.53], p < .001) or Asian (OR = 2.01, [95 % CI, 1.14-3.60], p = .017) counterparts, or patients with other racial identities (OR = 2.01, [95 % CI, 1.39, 2.92]; p < .001).

CONCLUSIONS AND RELEVANCE

Black individuals with COVID-19 had substantially higher risk of VTE compared to White or Asian individuals. Given racial disparities in thrombotic disease burden related to COVID-19, medical education, research, and health policy interventions are direly needed to ensure adequate disease awareness among Black individuals, to facilitate appropriate diagnosis and treatment among Black patients with suspected and confirmed VTE, and to advocate for culturally safe VTE prevention strategies, including pre-existing inequalities to the COVID-19 pandemic that persist after the crisis.

[Une combinaison très rare de thrombose veineuse et artérielle chez un patient atteint du COVID 19]

COVID-19 is an infectious disease caused by the SARS-CoV-2 virus. This epidemic has caused serious socio-economic problems worldwide, with a very high mortality rate. Several articles have been published in the literature showing the consequences of this disease on the human body. Among the most serious complications are venous and arterial thrombosis, which are rarely observed together in the same patient. In this article, we report an exceptional case of a patient with COVID-19 with the combination of intracardiac thrombus (left atrium) and venous thrombosis (splenic vein and portal trunk).

Evaluating thromboprophylaxis in the sickle cell disease population: Navigating the evidence gap

Sickle cell disease (SCD) arises from beta-globin gene mutations, with global estimates indicating around 500 000 affected neonates in 2021. In the United States, it is considered rare, impacting fewer than 200 000 individuals. The key pathogenic flaw lies in mutant haemoglobin S, prone to polymerization under low oxygen conditions, causing erythrocytes to adopt a sickled shape. This leads to complications like vascular occlusion, haemolytic anaemia, inflammation and organ damage. Beyond erythrocyte abnormalities however, there is a body of literature highlighting the hypercoagulable state that is likely a contributor to many of the complications we see in SCD. The persistent activation of the coagulation cascade results in thromboembolic events, notably venous thromboembolism (VTE) which is independently associated with increased mortality in both adults and children with SCD. While the increased risk of VTE in the SCD population seems well established, there is a lack of guidelines for thromboprophylaxis in this population. This Wider Perspective will describe the hypercoagulable state and increased thrombosis risk in the SCD population, as well as advocate for the development of evidence-based guidelines to aid in the prevention of VTE in SCD.

Cervical Spine Surgery Following COVID-19 Infection: When is it Safe to Proceed?

STUDY DESIGN

Retrospective.

OBJECTIVE

We utilized the NIH National COVID Cohort Collaborative (N3C) database to characterize the risk profile of patients undergoing spine surgery during multiple time windows following the COVID-19 infection.

SUMMARY OF BACKGROUND DATA

While the impact of COVID-19 on various organ systems is well documented, there is limited knowledge regarding its effect on perioperative complications following spine surgery or the optimal timing of surgery after an infection.

METHODS

We asked the National COVID Cohort Collaborative for patients who underwent cervical spine surgery. Patients were stratified into those with an initial documented COVID-19 infection within 3 time periods: 0-2 weeks, 2-6 weeks, or 6-12 weeks before surgery.

RESULTS

A total of 29,449 patients who underwent anterior approach cervical spine surgery and 46,379 patients who underwent posterior approach cervical spine surgery were included. Patients who underwent surgery within 2 weeks of their COVID-19 diagnosis had a significantly increased risk for venous thromboembolic events, sepsis, 30-day mortality, and 1-year mortality, irrespective of the anterior or posterior approach. Among patients undergoing surgery between 2 and 6 weeks after COVID-19 infection, the 30-day mortality risk remained elevated in patients undergoing a posterior approach only. Patients undergoing surgery between 6 and 12 weeks from the date of the COVID-19 infection did not show significantly elevated rates of any complications analyzed.

CONCLUSIONS

Patients undergoing either anterior or posterior cervical spine surgery within 2 weeks from the initial COVID-19 diagnosis are at increased risk for perioperative venous thromboembolic events, sepsis, and mortality. Elevated perioperative complication risk does not persist beyond 2 weeks, except for 30-day mortality in posterior approach surgeries. On the basis of these results, it may be warranted to postpone nonurgent spine surgeries for at least 2 weeks following a COVID-19 infection and advise patients of the increased perioperative complication risk when urgent surgery is required.

Bacterial infections as a risk factor for non-neoplastic portal vein thrombosis development in cirrhotic patients

BACKGROUND

Portal vein thrombosis (PVT) and sepsis are common complications in patients with liver cirrhosis. Factors that lead to PVT are not completely understood. This study aimed to investigate the possible association between bacterial infections and the development of PVT in cirrhotic patients.

PATIENTS AND METHODS

202 consecutive cirrhotic patients without previous infections, followed at the Liver Unit in Verona Hospital, were enrolled from 2017 to 2021 (median follow-up 3.3 years). During the follow-up period, PVT was diagnosed by ultrasound, CT and/or MRI, and episodes of bacterial infections requiring hospitalization were recorded. Malignant PVT was an exclusion criterion.

RESULTS

Of the 202 patients enrolled (68.3 % males, mean age 63.8 ± 11 years), 22 (10.8 %) developed PVT during the follow up. In patients with PVT, the prevalence of previous bacterial infections was significantly higher compared to patients without PVT (63.6% vs 31.1 %; p = 0.02). Cox regression analysis revealed that a history of bacterial infection was the only variable that demonstrated a significant association with the risk of de novo PVT occurrence (HR 4.04, 95 % CI: 1.68-9.65).

CONCLUSION

in patients with liver cirrhosis bacterial infections are a predisposing factor for the following development of PVT. Further studies are needed to confirm this evidence.

Prior COVID-19 and Venous Thromboembolism Risk in Total Joint Arthroplasty in Patients Over 65 Years of Age

BACKGROUND

The COVID-19 pandemic has been associated with increased risks of venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE). However, there is limited literature investigating prothrombotic states and complications after total hip arthroplasty (THA) and total knee arthroplasty (TKA). We investigated (1) trends in VTE, PE, and DVT rates post-THA and TKA from 2016 to 2019 compared to 2020 to 2021 and (2) associations between prior COVID-19 diagnosis and VTE, PE, and DVT.

METHODS

A national dataset was queried for elective THA and TKA cases from 2016 to 2021. We first assessed trends in 90-day VTE prevalence between 2016 to 2019 and 2020 to 2021. Second, we investigated associations between previous COVID-19 and 90-day VTE with regression models.

RESULTS

From 2016 to 2021, a total of 2,422,051 cases had an annual decreasing VTE prevalence from 2.2 to 1.9% (THA) and 2.5 to 2.2% (TKA). This was evident for both PE and DVT (all trend tests P < .001). After adjusting for covariates (including vaccination status), prior COVID-19 was associated with significantly increased odds of developing VTE in TKA patients (odds ratio 1.2, 95% confidence interval 1.1 to 1.4, P = .007), but not DVT or PE (P > .05). There were no significant associations between prior COVID-19 and VTE, DVT, or PE after THA (P > .05).

CONCLUSIONS

Our study suggests that a previous diagnosis of COVID-19 is associated with increased odds of VTE, but not DVT or PE, in TKA patients. Ongoing data monitoring is needed given our effect estimates, emerging COVID-19 variants, and evolving vaccination rates.

COVID-19 and the brain: understanding the pathogenesis and consequences of neurological damage

SARS-CoV-2 has been known remarkably since December 2019 as a strain of pathogenic coronavirus. Starting from the earlier stages of the COVID-19 pandemic until now, we have witnessed many cases of neurological damage caused by SARS-CoV-2. There are many studies and research conducted on COVID-19-positive-patients that have found brain-related abnormalities with clear neurological symptoms, ranging from simple headaches to life-threatening strokes. For treating neurological damage, knowing the actual pathway or mechanism of causing brain damage via SARS-CoV-2 is very important. For this reason, we have tried to explain the possible pathways of brain damage due to SARS-CoV-2 with mechanisms and illustrations. The SARS-CoV-2 virus enters the human body by binding to specific ACE2 receptors in the targeted cells, which are present in the glial cells and CNS neurons of the human brain. It is found that direct and indirect infections with SARS-CoV-2 in the brain result in endothelial cell death, which alters the BBB tight junctions. These probable alterations can be the reason for the excessive transmission and pathogenicity of SARS-CoV-2 in the human brain. In this precise review, we have tried to demonstrate the neurological symptoms in the case of COVID-19-positive-patients and the possible mechanisms of neurological damage, along with the treatment options for brain-related abnormalities. Knowing the transmission mechanism of SARS-CoV-2 in the human brain can assist us in generating novel treatments associated with neuroinflammation in other brain diseases.

Whole blood viscoelastic testing profile and mortality in patients hospitalized with acute COVID-19 pneumonia: A systematic review and meta-analysis

BACKGROUND

Several studies have evaluated the possible association between whole blood viscoelastic testing (VET) parameters in patients hospitalized for acute Coronavirus disease 2019 (COVID-19) pneumonia and mortality. A few studies found no significant differences between survivors and non-survivors, though other studies identified potential predictors of COVID-19-related mortality. We conducted a systematic review and meta-analysis of the literature to evaluate the possible association between standard thromboelastometry/graphy parameters and mortality in patients hospitalized for acute COVID-19 pneumonia.

METHODS

Relevant studies were searched through MEDLINE, EMBASE, and Google Scholar from their inception until 15th June 2023. We aimed to identify any study including: i) adults admitted to intensive care units (ICU) or medicine wards (MW) for acute COVID-19 pneumonia; ii) viscoelastic testing; iii) mortality.

RESULTS

We included 13 studies: nine prospective and four retrospective, 231 (30.4 %) non-survivors and 528 (69.6 %) survivors. Mortality rates ranged from 12.8 % to 67.5 %. The studies using the TEG apparatus found a significant difference in K time in the Kaolin test among survivors vs. non-survivors (mean difference [MD] 0.20, 95 % confidence interval [CI] 0.12, 0.28, I2 0%). The studies using the rotational thromboelastometry apparatus found a significant difference in CT-INTEM (MD -17.14, 95 % CI -29.23, -5.06, I2 0%) and LI60-EXTEM (MD -1.00, 95 % CI -1.00, -1.00, I2 0%) assays among survivors vs. non-survivors.

CONCLUSION

We identified no specific hypercoagulable or hypocoagulable profile associated with mortality in patients with COVID-19-related pneumonia. Large prospective studies are needed to explore the possible prognostic role of VET in this subset of patients.

Which are the optimal thromboprophylaxis strategies for hospitalized patients with COVID-19? current controversies

Novel coronavirus 2019 (COVID-19) represents a significant risk factor for the development of venous thromboembolism (VTE) in hospitalized with both moderate and severe/critical COVID-19. Herein, we present a brief updated review on emerging robust data on diverse thromboprophylaxis strategies used to mitigate VTE complications, as well as a personal point of view of current controversies in regards the use of therapeutic and prophylactic anticoagulation strategies, particularly in the moderately-ill subgroup of patients with COVID-19.

Thrombo-inflammatory response in hospitalised patients with COVID-19: a single institution experience

BACKGROUND

Severe COVID-19 causes acute inflammation, which is complicated by venous thromboembolism events (VTE). However, it is unclear if VTE risk has evolved over time since the COVID-19 outbreak.

AIMS

To determine markers of thrombo-inflammation and rates of symptomatic VTE in patients hospitalised for COVID-19 in a metropolitan hospital in Sydney, Australia.

METHODS

A retrospective, single-centre, cohort study was performed by reviewing electronic medical records of consecutive patients admitted to Royal Prince Alfred Hospital between March 2020 and September 2021. This period included three waves of COVID-19 outbreaks in Australia with the ancestral, alpha and delta variants. Standard coagulation assays and inflammatory markers were recorded over 4 weeks.

RESULTS

A total of 205 patients were consecutively admitted during the study period. Activated partial thromboplastin time, neutrophil count and C-reactive protein (CRP) were significantly increased in patients hospitalised in the intensive care unit (ICU) compared with non-ICU patients. The use of anti-inflammatory medication increased in 2021 compared with 2020. The mortality rate was 7.3% in our cohort. Ninety-four per cent of patients received anticoagulation with 6.3% of patients developing VTE.

CONCLUSION

We observed lower rates of VTE compared to the internationally reported rate for the same period. We conclude that in the setting of controlled hospital admission rate and standard anticoagulation guidelines, COVID-19 resulted in similar thrombo-inflammatory response and VTE rates over the first 1.5 years of the pandemic.

Prevalence of Pulmonary Embolism in COVID-19 at Quaternary Hospital Running Head: Pulmonary Embolism in COVID-19

Background

Patients with COVID-19 are at greater risk of pulmonary embolism.

Objective

The aim of the present study was to evaluate the monthly prevalence of pulmonary embolism diagnosed by angiotomography and mortality between March 2020 and May 2021 in more than 6000 patients hospitalized with COVID-19 at a single institution.

Methods

A clinical trial was conducted with evaluated medical records the patients hospitalized at the institution who developed pulmonary embolism determined by angiotomography. Monthly and overall mortality rates between March 2020 and May 2021 in this population were evaluated.

Results

A total of 6040 patients were hospitalized in this period, 203 of whom (3.36%) had an angiotomographic diagnosis of pulmonary embolism and 119 of these patients (58.62%) died. The largest number of patients with pulmonary embolism occurred in the periods from July to September 2020 and March to May 2021. No significant difference was found between mortality and the two peaks of the pandemic (p = 0.9, Fisher's exact test).

Conclusion

Pulmonary embolism is associated a higher mortality rate among patients with COVID-19. Therefore, one of the strategies is an emphasis on the prevention of thrombotic and embolic events.

Death and Venous Thromboembolism Analyses among Hospitalized COVID-19-Positive Patients: A Multicenter Study

BACKGROUND

Coagulation disorders are frequently encountered among patients infected with coronavirus disease 2019 (COVID-19), especially among admitted patients with more severe symptoms. This study aims to determine the mortality rate and incidence and risk factors for venous thromboembolism (VTE) in hospitalized patients with COVID-19.

METHODS

This retrospective observational cohort study was conducted from March to July 2020 using a hospital database. All adult patients (>18 years old) with laboratory-confirmed COVID-19 were included. Laboratory data and the real-time reverse transcriptase-polymerase chain reaction (rRT-PCR) for SARS-CoV-2 were obtained from medical records. The mortality rate and the incidence of VTE were established as study results. A multivariate logistic regression analysis was performed to identify predictors of thrombotic events.

RESULTS

rA total of 1024 confirmed COVID-19 patients were treated, of whom 110 (10.7%) were deceased and 58 patients (5.7%) developed VTE. Death occurred more frequently in patients older than 50 years and those admitted to the intensive care unit (ICU, 95%) and who received mechanical ventilation (62.7%). Multivariate analysis revealed that cancer patients were two times more likely to have VTE (adjusted odds ratio = 2.614; 95% CI = (1.048-6.519); p = 0.039). Other chronic diseases, such as diabetes, hypertension, and chronic kidney disease, were not associated with an increased risk of VTE.

CONCLUSIONS

One-tenth of hospitalized COVID-19 patients were deceased, and VTE was prevalent among patients with chronic conditions, such as cancer, despite anticoagulation therapy. Healthcare professionals should closely monitor individuals with a high risk of developing VTE to prevent unwanted complications.

A temporal analysis of perioperative complications following COVID-19 infection in patients undergoing lumbar spinal fusion: When is it safe to proceed?

Background Context

COVID-19 has been shown to adversely affect multiple organ systems, yet little is known about its effect on perioperative complications after spine surgery or the optimal timing of surgery after an infection. We used the NIH National COVID Cohort Collaborative (N3C) database to characterize the risk profile in patients undergoing spine surgery during multiple time windows following COVID-19 infection.

Methods

We queried the National COVID Cohort Collaborative, a database of 17.4 million persons with 6.9 million COVID-19 cases, for patients undergoing lumbar spinal fusion surgery. Patients were stratified into those with an initial documented COVID-19 infection within 3 time periods: 0 to 2 weeks, 2 to 6 weeks, or 6 to 12 weeks before surgery.

Results

A total of 60,541 patients who underwent lumbar spinal fusion procedures were included. Patients who underwent surgery within 2 weeks of their COVID-19 diagnosis had a significantly increased risk for venous thromboembolic events (OR 2.29, 95% CI 1.58-3.32), sepsis (OR 1.56, 95% CI 1.03-2.36), 30-day mortality (OR 5.55, 95% CI 3.53-8.71), and 1-year mortality (OR 2.70, 95% CI 1.91-3.82) compared with patients who were COVID negative during the same period. There was no significant difference in the rates of acute kidney injury or surgical site infection. Patients undergoing surgery between 2 and 6 weeks or between 6 and 12 weeks from the date of COVID-19 infection did not show significantly elevated rates of any complication analyzed.

Conclusions

Patients undergoing lumbar spinal fusion within 2 weeks from initial COVID-19 diagnosis are at increased risk for perioperative venous thromboembolic events and sepsis. This effect does not persist beyond 2 weeks, however, so it may be warranted to postpone non-urgent spine surgeries for at least 2 weeks following a COVID-19 infection or to consider a more aggressive VTE chemoprophylaxis regimen for urgent surgery in COVID-19 patients.

Low dose aspirin and clinical outcomes in patients with SARS-CoV-2 pneumonia: a propensity score-matched cohort analysis from the National SIMI‑COVID‑19 Registry

BACKGROUND

SARS- CoV-2 virus has had dramatic consequences worldwide being able to cause acute respiratory distress syndrome (ARDS), massive thrombosis and pulmonary embolism and, finally, patients' death. In COVID-19 infection, platelets have a procoagulant phenotype that can cause thrombosis in the pulmonary and systemic vascular network. Aspirin is a well-known anti-platelet drug widely used for the prevention of cardiovascular events and systematic reviews suggest a possible benefit of low-dose aspirin (LDA) use in the prevention and treatment of ARDS in patients with COVID-19 infection. However, several studies are available in the literature which do not support any benefits and no association with the patients' outcome. Therefore, currently available data are inconclusive.

MATERIALS AND PATIENTS

Data from the nationwide cohort multicenter study of the Italian Society of Internal Medicine (SIMI) were analyzed. We conducted a propensity score-matched cohort analysis to investigate the impact of chronic assumption of LDA on mortality of adult COVID-19 patients admitted in Internal Medicine Units (IMU). Data from 3044 COVID-19 patients who referred to 41 Italian hospitals between February 3rd to May 8th 2020 were analyzed. A propensity score-matched analysis was conducted using the following variables: age, sex, hypertension, hyperlipidemia diabetes, atrial fibrillation, cerebrovascular disease, COPD, CKD and stratified upon LDA usage, excluding anticoagulant treatment. After matching, 380 patients were included in the final analysis (190 in LDA group and 190 in no-LDA group).

RESULTS

66.2% were male, median age was 77 [70-83]. 34.8% of the population died during the hospitalization. Cardiovascular diseases were not significantly different between the groups. After comparison of LDA and no-LDA subgroups, we didn't record a significant difference in mortality rate (35.7% vs 33.7%) duration of hospital stay and ICU admission. In a logistic regression model, age (OR 1.05; 95% CI 1.01-1.09), FiO2 (OR 1.024; 95% CI 1.03-1.04) and days between symptoms onset and hospitalization (OR 0.93; 95% CI 0.87-0.99) were the only variables independently associated with death.

Incidence and Risk Factors Associated with Thromboembolic Events among Patients with COVID-19 Inpatients: A Retrospective Study

Aims and objectives

Despite thromboprophylaxis, some severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) patients develop thrombotic complications with poor prognosis. Our goal is to comprehensively assess the incidence, risk factors, and clinical outcomes associated with thromboembolic events (TE) among adult patients presenting with coronavirus disease-2019 (COVID-19).

Materials and methods

The study was conducted as an observational and retrospective study across COVID-19 patients (n = 207) in a tertiary care hospital in the Middle East and North Africa (MENA) region. Electronic health records were collected from the COVID-19 Database from April 2020 to December 2020 which included clinical history and TE.

Results

Fifty-six (27.05%) out of 207 patients (age: 54.42 ± 15.01 years) developed TE despite the anticoagulant therapy. The incidence of venous thromboembolism (VTE) was significantly higher for patients aged >50 years compared to <50 years (73.21% vs 26.79%, p < 0.05). There were no differences in the incidence of VTE between genders (p = 0.561). 165 patients (79.71%) received anticoagulant therapy, yet 48 (29%) developed TE. The most commonly used anticoagulant was low-molecular-weight heparin (LMWH, 47.34%). In spite of efficient treatment and medical management, the majority of patients with TE (45 out of 56 patients, 80.35%) experienced mortality. The comorbidities that significantly increase the risk of TE include hypertension (HTN) and ischemic heart disease (IHD). The laboratory parameters that were associated with an increased risk of VTE include ferritin, lactate dehydrogenase (LDH), and creatinine.

Conclusion

The COVID-19 patients develop thrombotic complications. Future studies should clarify the underlying mechanisms of TE and optimize the antithrombotic regimens in COVID-19 patients.

How to cite this article

Tashkandi WA. Incidence and Risk Factors Associated with Thromboembolic Events among Patients with COVID-19 Inpatients: A Retrospective Study. Indian J Crit Care Med 2023;27(11):830-836.

Aortic Thrombosis Associated with Three Types of COVID-19 Vaccine

Aortic thrombosis has been studied little in patients with COVID-19 and an association has recently been reported with the vaccine for this disease. The aim of the present study is to report five cases of aortic thrombosis at our institution within a three-month period associated with the COVID-19 vaccine. Five cases of aortic thrombosis were evaluated-three women and two men aged 29, 49, 51, 60, and 79 years. Four thrombi involved the thoracic aortic and one involved the abdominal aorta, with embolisms found in the kidneys, spleen, liver, upper limbs, and lower limbs. Embolectomy was performed on the limbs, and anticoagulant therapy was performed for the abdominal arteries. The patients recovered well and anticoagulant therapy was maintained. Aortic thrombosis is uncommon but was associated with the AstraZeneca vaccine in this case series.

National Trends in Anticoagulation Therapy for COVID-19 Hospitalized Adults in the United States: Analyses of the National COVID Cohort Collaborative

BACKGROUND

Anticoagulation (AC) utilization patterns and their predictors among hospitalized coronavirus disease 2019 (COVID-19) patients have not been well described.

METHODS

Using the National COVID Cohort Collaborative, we conducted a retrospective cohort study (2020-2022) to assess AC use patterns and identify factors associated with therapeutic AC employing modified Poisson regression.

RESULTS

Among 162 842 hospitalized COVID-19 patients, 64% received AC and 24% received therapeutic AC. Therapeutic AC use declined from 32% in 2020 to 12% in 2022, especially after December 2021. Therapeutic AC predictors included age (relative risk [RR], 1.02; 95% confidence interval [CI], 1.02-1.02 per year), male (RR, 1.29; 95% CI, 1.27-1.32), non-Hispanic black (RR, 1.16; 95% CI, 1.13-1.18), obesity (RR, 1.48; 95% CI, 1.43-1.52), increased length of stay (RR, 1.01; 95% CI, 1.01-1.01 per day), and invasive ventilation (RR, 1.64; 95% CI, 1.59-1.69). Vaccination (RR, 0.88; 95% CI, 84-.92) and higher Charlson Comorbidity Index (CCI) (RR, 0.98; 95% CI, .97-.98) were associated with lower therapeutic AC.

CONCLUSIONS

Overall, two-thirds of hospitalized COVID-19 patients received any AC and a quarter received therapeutic dosing. Therapeutic AC declined after introduction of the Omicron variant. Predictors of therapeutic AC included demographics, obesity, length of stay, invasive ventilation, CCI, and vaccination, suggesting AC decisions driven by clinical factors including COVID-19 severity, bleeding risks, and comorbidities.

Systemic Anticancer Therapy and Thromboembolic Outcomes in Hospitalized Patients With Cancer and COVID-19

Importance

Systematic data on the association between anticancer therapies and thromboembolic events (TEEs) in patients with COVID-19 are lacking.

Objective

To assess the association between anticancer therapy exposure within 3 months prior to COVID-19 and TEEs following COVID-19 diagnosis in patients with cancer.

Design, Setting, and Participants

This registry-based retrospective cohort study included patients who were hospitalized and had active cancer and laboratory-confirmed SARS-CoV-2 infection. Data were accrued from March 2020 to December 2021 and analyzed from December 2021 to October 2022.

Exposure

Treatments of interest (TOIs) (endocrine therapy, vascular endothelial growth factor inhibitors/tyrosine kinase inhibitors [VEGFis/TKIs], immunomodulators [IMiDs], immune checkpoint inhibitors [ICIs], chemotherapy) vs reference (no systemic therapy) in 3 months prior to COVID-19.

Main Outcomes and Measures

Main outcomes were (1) venous thromboembolism (VTE) and (2) arterial thromboembolism (ATE). Secondary outcome was severity of COVID-19 (rates of intensive care unit admission, mechanical ventilation, 30-day all-cause mortality following TEEs in TOI vs reference group) at 30-day follow-up.

Results

Of 4988 hospitalized patients with cancer (median [IQR] age, 69 [59-78] years; 2608 [52%] male), 1869 had received 1 or more TOIs. Incidence of VTE was higher in all TOI groups: endocrine therapy, 7%; VEGFis/TKIs, 10%; IMiDs, 8%; ICIs, 12%; and chemotherapy, 10%, compared with patients not receiving systemic therapies (6%). In multivariable log-binomial regression analyses, relative risk of VTE (adjusted risk ratio [aRR], 1.33; 95% CI, 1.04-1.69) but not ATE (aRR, 0.81; 95% CI, 0.56-1.16) was significantly higher in those exposed to all TOIs pooled together vs those with no exposure. Among individual drugs, ICIs were significantly associated with VTE (aRR, 1.45; 95% CI, 1.01-2.07). Also noted were significant associations between VTE and active and progressing cancer (aRR, 1.43; 95% CI, 1.01-2.03), history of VTE (aRR, 3.10; 95% CI, 2.38-4.04), and high-risk site of cancer (aRR, 1.42; 95% CI, 1.14-1.75). Black patients had a higher risk of TEEs (aRR, 1.24; 95% CI, 1.03-1.50) than White patients. Patients with TEEs had high intensive care unit admission (46%) and mechanical ventilation (31%) rates. Relative risk of death in patients with TEEs was higher in those exposed to TOIs vs not (aRR, 1.12; 95% CI, 0.91-1.38) and was significantly associated with poor performance status (aRR, 1.77; 95% CI, 1.30-2.40) and active/progressing cancer (aRR, 1.55; 95% CI, 1.13-2.13).

Conclusions and Relevance

In this cohort study, relative risk of developing VTE was high among patients receiving TOIs and varied by the type of therapy, underlying risk factors, and demographics, such as race and ethnicity. These findings highlight the need for close monitoring and perhaps personalized thromboprophylaxis to prevent morbidity and mortality associated with COVID-19-related thromboembolism in patients with cancer.

Short- and long-term effects of the COVID-19 pandemic on patients with cardiovascular diseases: A mini-review

The COVID-19 pandemic had profound implications for patients with cardiovascular diseases (CVDs), both in the short- and long-term. In this article, we provide an overview of the effects of the pandemic on individuals with preexisting cardiovascular conditions. In the short term, the severe acute respiratory syndrome coronavirus 2 infection increased the risk of many cardiovascular events. Furthermore, the pandemic has disrupted health-care systems worldwide, leading to constraints in routine care, and limited access to specialized cardiovascular services and procedure. This has resulted in increased morbidity and mortality rates among patients with CVD (coronary artery disease, hypertrophic cardiomyopathy, heart failure (HF), heart transplant recipients, atrial fibrillation, atrial flutter, previous stroke, or previous peripheral artery disease). In the long term, the COVID-19 impact on patients with CVD extends beyond the acute phase of the disease. Studies have highlighted the development of long-term cardiovascular complications in COVID-19 survivors, such as acute coronary syndrome myocarditis, HF, stroke, venous thromboembolism, and arrhythmias, which may lead to a surge of new cases associated with CVD in the postpandemic era. Health-care systems must prioritize cardiovascular care, developing strategies to identify the patients at higher risk and provide the care to minimize the impact of the pandemic on patients with CVD.

Thrombotic complications in children with Coronavirus disease 2019 and Multisystem Inflammatory Syndrome of Childhood

Coronavirus disease 2019 (COVID-19) associated coagulopathy is multifactorial and involves inflammation driven hypercoagulability, endothelial dysfunction, platelet activation, and impaired fibrinolysis. Hospitalized adults with COVID-19 are at an increased risk of both venous thromboembolism and ischemic stroke, resulting in adverse outcomes, including increased mortality. Although COVID-19 in children follows a less severe course, both arterial and venous thromboses have been reported in hospitalized children with COVID-19. Additionally, some children develop a postinfectious, hyperinflammatory illness termed multisystem inflammatory syndrome of childhood (MIS-C), which is also associated with hypercoagulability and thrombosis. Several randomized trials have evaluated the safety and efficacy of antithrombotic therapy in adults with COVID-19, although similar pediatric data are lacking. In this narrative review, we discuss the postulated pathophysiology of COVID-19 coagulopathy and summarize principal findings of the recently completed adult trials of antithrombotic therapy. We provide an up-to-date summary of pediatric studies investigating the rate of venous thromboembolism and ischemic stroke in COVID-19 and multisystem inflammatory syndrome of childhood in addition to reviewing the findings of the single, nonrandomized pediatric trial investigating the safety of prophylactic anticoagulation. Lastly, we outline adult and pediatric consensus guidelines on the use of antithrombotic therapy in this cohort. A detailed discussion of the practical implementation and current limitations of published data will hopefully address the knowledge deficits surrounding the use of antithrombotic therapy in children with COVID-19 and generate hypotheses for future research.

[Expert consensus on the clinical treatment of burn patients complicated with Coronavirus infection (2023 version)]

With China downgrading the management of Coronavirus infection (COVID-19) from Category A to Category B, a large number of COVID-19 patients have occurred in multiple waves across the country. Meanwhile, the long-term impact of Coronavirus on the body has gradually been noticed. However, the clinical treatment of burns complicated with COVID-19 is still a major challenge in Chinese burn centers. It is then essential to standardize the clinical treatment of such patients, improve the prognosis to the greatest extent, and provide valuable experiences for similar infectious diseases in future. Therefore, Chinese Burn Association, Burn Medicine Branch of China International Exchange and Promotion Association for Medical and Healthcare, and Editorial Committee of Chinese Journal of Burns and Wounds jointly initiated and organized multidisciplinary experts to develop this expert consensus based on the current medical evidence, clinical practice, and authoritative guidelines of other disciplines, in order to standardize the clinical treatment of burn patients complicated with COVID-19.

Impact of COVID-19 Infection on the Clinical Outcomes of Pulmonary Embolism Hospitalizations : A Nationwide Analysis

There is an increased risk of venous thromboembolism among patients with COVID-19 infection, with the risk being higher among those needing the intensive level of care. Existing data is, however, limited regarding the outcomes of patients admitted with concurrent COVID-19 infection and pulmonary embolism (PE). All acute PE admissions were identified from the National Inpatient Sample database during 2020 using ICD-10 codes. Patients were subsequently classified into those with and without COVID-19 infection. The primary outcome of interest was in-hospital mortality. Using multivariate logistic regression, the predictors of mortality were assessed for patients with concurrent acute PE and COVID-19. The database query generated 278,840 adult patients with a primary diagnosis of PE. Of these, 4580 patients had concurrent PE and COVID-19 infection. The concurrent PE and COVID-19 infection group had a higher proportion of Black-American and Hispanic patients, and those living in the zip codes associated with the lowest annualized income compared to the PE alone group. Furthermore, patients in the concurrent PE and COVID-19 infection group had an increased risk of in-hospital mortality (adjusted odds ratio [aOR]:1.62; 95% CI: 1.17-2.24; P = 0.004), septic shock (aOR: 1.66; 95% CI 1.10-2.52; P = 0.016), respiratory failure (aOR: 1.78; 95% CI 1.53-2.06; P = 0.001), and a longer hospital stay [5.5 days vs 4.59 days; P = 0.001). Concurrent COVID-19 and PE admissions is associated with an increased in-hospital mortality, risk of septic shock and respiratory failure, and a longer length of hospital stay.

Exploring heterogeneity in reported venous thromboembolism risk in COVID-19 and comparison to other viral pneumonias: a systematic review and meta-regression

Background

Sources of heterogeneity in venous thromboembolism (VTE) risk in COVID-19 are unclear and comparisons to other viruses are lacking.

Objectives

To describe VTE risk in patients with COVID-19, explore sources of heterogeneity, and make comparisons with other viral pneumonia.

Methods

PubMed and Embase data were searched on March 14, 2021, for studies on VTE in adults hospitalized with viral pneumonia. VTE risk estimates were pooled in a random effects meta-analysis stratified by virus type. Heterogeneity in COVID-19 was explored in multivariable meta-regression.

Results

Seventy studies in COVID-19 (intensive care [ICU] [47] vs ward [23]), 4 studies in seasonal influenza (ICU [3] vs ward [1]), 2 ICU studies in H1N1 and 1 ICU study in SARS-CoV-1 were included. For COVID-19 ICU, pooled VTE risk was 19.6% (95% confidence interval [CI], 16.2%-23.5; I2 = 92.8%) for nonscreening studies and 30.0% (95% CI, 17.9%-45.7%; I2 = 81.9%) for screening studies. For COVID-19 ward, pooled VTE risk was 3.4% (95% CI, 2.4%-4.7%; I2 = 91.3%) and 22.5% (95% CI, 10.2%-42.7%; I2 = 91.6%) for nonscreening and screening studies, respectively. Higher sample size was associated with lower VTE risk. Pooled VTE risk in seasonal influenza and H1N1 at ICU were 9.0% (95% CI, 5.6%-14.2%; I2 = 39.7%) and 29.2% (95% CI, 8.7%-64.2%; I2 = 77.9%), respectively. At ward, VTE risk of seasonal influenza was 2.4% (95% CI, 2.1%-2.7%). In SARS-CoV-1, VTE risk was 47.8% (95% CI, 34.0-62.0).

Conclusion

Pooled risk estimates in COVID-19 should be interpreted cautiously as a high degree of heterogeneity is present, which hinders comparison to other viral pneumonia. The association of VTE risk in COVID-19 to sample size suggests publication bias.

Rotational Thromboelastometry (ROTEM®) in Relation to Inflammatory Biomarkers and Clinical Outcome in COVID-19 Patients

Background: The pathogenesis of hypercoagulability in COVID-19 patients is complex and not fully understood. Rotational thromboelastometry (ROTEM^®) is a viscoelastic method that allows the definition of a patient's hemostatic profile. This study aimed to assess the relationship between ROTEM^® parameters, the profile of inflammatory cytokines, and clinical outcomes in COVID-19 patients. Methods: A total of 63 participants (n = 29 symptomatic non-ICU COVID-19 patients, and n = 34 healthy controls) were prospectively included in the study. We assessed the relationship between the parameters of three ROTEM^® tests (NATEM^®, EXTEM^®, and FIBTEM^®) and levels of CRP, interleukin-8, interleukin-1β, interleukin-6, interleukin-10, tumor necrosis factor, interleukin 12p70, and clinical outcomes. Results: ROTEM^® indicated hypercoagulability in COVID-19 patients in all the tests performed. The levels of all inflammatory cytokines were significantly higher in COVID-19 patients. NATEM more frequently detected hypercoagulability in COVID-19 patients compared to EXTEM. The strongest correlations with inflammatory biomarkers and CT severity score were with FIBTEM parameters. The elevated maximum clot elasticity (MCE) in FIBTEM was the strongest predictor of poor outcomes. Conclusions: Increased FIBTEM MCE may be associated with greater severity of COVID-19. Non-activated ROTEM (NATEM test) seems to be more valuable for detecting hypercoagulability in COVID-19 patients compared to the tissue factor activated test (EXTEM).

A Case Report of Disseminated Thromboses and Cardiac Ischemia in a Patient With COVID-19 Pneumonia

The novel coronavirus disease (COVID-19) pandemic caused by the SARS-CoV-2 virus started in December 2019 in the city of Wuhan, in China's Hubei province. This virus quickly spread worldwide, and on March 11, 2020, it was declared a pandemic. Thrombosis, as a hallmark of severe disease, was recognized early as a cause of death; however, the exact pathophysiological mechanism is still not fully understood. We are reporting the case of a 46-year-old patient who presented with multiple arterial thromboses in the setting of an acute COVID-19 infection requiring systemic thrombolytic therapy and thrombectomy.

Effect of Anticoagulants in Pulmonary Thromboembolism in Post-COVID-19 Patients

Background and objective COVID-19 may predispose to both venous and arterial thromboembolism (VTE and ATE) due to excessive inflammation, immobilization, and hypoxia. The purpose of this study is to evaluate clinical and laboratory risk factors, as well as related medications such as anticoagulants, to predict the risk of thromboembolic disease and/or death in COVID-19 patients. Methods Over a period of 14 months (from August 2020 to September 2021), a total of 145 consecutive patients with signs and symptoms suspicious of pulmonary embolism (PE) were referred for perfusion single-photon emission computed tomography/computed tomography (Q SPECT/CT). All patients had a history of SARS‑CoV‑2 infection, diagnosed with a positive real-time polymerase chain reaction (RT-PCR) test. Results Among the 145 patients included in the study, the risk of PE was found to be greater in elderly patients (odds ratio [OR] [95% CI]: 1.05 [1.02‑1.07]; p<0.001) and in patients with higher maximum d-dimer levels (OR [95% CI]: 1.14 [1.01‑1.3]; p=0.04). We also analyzed the utility of the maximum d-dimer level for predicting acute PE with receiver operating characteristic (ROC) curve analysis. For d‑dimer = 0.5 mg/dL, cut-off sensitivity is 91%, specificity is 23%, and for d-dimer = 1 mg/dL, cut-off sensitivity is 79%, specificity is 43% Conclusion D-dimer titers were higher in the PE group in our study. Another significant finding was that, possibly due to thromboinflammation, anticoagulants did not prevent the development of PE in COVID-19 patients.

EFFECTS OF SARS COVID-19 POSITIVITY STATUS ON VENOUS THROMBOSIS AND PULMONARY EMBOLISM RATES IN TRAUMA PATIENTS

ABSTRACT

Introduction : COVID-19-induced coagulopathy (CIC) can increase the risk of thromboembolism without underlying clotting disorders, even when compared with other respiratory viruses. Trauma has a known association with hypercoagulability. Trauma patients with concurrent COVID-19 infection potentially have an even greater risk of thrombotic events. The purpose of this study was to evaluate venous thromboembolism (VTE) rates in trauma patients with COVID-19. Methods : This study reviewed all adult patients (≥18 years of age) admitted to the Trauma Service from April through November 2020 for a minimum of 48 hours. Patients were grouped based off COVID-19 status and compared for inpatient VTE chemoprophylaxis regimen, thrombotic complications defined as deep vein thrombosis, pulmonary embolism, myocardial infarction, and cerebrovascular accident, intensive care unit (ICU) length of stay, hospital length of stay, and mortality. Results : A total of 2,907 patients were reviewed and grouped into COVID-19-positive (n = 110) and COVID-19-negative (n = 2,797) groups. There was no difference in terms of receiving deep vein thrombosis chemoprophylaxis or type, but a longer time to initiation in the positive group ( P = 0.0012). VTE occurred in 5 (4.55%) positive and 60 (2.15%) negative patients without a significant difference between the groups, as well as no difference in type of VTE observed. Mortality was higher ( P = 0.009) in the positive group (10.91%). Positive patients had longer median ICU LOS ( P = 0.0012) and total LOS ( P < 0.001). Conclusion : There were no increased rates of VTE complications between COVID-19-positive and -negative trauma patients, despite a longer time to initiation of chemoprophylaxis in the COVID-19-positive group. COVID-19-positive patients had increased ICU LOS, total LOS, and mortality, which are likely due to multifactorial causes but primarily related to their underlying COVID-19 infection.

Association Between the Development of Thrombosis and Worsening of Disease Severity in Patients With Moderate COVID-19 on Admission - From the CLOT-COVID Study

BACKGROUND

The worsening of coronavirus disease 2019 (COVID-19) severity is a critical issue in current clinical settings and may be associated with the development of thrombosis.

METHODS AND RESULTS

This study used patient data obtained in the CLOT-COVID study, a retrospective multicenter cohort study. The demographics of patients with moderate COVID-19 on admission with and without worsened severity during hospitalization were compared and predictors were identified. Of 927 patients with moderate COVID-19 on admission, 182 (19.6%) had worsened severity during hospitalization. Patients with worsening of severity were older, more likely to have hypertension, diabetes, heart disease, and active cancer, and more likely to use pharmacological thromboprophylaxis. Patients with worsening of severity had higher D-dimer levels on admission and were more likely to develop thrombosis and major bleeding during hospitalization than those without worsening. Increased age (odds ratio [OR]: 1.02, 95% confidence interval [CI]: 1.01-1.03, P=0.005), diabetes (OR: 1.63, 95% CI: 1.11-2.33, P=0.012), D-dimer levels >1.0 μg/mL on admission (OR: 2.10, 95% CI: 1.45-3.03, P<0.001), and thrombosis (OR: 6.28, 95% CI: 2.72-14.53, P<0.001) were independently associated with worsening of COVID-19 severity.

CONCLUSIONS

Approximately 20% of patients with moderate COVID-19 had worsened severity during hospitalization. Increased age, diabetes, D-dimer levels >1.0 μg/mL on admission, and the development of thrombosis during hospitalization were significantly associated with worsened COVID-19 severity.

Incidence of lower limb deep vein thrombosis in patients with COVID-19 pneumonia through different waves of SARS-CoV-2 pandemic: A multicenter prospective study

OBJECTIVE

The aim of this study was to evaluate the incidence of deep vein thrombosis (DVT) of the lower limbs in patients hospitalized with COVID-19 pneumonia in a non-ICU setting according to the different waves of the SARS-CoV-2 pandemic.

METHODS

Multicenter, prospective study of patients with COVID-19 pneumonia admitted to Internal Medicine units in Italy during the first (March-May 2020) and subsequent waves (November 2020 -April 2021) of the pandemic using a serial compression ultrasound (CUS) surveillance to detect DVT of the lower limbs.

RESULTS

Three-hundred-sixty-three consecutive patients were enrolled. The pooled incidence of DVT was 8%: 13.5% in the first wave, and 4.2% in the subsequent waves (p = 0.002). The proportion of patients with early (< 4 days) detection of DVT was higher in patients during the first wave with respect to those of subsequent waves (8.1% vs 1.9%; p = 0.004). Patients enrolled in different waves had similar clinical characteristics, and thrombotic risk profile. Less patients during the first wave received intermediate/high dose anticoagulation with respect to those of the subsequent waves (40.5% vs 54.5%; p = 0.005); there was a significant difference in anticoagulant regimen and initiation of thromboprophylaxis at home (8.1% vs 25.1%; p<0.001).

CONCLUSIONS

In acutely ill patients with COVID-19 pneumonia, the incidence of DVT of the lower limbs showed a 3-fold decrease during the first with respect to the subsequent waves of the pandemic. A significant increase in thromboprophylaxis initiation prior to hospitalization, and the increase of the intensity of anticoagulation during hospitalization, likely, played a relevant role to explain this observation.

Contribution of genotypes in Prothrombin and Factor V Leiden to COVID-19 and disease severity in patients at high risk for hereditary thrombophilia

Thrombotic and microangiopathic effects have been reported in COVID-19 patients. This study examined the contribution of the hereditary thrombophilia factors Prothrombin (FII) and Factor V Leiden (FVL) genotypes to the severity of COVID-19 disease and the development of thrombosis. This study investigated FII and FVL alleles in a cohort of 9508 patients (2606 male and 6902 female) with thrombophilia. It was observed that 930 of these patients had been infected by SARS-CoV-2 causing COVID-19. The demographic characteristics of the patients and their COVID-19 medical history were recorded. Detailed clinical manifestations were analyzed in a group of cases (n = 4092). This subgroup was age and gender-matched. FII and FVL frequency data of healthy populations without thrombophilia risk were obtained from Bursa Uludag University Medical Genetic Department's Exome Databank. The ratio of males (31.08%; 27.01%) and the mean age (36.85 ± 15.20; 33.89 ± 14.14) were higher among COVID-19 patients compared to non-COVID-19 patients. The prevalence of FVL and computerized tomography (CT) positivity in COVID-19 patients was statistically significant in the thrombotic subgroup (p < 0.05). FVL prevalence, CT positivity rate, history of thrombosis, and pulmonary thromboembolism complication were found to be higher in deceased COVID-19 patients (p < 0.05). Disease severity was mainly affected by FVL and not related to genotypes at the Prothrombin mutations. Overall, disease severity and development of thrombosis in COVID-19 are mainly affected by the variation within the FVL gene. Possible FVL mutation should be investigated in COVID-19 patients and appropriate treatment should be started earlier in FVL-positive patients.

Chronic anti-coagulation therapy reduced mortality in patients with high cardiovascular risk early in COVID-19 pandemic

BACKGROUND

Coronavirus disease 2019 (COVID-19) is associated with provoked thrombo-inflammatory responses. Early in the COVID-19 pandemic this was thought to contribute to hypercoagulability and multi-organ system complications in infected patients. Limited studies have evaluated the impact of therapeutic anti-coagulation therapy (AC) in alleviating these risks in COVID-19 positive patients. Our study aimed to investigate whether long-term therapeutic AC can decrease the risk of multi-organ system complications (MOSC) including stroke, limb ischemia, gastrointestinal (GI) bleeding, in-hospital and intensive care unit death in COVID-19 positive patients hospitalized during the early phase of the pandemic in the United States.

METHODS

A retrospective analysis was conducted of all COVID-19 positive United States Veterans between March 2020 and October 2020. Patients receiving continuous outpatient therapeutic AC for a least 90 days prior to their initial COVID-19 positive test were assigned to the AC group. Patients who did not receive AC were included in a control group. We analyzed the primary study outcome of MOSC between the AC and control groups using binary logistic regression analysis (Odd-Ratio; OR).

RESULTS

We identified 48,066 COVID-19 patients, of them 879 (1.8%) were receiving continuous therapeutic AC. The AC cohort had significantly worse comorbidities than the control group. On the adjusted binary logistic regression model, therapeutic AC significantly decreased in-hospital mortality rate (OR; 0.67, p = 0.04), despite a higher incidence of GI bleeding (OR; 4.00, p = 0.02). However, therapeutic AC did not significantly reduce other adverse events.

CONCLUSION

AC therapy reduced in-hospital death early in the COVID-19 pandemic among patients who were hospitalized with the infection. However, it did not decrease the risk of MOSC. Additional trials are needed to determine the effectiveness of AC in preventing complications associated with ongoing emerging strains of the COVID-19 virus.

The Collateral Benefit of COVID Pandemic: Improved Pharmacological Venous Thromboembolism Prophylaxis Practices in Non-COVID Patients

Background

COVID-19 creates a hypercoagulable state with a wide spectrum of clinical manifestations. Of those, venous thromboembolism (VTE) is prevalent, and numerous studies have highlighted the importance of VTE prophylaxis. Pre-pandemic VTE prophylaxis practices have already been poor, despite guidelines. We hypothesized that the gap between guidelines and practices might have been closed due to increased awareness.

Materials and Methods

Non-COVID-19 patients hospitalized in the internal medicine ward of a university hospital between January 1st, 2021, and June 30th, 2021, were assessed. VTE risk and thromboprophylaxis requirements were assessed using the Padua Prediction Score (PPS). The results were compared with the findings of the study conducted in the same setting before the pandemic.

Results

A total of 267 patients were included, and 81 patients (30.3%) received prophylaxis. A total of 128 patients' (47.9%) PPS was ≥ 4, and 69 patients (53.9%) received prophylaxis; 12 low-risk patients (8.6%) received prophylaxis although it was not indicated. Compared to the pre-pandemic figures, both appropriate prophylaxis use and overuse rates have risen. While the increment rate of appropriate prophylaxis was statistically significant, the increment rate of overuse did not reach statistical significance. Patients hospitalized for infectious diseases and respiratory failure were more likely to receive appropriate prophylaxis.

Conclusion

We have demonstrated a significant increase in appropriate pharmacologic prophylaxis rates among high-risk patients. Besides all the collateral damage the pandemic has created, it might also have brought collateral benefits with regards to VTE prophylaxis.

Chronic Anti-Coagulation Therapy Reduced Mortality In Patients With High Cardiovascular Risk Early In COVID-19 Pandemic

Background: Coronavirus disease 2019 (COVID-19) is associated with provoked thrombo-inflammatory responses. Early in the COVID-19 pandemic this was thought to contribute to hypercoagulability and multi-organ system complications in infected patients. Limited studies have evaluated the impact of therapeutic anti-coagulation therapy (AC) in alleviate these risks in COVID-19 positive patients. Our study aimed to investigate whether long-term therapeutic AC can decrease the risk of multi-organ system complications (MOSC) including stroke, limb ischemia, gastrointestinal (GI) bleeding, in-hospital and intensive care unit death in COVID-19 positive patients during the early phase of the pandemic in the United States. Methods: A retrospective analysis was conducted of all COVID-19 positive United States Veterans between March 2020 and October 2020. Patients receiving continuous therapeutic AC for a least 30 days prior to or after their initial COVID-19 positive test were assigned to the AC group. Patients who did not receive AC were included in a control group. We analyzed the primary study outcome of MOSC between the AC and control groups using binary logistic regression analysis (Odd-Ratio; OR). Results: We identified 48,066 COVID-19 patients, of them 879 (1.8%) were receiving continuous therapeutic AC. The AC cohort had significantly worse comorbidities than the control group. On the adjusted binary logistic regression model, therapeutic AC significantly decreased in-hospital mortality rate (OR; 0.67, p = 0.04), despite a higher incidence of GI bleeding (OR; 4.00, p = 0.02). However, therapeutic AC did not significantly reduce other adverse events. Conclusion: AC therapy reduced in-hospital death early in the COVID-19 pandemic among patients who were hospitalized with the infection. However, it did not decrease the risk of MOSC. Additional trials are needed to determine the effectiveness of AC in preventing complications associated with ongoing emerging strains of the COVID-19 virus.

Chronic Anti-Coagulation Therapy Reduced Mortality In Patients With High Cardiovascular Risk Early In COVID-19 Pandemic

Background: Coronavirus disease 2019 (COVID-19) is associated with provoked thrombo-inflammatory responses. Early in the COVID-19 pandemic this was thought to contribute to hypercoagulability and multi-organ system complications in infected patients. Limited studies have evaluated the impact of therapeutic anti-coagulation therapy (AC) in alleviate these risks in COVID-19 positive patients. Our study aimed to investigate whether long-term therapeutic AC can decrease the risk of multi-organ system complications (MOSC) including stroke, limb ischemia, gastrointestinal (GI) bleeding, in-hospital and intensive care unit death in COVID-19 positive patients during the early phase of the pandemic in the United States. Methods: A retrospective analysis was conducted of all COVID-19 positive United States Veterans between March 2020 and October 2020. Patients receiving continuous therapeutic AC for a least 30 days prior to or after their initial COVID-19 positive test were assigned to the AC group. Patients who did not receive AC were included in a control group. We analyzed the primary study outcome of MOSC between the AC and control groups using binary logistic regression analysis (Odd-Ratio; OR). Results: We identified 48,066 COVID-19 patients, of them 879 (1.8%) were receiving continuous therapeutic AC. The AC cohort had significantly worse comorbidities than the control group. On the adjusted binary logistic regression model, therapeutic AC significantly decreased in-hospital mortality rate (OR; 0.67, p = 0.04), despite a higher incidence of GI bleeding (OR; 4.00, p = 0.02). However, therapeutic AC did not significantly reduce other adverse events. Conclusion: AC therapy reduced in-hospital death early in the COVID-19 pandemic among patients who were hospitalized with the infection. However, it did not decrease the risk of MOSC. Additional trials are needed to determine the effectiveness of AC in preventing complications associated with ongoing emerging strains of the COVID-19 virus.

A Rare Combination of Arterial and Venous Thrombosis as a Sequalae of COVID-19

Coronavirus disease 2019 (COVID-19) has been a devastating condition claiming millions of lives, crippling countless people, and causing economic turmoil all over the world since the outbreak started in Wuhan Province of China in December 2019. Numerous papers have been published in the literature about COVID-19-related complications affecting almost all systems in the human body. One of the severe complications of this disease is thromboembolism, which affects both the arterial and venous systems and is well documented. There are few reports about both arterial and venous system involvement in the same patient. Herein, we report the case of COVID-19, who presented with critical limb ischemia caused by both arterial and venous thrombosis.

Fibrinolysis in COVID-19: Impact on Clot Lysis and Modulation of Inflammation

COVID-19 is a multisystem disease caused by SARS-CoV-2 and is associated with an imbalance between the coagulation and fibrinolytic systems. Overall, hypercoagulation, hypofibrinolysis and fibrin-clot resistance to fibrinolysis predispose patients to thrombotic and thromboembolic events. In the lungs, the virus triggers alveolar and interstitial fibrin deposition, endothelial dysfunction, and pulmonary intravascular coagulation, all events intrinsically associated with the activation of inflammation and organ injury. Adding to the pathogenesis of COVID-19, there is a positive feedback loop by which local fibrin deposition in the lungs can fuel inflammation and consequently dysregulates coagulation, a process known as immunothrombosis. Therefore, fibrinolysis plays a central role in maintaining hemostasis and tissue homeostasis during COVID-19 by cleaning fibrin clots and controlling feed-forward products of coagulation. In addition, components of the fibrinolytic system have important immunomodulatory roles, as evidenced by studies showing the contribution of Plasminogen/Plasmin (Plg/Pla) to the resolution of inflammation. Herein, we review clinical evidence for the dysregulation of the fibrinolytic system and discuss its contribution to thrombosis risk and exacerbated inflammation in severe COVID-19. We also discuss the current concept of an interplay between fibrinolysis and inflammation resolution, mirroring the well-known crosstalk between inflammation and coagulation. Finally, we consider the central role of the Plg/Pla system in resolving thromboinflammation, drawing attention to the overlooked consequences of COVID-19-associated fibrinolytic abnormalities to local and systemic inflammation.

Impact of COVID-19 on Non-Pulmonary Critical Illness: Prevalence, Clinical Manifestations, Management, and Outcomes

Although respiratory manifestations are the most common driver of hospitalization, SARS-CoV-2 infection has a wide range of manifestations, including multisystem organ failure in severe cases. This review discusses the prevalence, pathophysiology, clinical manifestations, treatment, and outcomes of nonpulmonary organ dysfunction from SARS-CoV2, including renal, liver, cardiac, neurologic, and coagulation system dysfunction. At this time, management largely focuses on supportive care practices that are applicable regardless of the cause of organ injury.

Pathophysiological mechanisms of thrombosis in acute and long COVID-19

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.

No apparent association between mRNA COVID-19 vaccination and venous thromboembolism

By January 2022 over ten billion doses of COVID-19 vaccines had been administered worldwide. Concerns about COVID-19 vaccine-associated thrombosis arose after the characterization of a rare prothrombotic condition associated with adenoviral vector-based COVID-19 vaccines known as vaccine-induced immune thrombotic thrombocytopenia (VITT). Although mRNA COVID-19 vaccines have not been linked to VITT, concerns about thrombosis after vaccination persist despite safety data from hundreds of millions of recipients of mRNA COVID-19 vaccines. With widespread vaccination some VTE will occur shortly after vaccination by chance alone because VTE is a common condition that affects 1 to 2 in 1000 persons each year. Detailed analysis is required to determine whether these VTE events are coincidental or associated when they occur in close proximity to mRNA vaccine administration. This paper will review what is currently known about rates of VTE after mRNA vaccination in adults, discuss the reasons why uncertainty on this topic persists, and briefly review the implications of these findings for clinical practice and health policy.

Evaluation of the prevalence of new-onset musculoskeletal symptoms in patients hospitalized for severe SARS-CoV-2 infection during the first two COVID waves in France: A descriptive analysis of the clinical data warehouse of 39 hospitals in France

OBJECTIVE

To determine the prevalence of musculoskeletal (MSK) symptoms appearing after a SARS-CoV-2 infection.

METHODS

This was an observational cohort based on data available at the Assistance publique-Hôpitaux de Paris (AP-HP) Clinical Data Warehouse (which includes data of more than 11 million patients treated in the 39 hospitals from AP-HP). The data collected included both ICD-10 codes in discharge summaries, and recurring wording expressions search on medical electronic documents. To be included in the analysis, patients had to have a positive RT-PCR for SARS-CoV-2 and be admitted in any department of AP-HP. Patients with previous history of any MSK condition were excluded. MSK conditions were considered if occurring up to 90days after the positive RT-PCR. Demographics and disease characteristics including treatment were compared in both groups (MSK yes/no) by t-test or Chi² test, accordingly.

RESULTS

In total, 17,771 patients had a positive SARS-CoV-2 RT-PCR at APHP and were admitted in any department of AP-HP. Among them, 15,601 had no previous history of MSK condition and among them, 1370 (8.8%) presented with MSK symptoms after the viral infection. The most prevalent MSK symptoms were back pain (32.9%), followed by arthralgia (29.9%), radicular pain (20.2%) and arthritis (22.8%). Patients with MSK symptoms (MSK+) were older (67 y vs. 64 y, P<0.01), more frequently obese (29% vs. 25%, P=0.03), hypertensive (34% vs. 30%, P<0.01) and with diabetes (21% vs. 18%, P<0.01). Treatment for SARS-CoV-2 was slightly different in both groups, with higher corticosteroids (40.7% vs. 29.0%, P<0.01), antivirals (21.5% vs. 15.3%, P<0.01) and immunosuppressors (8.5% vs. 4.5%, P<0.01) prescription rates in the MSK+ group.

CONCLUSION

MSK symptoms occurred in almost 9% of patients admitted to the hospital after a SARS-CoV-2 infection, particularly in older and more comorbid patients. Further analysis evaluating whether these symptoms remain over time are needed.