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Rossio R, Tettamanti M, Galbussera AA, Gualtierotti R, Giachi A, Torri A, Montano N, Fracanzani AL, Bandera A, Nobili A, Peyvandi F. Bleeding and thrombotic events and intensity of heparin therapy in the two first waves of COVID-19. Intern Emerg Med 2024:10.1007/s11739-024-03635-2. [PMID: 38761332 DOI: 10.1007/s11739-024-03635-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 05/05/2024] [Indexed: 05/20/2024]
Abstract
A systemic inflammatory response occurs during SARS-CoV2 infection and is associated with hypercoagulability and thrombotic events. From March 2020 in our hospital different dosages of low-molecular weight heparin (LMWH) were introduced according to the level of patient care intensity. Because bleeding episodes occurred in hospitalized COVID-19 patients on heparin, the dosage of LMWH at the end of first wave was tailored on the severity of COVID-19. The aim of this study is to describe bleeding and thrombotic events in patients hospitalized with SARS-CoV2 infection on LMWH therapy in the two waves of COVID-19 and analyze the factors associated with these events. Among 1143 patients enrolled in the COVID-19 Network registry, 912 were included in the analysis, 537 of them admitted during the first wave and 375 during the second. Bleeding events were 30 (3.3%): 22 (2.4%) major and 8 (0.9%) non-major. Arterial and venous thrombotic events were 6 (0.7%) and 24 (2.6%). The incidence of venous thrombotic events was higher in the first than in the second wave (0.29% [95% CI 0.20-0.45] events/day vs. 0.05% [95% CI 0.02-0.16]), with a 71% risk reduction (95% CI 22%-94%). The incidence of bleeding was 0.33% (95% CI 0.22-0.50) vs 0.14% events/day (95% CI 0.07-0.28), with no statistical between-wave difference (HR 0.41 95% CI 0.16-1.08). After adjusting for the competing risks of death and comorbidities, patients in the second wave had lower odds to have thrombotic events than in the first wave (0.24 HR [95% C.I. 0.07-0.89]). In this retrospective study on COVID-19 we found a low rate of hemorrhagic and thrombotic events, that may be explained by the absence in the case material of patients admitted to intensive care unit.
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Affiliation(s)
- Raffaella Rossio
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Sforza 35, Milan, Italy.
| | - Mauro Tettamanti
- Laboratory of Geriatric Epidemiology, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | | | - Roberta Gualtierotti
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Sforza 35, Milan, Italy
- Department of Pathophysiology and Transplantation, Università Degli Studi Di Milano, Milan, Italy
| | - Andrea Giachi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Sforza 35, Milan, Italy
| | - Adriana Torri
- Department of Pathophysiology and Transplantation, Università Degli Studi Di Milano, Milan, Italy
| | - Nicola Montano
- Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, 20122, Milan, Italy
| | - Anna Ludovica Fracanzani
- Department of Pathophysiology and Transplantation, Unit of Metabolic and Internal Medicine, University of Milan, Milan, Italy
| | - Alessandra Bandera
- Infectious Diseases Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessandro Nobili
- Laboratory of Geriatric Epidemiology, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Sforza 35, Milan, Italy
- Department of Pathophysiology and Transplantation, Università Degli Studi Di Milano, Milan, Italy
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2
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Poloni A, Casalini G, Pozza G, Giacomelli A, Colaneri M, Carrozzo G, Caloni B, Ciubotariu CL, Zacheo M, Rabbione A, Pieruzzi M, Barone F, Passerini M, Ridolfo AL, Rizzardini G, Gori A, Antinori S. Major Bleeding Events in Hospitalized COVID-19 Patients: A Retrospective Observational Study. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:814. [PMID: 38792997 PMCID: PMC11122796 DOI: 10.3390/medicina60050814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/08/2024] [Accepted: 05/14/2024] [Indexed: 05/26/2024]
Abstract
Thromboprophylaxis/anticoagulation treatment is often required in hospitalized COVID-19 patients. We aimed to estimate the prevalence of major bleeding events in hospitalized COVID-19 patients. This was a retrospective observational study including all COVID-19 hospitalized patients ≥18 years of age at one reference center in northern Italy. The crude prevalence (between February 2020-2022) of major bleeding events was estimated as the number of major bleeding episodes divided by patients at risk. Uni- and multivariable Cox models were built to assess factors potentially associated with major bleeding events. Twenty-nine (0.98%) out of 2,945 COVID-19 patients experienced a major bleeding event [prevalence of 0.55% (95%CI 0.37-0.79)], of which five were fatal. Patients who experienced a major bleeding event were older [78 years (72-84 IQR) vs. 67 years (55-78 IQR), p-value < 0.001] and more frequently exposed to anti-aggregating therapy (44.8% vs. 20.0%, p-value 0.002) when compared to those who did not. In the multivariable Cox model, age [per 1 year more AHR 1.05 (CI95% 1.02-1.09)] was independently associated with an increased risk of major bleeding events. A strict monitoring of older hospitalized COVID-19 patients is warranted due to the risk of major bleeding events.
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Affiliation(s)
- Andrea Poloni
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20122 Milan, Italy; (A.P.); (G.P.); (G.C.); (B.C.); (C.L.C.); (M.Z.); (A.R.); (M.P.); (F.B.); (A.G.); (S.A.)
- III Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy; (G.C.); (A.L.R.)
| | - Giacomo Casalini
- III Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy; (G.C.); (A.L.R.)
| | - Giacomo Pozza
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20122 Milan, Italy; (A.P.); (G.P.); (G.C.); (B.C.); (C.L.C.); (M.Z.); (A.R.); (M.P.); (F.B.); (A.G.); (S.A.)
- III Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy; (G.C.); (A.L.R.)
| | - Andrea Giacomelli
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20122 Milan, Italy; (A.P.); (G.P.); (G.C.); (B.C.); (C.L.C.); (M.Z.); (A.R.); (M.P.); (F.B.); (A.G.); (S.A.)
- III Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy; (G.C.); (A.L.R.)
| | - Marta Colaneri
- II Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy; (M.C.); (M.P.)
| | - Giorgia Carrozzo
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20122 Milan, Italy; (A.P.); (G.P.); (G.C.); (B.C.); (C.L.C.); (M.Z.); (A.R.); (M.P.); (F.B.); (A.G.); (S.A.)
- III Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy; (G.C.); (A.L.R.)
| | - Beatrice Caloni
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20122 Milan, Italy; (A.P.); (G.P.); (G.C.); (B.C.); (C.L.C.); (M.Z.); (A.R.); (M.P.); (F.B.); (A.G.); (S.A.)
- III Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy; (G.C.); (A.L.R.)
| | - Cosmin Lucian Ciubotariu
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20122 Milan, Italy; (A.P.); (G.P.); (G.C.); (B.C.); (C.L.C.); (M.Z.); (A.R.); (M.P.); (F.B.); (A.G.); (S.A.)
- III Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy; (G.C.); (A.L.R.)
| | - Martina Zacheo
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20122 Milan, Italy; (A.P.); (G.P.); (G.C.); (B.C.); (C.L.C.); (M.Z.); (A.R.); (M.P.); (F.B.); (A.G.); (S.A.)
- III Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy; (G.C.); (A.L.R.)
| | - Andrea Rabbione
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20122 Milan, Italy; (A.P.); (G.P.); (G.C.); (B.C.); (C.L.C.); (M.Z.); (A.R.); (M.P.); (F.B.); (A.G.); (S.A.)
- III Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy; (G.C.); (A.L.R.)
| | - Margherita Pieruzzi
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20122 Milan, Italy; (A.P.); (G.P.); (G.C.); (B.C.); (C.L.C.); (M.Z.); (A.R.); (M.P.); (F.B.); (A.G.); (S.A.)
- III Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy; (G.C.); (A.L.R.)
| | - Federico Barone
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20122 Milan, Italy; (A.P.); (G.P.); (G.C.); (B.C.); (C.L.C.); (M.Z.); (A.R.); (M.P.); (F.B.); (A.G.); (S.A.)
- III Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy; (G.C.); (A.L.R.)
| | - Matteo Passerini
- II Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy; (M.C.); (M.P.)
| | - Anna Lisa Ridolfo
- III Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy; (G.C.); (A.L.R.)
| | - Giuliano Rizzardini
- I Division of Infectious Diseases, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy;
| | - Andrea Gori
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20122 Milan, Italy; (A.P.); (G.P.); (G.C.); (B.C.); (C.L.C.); (M.Z.); (A.R.); (M.P.); (F.B.); (A.G.); (S.A.)
- II Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy; (M.C.); (M.P.)
- Centre for Multidisciplinary Research in Health Science (MACH), Università degli Studi di Milano, 20122 Milan, Italy
| | - Spinello Antinori
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20122 Milan, Italy; (A.P.); (G.P.); (G.C.); (B.C.); (C.L.C.); (M.Z.); (A.R.); (M.P.); (F.B.); (A.G.); (S.A.)
- III Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy; (G.C.); (A.L.R.)
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Rathore SS, Wint ZS, Goyal A, Jeswani BM, Farrukh AM, Nieto-Salazar MA, Thugu TR, Erva S, Mehmood R, Toro-Velandia AC, Aneis H, Ratnani S, Al Shyyab IMY. Prevalence and outcomes of upper gastrointestinal bleeding in COVID-19: A systematic review and meta-analysis. Rev Med Virol 2024; 34:e2509. [PMID: 38282392 DOI: 10.1002/rmv.2509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/02/2023] [Accepted: 12/17/2023] [Indexed: 01/30/2024]
Abstract
Upper gastrointestinal bleeding (UGIB) in COVID-19 presents challenges in patient management. Existing studies lack comprehensive review due to varied designs, samples, and demographics. A meta-analysis can provide valuable insights into the incidence, features, and outcomes of UGIB in COVID-19. A comprehensive literature search was carried out using several databases. We considered all appropriate observational studies from all over the world. Mantel-Haenszel odds ratios and associated 95% confidence intervals (CIs) were produced to report the overall effect size using random effect models. Besides, Random effects models were used to calculate the overall pooled prevalence. Funnel plots, Egger regression tests, and Begg-Mazumdar's rank correlation test were used to appraise publication bias. Data from 21 articles consisting of 26,933 COVID-19 patients were considered. The pooled estimate of UGIB prevalence in patients admitted with COVID-19 across studies was 2.10% (95% CI, 1.23-3.13). Similarly, the overall pooled estimate for severity, mortality, and rebleeding in COVID-19 patients with UGIB was 55% (95% CI, 37.01-72.68), 29% (95% CI, 19.26-40.20) and 12.7% (95% CI, 7.88-18.42) respectively. Further, UGIB in COVID-19 patients was associated with increased odds of severity (OR = 3.52, 95% CI 1.80-6.88, P = 0.001) and mortality (OR = 2.16, 95% CI 1.33-3.51, P = 0.002) compared with patients without UGIB. No significant publication bias was evident in the meta-analysis. The results of our study indicate that UGIB in individuals with COVID-19 is linked to negative outcomes such as severe illness, higher mortality rates, and an increased risk of re-bleeding. These findings highlight the significance of identifying UGIB as a significant complication in COVID-19 cases and emphasise the importance of timely clinical assessment and proper treatment.
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Affiliation(s)
| | - Zario Shai Wint
- All American Institute of Medical Sciences, Black River, Jamaica
| | - Aman Goyal
- Department of Internal Medicine, Seth GS Medical College and KEM Hospital, Mumbai, India
| | | | | | | | | | - Snigdha Erva
- MNR Medical College and Hospital, Sangareddy, India
| | - Raafay Mehmood
- First Faculty of Medicine, Charles University, Prague, Czech Republic
| | | | - Hamam Aneis
- Department of Internal Medicine, UPMC, Mckeesport, Pennsylvania, USA
| | - Sunny Ratnani
- Saint James School of Medicine, The Quarter, Anguilla
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4
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Papi A, Stapleton RD, Shore PM, Bica MA, Chen Y, Larbig M, Welte T. Efficacy and Safety of Garadacimab in Combination with Standard of Care Treatment in Patients with Severe COVID-19. Lung 2023; 201:159-170. [PMID: 37000214 PMCID: PMC10064633 DOI: 10.1007/s00408-023-00615-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 03/21/2023] [Indexed: 04/01/2023]
Abstract
BACKGROUND Garadacimab, a fully human IgG4 monoclonal antibody, inhibits the kallikrein-kinin pathway at a key initiator, activated coagulation factor XII (FXIIa), and may play a protective role in preventing the progression of COVID-19. This phase 2 study evaluated the efficacy and safety of garadacimab plus standard of care (SOC) versus placebo plus SOC in patients with severe COVID-19. METHODS Patients hospitalised with COVID-19 were randomised (1:1) to a single intravenous dose of garadacimab (700 mg) plus SOC or placebo plus SOC. Co-primary endpoint was incidence of endotracheal intubation or death between randomisation and Day 28. All-cause mortality, safety and pharmacokinetic/pharmacodynamic parameters were assessed. RESULTS No difference in incidence of tracheal intubation or death (p = 0.274) or all-cause mortality was observed (p = 0.382). Garadacimab was associated with a lower incidence of treatment-emergent adverse events (60.3% vs 67.8%) and fewer serious adverse events (34 vs 45 events) versus placebo. No garadacimab-related deaths or bleeding events were reported, including in the 45.9% (n = 28/61) of patients who received concomitant heparin. Prolonged activated partial thromboplastin time (aPTT), and increased coagulation factor XII (FXII) levels were observed with garadacimab versus placebo to Day 14, whilst FXIIa-mediated kallikrein activity (FXIIa-mKA) was suppressed to Day 28. CONCLUSION In patients with severe COVID-19, garadacimab did not confer a clinical benefit over placebo. Transient aPTT prolongation and suppressed FXIIa-mKA showed target engagement of garadacimab that was not associated with bleeding events even with concomitant anticoagulant use. The safety profile of garadacimab was consistent with previous studies in patients with hereditary angioedema. CLINICALTRIALS GOV IDENTIFIER NCT04409509. Date of registration: 28 May, 2020.
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Affiliation(s)
- Alberto Papi
- Respiratory Department, University of Ferrara, 44100, Ferrara, Italy.
| | - Renee D Stapleton
- Pulmonary and Critical Care Medicine, University of Vermont, Burlington, VT, USA
| | - Paul M Shore
- Clinical Development, CSL Behring, King of Prussia, USA
| | - Mihai Alexandru Bica
- Global Clinical Safety and Pharmacovigilance, CSL Behring Innovation, Marburg, Germany
| | - Younan Chen
- Biostatistics, CSL Behring, King of Prussia, USA
| | | | - Tobias Welte
- Department of Pulmonary and Infectious Diseases, Hannover Medical School, Hannover, Germany
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5
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Abrashev H, Ananiev J, Georgieva E. Case Report: Spontaneous Left Inferior Epigastric Artery Injury in a COVID-19 Female Patient Undergoing Anticoagulation Therapy. J Clin Med 2023; 12:jcm12051842. [PMID: 36902629 PMCID: PMC10003174 DOI: 10.3390/jcm12051842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/20/2023] [Accepted: 02/23/2023] [Indexed: 03/02/2023] Open
Abstract
Since the beginning of the pandemic, a recommendation was made for the use of anticoagulants in high-risk hospitalized patients. This therapeutic approach has positive and negative effects regarding the outcome of the disease. Anticoagulant therapy prevents thromboembolic events, but it can also lead to spontaneous hematoma formation, or be accompanied by massive active bleeding. We present a 63-year-old COVID-19-positive female patient with a massive retroperitoneal hematoma and spontaneous left inferior epigastric artery injury.
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Affiliation(s)
- Hristo Abrashev
- Department of Special Surgery, Orthopedics, and Traumatology, Clinic of Vascular Surgery, Medical Faculty, Trakia University, 6000 Stara Zagora, Bulgaria
| | - Julian Ananiev
- Department of General and Clinical Pathology, Forensic Medicine and Deontology and Dermatovenereology, Medical Faculty, Trakia University, 6000 Stara Zagora, Bulgaria
| | - Ekaterina Georgieva
- Department of General and Clinical Pathology, Forensic Medicine and Deontology and Dermatovenereology, Medical Faculty, Trakia University, 6000 Stara Zagora, Bulgaria
- Department of Chemistry and Biochemistry, Medical Faculty, Trakia University, 6000 Stara Zagora, Bulgaria
- Correspondence: ; Tel.: +359-878552006
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Incidence, risk factors, and clinical impact of major bleeding in hospitalized patients with COVID-19: a sub-analysis of the CLOT-COVID Study. Thromb J 2022; 20:53. [PMID: 36127738 PMCID: PMC9485792 DOI: 10.1186/s12959-022-00414-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 08/07/2022] [Indexed: 11/10/2022] Open
Abstract
Background The coronavirus disease 2019 (COVID-19) causes extensive coagulopathy and a potential benefit of anticoagulation therapy has been documented for prevention of thromboembolic events. Bleeding events has also been reported as a notable complication; whereas, the incidence, risks, and clinical impact of bleeding remain unclear. Method The CLOT-COVID Study was a nationwide, retrospective, multicenter cohort study on consecutive hospitalized patients with COVID-19 in Japan between April 2021 and September 2021. In this sub-analysis, we compared the characteristics of patients with and without major bleeding; moreover, we examined the risk factors for and clinical impact of bleeding events. Results Among 2882 patients with COVID-19, 57 (2.0%) had major bleeding. The incidence of major bleeding increased with COVID-19 severity as follows: 0.5%, 2.3%, and 12.3% in patients with mild, moderate, and severe COVID-19, respectively. COVID-19 severity, history of major bleeding, and anticoagulant type/dose were independently and additively associated with the bleeding incidence. Compared with patients without major bleeding, those with major bleeding exhibited a longer duration of hospitalization (9 [6–14] vs 28 [19–43] days, P < 0.001) and higher mortality during hospitalization (4.9% vs. 35.1%, P < 0.001). Conclusions In the real-world clinical practice, the incidence of major bleeding was not uncommon, especially in patients with severe COVID-19. Independent risk factors for major bleeding included history of major bleeding, COVID-19 severity, and anticoagulant use, which could be associated with poor clinical outcomes including higher mortality. Precise recognition of the risks for bleeding may be helpful for an optimal use of anticoagulants and for better outcomes in patients with COVID-19.
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7
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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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8
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Wiegele M, Laxar D, Schaden E, Baierl A, Maleczek M, Knöbl P, Hermann M, Hermann A, Zauner C, Gratz J. Subcutaneous Enoxaparin for Systemic Anticoagulation of COVID-19 Patients During Extracorporeal Life Support. Front Med (Lausanne) 2022; 9:879425. [PMID: 35899208 PMCID: PMC9309531 DOI: 10.3389/fmed.2022.879425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 06/22/2022] [Indexed: 12/11/2022] Open
Abstract
Background Extracorporeal membrane oxygenation, with an inherent requirement for anticoagulation to avoid circuit thrombosis, is a key element in the treatment of respiratory failure associated with COVID-19. Anticoagulation remains challenging, the standard of care being intravenous continuous administration of unfractionated heparin. Yet regimens vary. Some intensive care units in our center have successfully used enoxaparin subcutaneously in recent years and throughout the pandemic. Methods We retrospectively analyzed adult COVID-19 patients with respiratory failure who had been systemically anticoagulated using either enoxaparin or unfractionated heparin. The choice of anticoagulant therapy was based on the standard of the intensive care unit. Defined thromboembolic and hemorrhagic events were analyzed as study endpoints. Results Of 98 patients, 62 had received enoxaparin and 36 unfractionated heparin. All hazard ratios for the thromboembolic (3.43; 95% CI: 1.08–10.87; p = 0.04), hemorrhagic (2.58; 95% CI: 1.03–6.48; p = 0.04), and composite (2.86; 95% CI: 1.41–5.92; p = 0.007) endpoints favored enoxaparin, whose efficient administration was verified by peak levels of anti-factor Xa (median: 0.45 IU ml−1; IQR: 0.38; 0.56). Activated partial thromboplastin time as well as thrombin time differed significantly (both p<0.001) between groups mirroring the effect of unfractionated heparin. Conclusions This study demonstrates the successful use of subcutaneous enoxaparin for systemic anticoagulation in patients with COVID-19 during extracorporeal membrane oxygenation. Our findings are to be confirmed by future prospective, randomized, controlled trials.
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Affiliation(s)
- Marion Wiegele
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Daniel Laxar
- Ludwig Boltzmann Institute Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria
| | - Eva Schaden
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria
| | - Andreas Baierl
- Department of Statistics and Operations Research University of Vienna, Vienna, Austria
| | - Mathias Maleczek
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria
| | - Paul Knöbl
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Martina Hermann
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria
| | - Alexander Hermann
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Christian Zauner
- Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Johannes Gratz
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
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9
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Bleeding and thrombotic events in patients with severe COVID-19 supported with extracorporeal membrane oxygenation: a nationwide cohort study. Intensive Care Med 2022; 48:1039-1052. [PMID: 35829723 DOI: 10.1007/s00134-022-06794-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 06/01/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE To describe bleeding and thrombotic events and their risk factors in patients receiving extracorporeal membrane oxygenation (ECMO) for severe coronavirus disease 2019 (COVID-19) and to evaluate their impact on in-hospital mortality. METHODS The ECMOSARS registry included COVID-19 patients supported by ECMO in France. We analyzed all patients included up to March 31, 2022 without missing data regarding bleeding and thrombotic events. The association of bleeding and thrombotic events with in-hospital mortality and pre-ECMO variables was assessed using multivariable logistic regression models. RESULTS Among 620 patients supported by ECMO, 29% had only bleeding events, 16% only thrombotic events and 20% both bleeding and thrombosis. Cannulation site (18% of patients), ear nose and throat (12%), pulmonary bleeding (9%) and intracranial hemorrhage (8%) were the most frequent bleeding types. Device-related thrombosis and pulmonary embolism/thrombosis accounted for most of thrombotic events. In-hospital mortality was 55.7%. Bleeding events were associated with in-hospital mortality (adjusted odds ratio (adjOR) = 2.91[1.94-4.4]) but not thrombotic events (adjOR = 1.02[0.68-1.53]). Intracranial hemorrhage was strongly associated with in-hospital mortality (adjOR = 13.5[4.4-41.5]). Ventilation duration before ECMO ≥ 7 days and length of ECMO support were associated with bleeding. Thrombosis-associated factors were fibrinogen ≥ 6 g/L and length of ECMO support. CONCLUSIONS In a nationwide cohort of COVID-19 patients supported by ECMO, bleeding incidence was high and associated with mortality. Intracranial hemorrhage incidence was higher than reported for non-COVID patients and carried the highest risk of death. Thrombotic events were less frequent and not associated with mortality. Length of ECMO support was associated with a higher risk of both bleeding and thrombosis, supporting the development of strategies to minimize ECMO duration.
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10
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Lee Y, Jehangir Q, Lin CH, Li P, Sule AA, Poisson L, Balijepally V, Halabi AR, Patel K, Krishnamoorthy G, Nair GB. 3D-PAST: Risk Assessment Model for Predicting Venous Thromboembolism in COVID-19. J Clin Med 2022; 11:jcm11143949. [PMID: 35887713 PMCID: PMC9325096 DOI: 10.3390/jcm11143949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 06/25/2022] [Accepted: 07/04/2022] [Indexed: 12/22/2022] Open
Abstract
Hypercoagulability is a recognized feature in SARS-CoV-2 infection. There exists a need for a dedicated risk assessment model (RAM) that can risk-stratify hospitalized COVID-19 patients for venous thromboembolism (VTE) and guide anticoagulation. We aimed to build a simple clinical model to predict VTE in COVID-19 patients. This large-cohort, retrospective study included adult patients admitted to four hospitals with PCR-confirmed SARS-CoV-2 infection. Model training was performed on 3531 patients hospitalized between March and December 2020 and validated on 2508 patients hospitalized between January and September 2021. Diagnosis of VTE was defined as acute deep vein thrombosis (DVT) or pulmonary embolism (PE). The novel RAM was based on commonly available parameters at hospital admission. LASSO regression and logistic regression were performed, risk scores were assigned to the significant variables, and cutoffs were derived. Seven variables with assigned scores were delineated as: DVT History = 2; High D-Dimer (>500−2000 ng/mL) = 2; Very High D-Dimer (>2000 ng/mL) = 5; PE History = 2; Low Albumin (<3.5 g/dL) = 1; Systolic Blood Pressure <120 mmHg = 1, Tachycardia (heart rate >100 bpm) = 1. The model had a sensitivity of 83% and specificity of 53%. This simple, robust clinical tool can help individualize thromboprophylaxis for COVID-19 patients based on their VTE risk category.
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Affiliation(s)
- Yi Lee
- Department of Medicine, St. Joseph Mercy Oakland Hospital, Pontiac, MI 48341, USA; (Q.J.); (A.A.S.); (G.K.)
- Correspondence: or ; Tel.: +1-(248) 858-3000
| | - Qasim Jehangir
- Department of Medicine, St. Joseph Mercy Oakland Hospital, Pontiac, MI 48341, USA; (Q.J.); (A.A.S.); (G.K.)
| | - Chun-Hui Lin
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI 48202, USA; (C.-H.L.); (P.L.); (L.P.)
| | - Pin Li
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI 48202, USA; (C.-H.L.); (P.L.); (L.P.)
| | - Anupam A. Sule
- Department of Medicine, St. Joseph Mercy Oakland Hospital, Pontiac, MI 48341, USA; (Q.J.); (A.A.S.); (G.K.)
- Department of Informatics, St. Joseph Mercy Oakland Hospital, Pontiac, MI 48341, USA
| | - Laila Poisson
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI 48202, USA; (C.-H.L.); (P.L.); (L.P.)
| | | | - Abdul R. Halabi
- Division of Cardiology, St. Joseph Mercy Oakland Hospital, Pontiac, MI 48341, USA; (A.R.H.); (K.P.)
- William Beaumont School of Medicine, Oakland University, Auburn Hills, MI 48307, USA;
| | - Kiritkumar Patel
- Division of Cardiology, St. Joseph Mercy Oakland Hospital, Pontiac, MI 48341, USA; (A.R.H.); (K.P.)
| | - Geetha Krishnamoorthy
- Department of Medicine, St. Joseph Mercy Oakland Hospital, Pontiac, MI 48341, USA; (Q.J.); (A.A.S.); (G.K.)
| | - Girish B. Nair
- William Beaumont School of Medicine, Oakland University, Auburn Hills, MI 48307, USA;
- Division of Pulmonary and Critical Care Medicine, Beaumont Health System, Royal Oak, MI 48183, USA
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11
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Sochet AA, Morrison JM, Jaffray J, Godiwala N, Wilson HP, Thornburg CD, Bhat RV, Zia A, Lawrence C, Kudchadkar SR, Hamblin F, Russell CJ, Streiff MB, Spyropoulos AC, Amankwah EK, Goldenberg NA. Enoxaparin Thromboprophylaxis in Children Hospitalized for COVID-19: A Phase 2 Trial. Pediatrics 2022; 150:e2022056726. [PMID: 35484817 DOI: 10.1542/peds.2022-056726] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Evidence regarding the safety and efficacy of anticoagulant thromboprophylaxis among pediatric patients hospitalized for coronavirus disease 2019 (COVID-19) is limited. We sought to evaluate safety, dose-finding, and preliminary efficacy of twice-daily enoxaparin as primary thromboprophylaxis among children hospitalized for symptomatic COVID-19, including primary respiratory infection and multisystem inflammatory syndrome in children (MISC). METHODS We performed a phase 2, multicenter, prospective, open-label, single-arm clinical trial of twice-daily enoxaparin (initial dose: 0.5mg/kg per dose; max: 60mg; target anti-Xa activity: 0.20-0.49IU/mL) as primary thromboprophylaxis for children <18 years of age hospitalized for symptomatic COVID-19. Study endpoints included: cumulative incidence of International Society of Thrombosis and Haemostasis-defined clinically relevant bleeding; enoxaparin dose-requirements; and cumulative incidence of venous thromboembolism within 30-days of hospital discharge. Descriptive statistics summarized endpoint estimates that were further evaluated by participant age (±12 years) and clinical presentation. RESULTS Forty children were enrolled and 38 met analyses criteria. None experienced clinically relevant bleeding. Median (interquartile range) dose to achieve target anti-Xa levels was 0.5 mg/kg (0.48-0.54). Dose-requirement did not differ by age (0.5 [0.46-0.52] mg/kg for age ≥12 years versus 0.52 [0.49-0.55] mg/kg for age <12 years, P = .51) but was greater for participants with MISC (0.52 [0.5-0.61] mg/kg) as compared with primary COVID-19 (0.48 [0.39-0.51] mg/kg, P = .010). Two children (5.3%) developed central-venous catheter-related venous thromboembolism. No serious adverse events were related to trial intervention. CONCLUSIONS Among children hospitalized for COVID-19, thromboprophylaxis with twice-daily enoxaparin appears safe and warrants further investigation to assess efficacy.
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Affiliation(s)
| | | | - Julie Jaffray
- Department of Pediatrics, Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Nihal Godiwala
- Department of Pediatrics, Louisiana State University School of Medicine, New Orleans, Louisiana
| | - Hope P Wilson
- Department of Pediatrics, University of Alabama School of Medicine, Birmingham, Alabama
| | - Courtney D Thornburg
- Department of Pediatrics, University of California San Diego, La Jolla, California Division of Hematology and Oncology, Rady Children's Hospital San Diego, San Diego, California
| | - Rukhmi V Bhat
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ayesha Zia
- Department of Pediatrics, The University of Texas Southwestern, Dallas, Texas
| | | | - Sapna R Kudchadkar
- Critical Care Medicine
- Pediatrics
- Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Christopher J Russell
- Department of Pediatrics, Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California
| | | | - Alex C Spyropoulos
- Department of Medicine, Zucker School of Medicine at Hofstra and Northwell and Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Ernest K Amankwah
- Departments of Anesthesia
- Pediatrics
- Oncology, Johns Hopkins All Children's Institute for Clinical and Translational Research
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12
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Muñoz OM, Ruiz-Talero P, Hernández-Florez C, Lombo-Moreno CE, Casallas-Rivera MA, Mayorga-Hernández CA. Validation of the PESI Scale to Predict in-Hospital Mortality in Patients with Pulmonary Thromboembolism Secondary to SARS CoV - 2 Infection. Clin Appl Thromb Hemost 2022; 28:10760296221102940. [PMID: 35593084 PMCID: PMC9125100 DOI: 10.1177/10760296221102940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To evaluate the discriminative ability and the calibration of the Pulmonary Embolism Severity Index (PESI) to predict in-hospital mortality in patients with Pulmonary Embolism (PE) secondary to COVID 19 in two hospitals in Bogotá. METHODS External validation study of a prediction model based on a retrospective cohort of patients with PE secondary to COVID-19 treated at Hospital Universitario San Ignacio and Hospital universitario La Samaritana, between March 2020 and August 2021. Calibration of the scale was evaluated using the Hosmer-Lemeshow test and a calibration belt diagram. Discrimination ability was evaluated using a ROC curve. RESULTS 272 patients were included (median age 61.5 years, male 58.8%). PE was diagnosed in 45.6% of the patients at the time of admission. Of the remaining 54.4%, 95.9% received thromboprophylaxis until the time of diagnosis.17.6% of the patients died. Regarding calibration, the scale systematically underestimates risk in all classes of PESI. For class I, the ratio of observed/expected events was 4.4 vs 0.8%, class II 4.8 vs 1.8%, class III 15.2 vs 4.2%, class IV 14.3 vs 5.9% and class V 46.7 vs 5.8%. The calibration test rejected the adequate calibration hypothesis (p < 0.001). The discriminatory ability was adequate (AUC = 0.7128, 95% CI 0.63-0.79). CONCLUSIONS The PESI scale in patients with PE secondary to COVID 19 underestimates the risk of in-hospital mortality, while maintaining adequate discrimination. It is suggested not to use the PESI scale until it is recalibrated in this context.
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Affiliation(s)
- Oscar M Muñoz
- Internal Medicine Department, Pontificia Universidad Javeriana, Bogota, Colombia,Hospital Universitario San Ignacio, Bogota, Colombia
| | - Paula Ruiz-Talero
- Internal Medicine Department, Pontificia Universidad Javeriana, Bogota, Colombia,Hospital Universitario San Ignacio, Bogota, Colombia
| | - Catalina Hernández-Florez
- Internal Medicine Department, Pontificia Universidad Javeriana, Bogota, Colombia,Hospital Universitario San Ignacio, Bogota, Colombia
| | - Carlos Ernesto Lombo-Moreno
- Internal Medicine Department, Pontificia Universidad Javeriana, Bogota, Colombia,Carlos Ernesto Lombo-Moreno, Internal Medicine, Pontificia Universidad Javeriana, Cra 7 # 40-62. Piso 7, Bogotá, Colombia.
| | - Martha Alejandra Casallas-Rivera
- RICAVTA investigation group, Bogota, Colombia,Internal Medicine Department, Hospital Universitario La Samaritana, Bogota, Colombia,Universidad de La Sabana, Chia, Colombia
| | - Carol Anne Mayorga-Hernández
- Internal Medicine Department, Hospital Universitario La Samaritana, Bogota, Colombia,Universidad de La Sabana, Chia, Colombia
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13
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Yasuda H, Mayumi T, Okano H. Efficacy of different anticoagulant doses for patients with COVID-19: a systematic review and network meta-analysis. Infection 2022; 50:1453-1463. [PMID: 35355236 PMCID: PMC8966866 DOI: 10.1007/s15010-022-01809-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 03/17/2022] [Indexed: 02/08/2023]
Abstract
Purpose Methods Results Conclusions Trial registration number and registration dates Supplementary Information
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14
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Mohamed A, Shemanski SM, Saad MO, Ploetz J, Haines MM, Schlachter AB, Hamarshi MS. Anti-Xa Directed Thromboprophylaxis in Critically Ill Patients with Coronavirus Disease 2019. Clin Appl Thromb Hemost 2022; 28:10760296221116350. [PMID: 35924413 PMCID: PMC9358597 DOI: 10.1177/10760296221116350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: To compare Anti-Xa directed thromboprophylaxis using low molecular weight heparin (LMWH) (anti-Xa peak goal 0.2-0.5 IU/mL) to alternative anticoagulation strategies in critically ill COVID-19 patients. Methods: This was a retrospective, multicenter, single health-system study. Primary outcomes were thromboembolic events and clinically important bleeding events. Secondary outcomes included dosing comparisons between LMWH cohorts. Main Results: A total of 695 patients were included. No differences were found in the incidence of thrombotic events with any of the dosing strategies. The incidence of major bleeding was significantly higher in the standard dose thromboprophylaxis, intermediate dose subcutaneous heparin (SQH), and therapeutic anticoagulation cohorts. Forty-nine percent of patients within the anti-Xa directed group had their first anti-Xa peak at goal, while 43% were above goal. Patients who had levels above goal had dose modifications made, therefore anti-Xa directed LMWH resulted in significantly lower total daily doses compared to intermediate dose LMWH. Conclusions: Anti-Xa directed LMWH dosing provided comparable thromboprophylaxis with lower total daily doses of LMWH in critically ill COVID-19 patients. Further randomized controlled trials are needed to confirm our findings.
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Affiliation(s)
- Adham Mohamed
- 24091Saint Luke's Hospital of Kansas City, Kansas City, MO, USA
| | | | - Mohamed O Saad
- Al-Wakra Hospital, 36977Hamad Medical Corporation, Doha, Qatar
| | | | - Michelle M Haines
- 24091Saint Luke's Hospital of Kansas City, Kansas City, MO, USA.,12272University of Missouri-Kansas City, School of Medicine, Kansas City, MO, USA
| | - Andrew B Schlachter
- 24091Saint Luke's Hospital of Kansas City, Kansas City, MO, USA.,12272University of Missouri-Kansas City, School of Medicine, Kansas City, MO, USA
| | - Majdi S Hamarshi
- 24091Saint Luke's Hospital of Kansas City, Kansas City, MO, USA.,12272University of Missouri-Kansas City, School of Medicine, Kansas City, MO, USA
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15
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Zhang S, Li Y, Liu G, Su B. Intermediate-to-therapeutic versus prophylactic anticoagulation for coagulopathy in hospitalized COVID-19 patients: a systemic review and meta-analysis. Thromb J 2021; 19:91. [PMID: 34819094 PMCID: PMC8611638 DOI: 10.1186/s12959-021-00343-1] [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: 09/30/2021] [Accepted: 11/04/2021] [Indexed: 02/08/2023] Open
Abstract
Background Anticoagulation in hospitalized COVID-19 patients has been associated with survival benefit; however, the optimal anticoagulant strategy has not yet been defined. The objective of this meta-analysis was to investigate the effect of intermediate-to-therapeutic versus prophylactic anticoagulation for thromboprophylaxis on the primary outcome of in-hospital mortality and other patient-centered secondary outcomes in COVID-19 patients. Methods MEDLINE, EMBASE, and Cochrane databases were searched from inception to August 10th 2021. Cohort studies and randomized clinical trials that assessed the efficacy and safety of intermediate-to-therapeutic versus prophylactic anticoagulation in hospitalized COVID-19 patients were included. Baseline characteristics and relevant data of each study were extracted in a pre-designed standardized data-collection form. The primary outcome was all-cause in-hospital mortality and the secondary outcomes were incidence of thrombotic events and incidence of any bleeding and major bleeding. Pooled analysis with random effects models yielded relative risk with 95 % CIs. Results This meta-analysis included 42 studies with 28,055 in-hospital COVID-19 patients totally. Our pooled analysis demonstrated that intermediate-to-therapeutic anticoagulation was not associated with lower in-hospital mortality (RR=1.12, 95 %CI 0.99-1.25, p=0.06, I2=77 %) and lower incidence of thrombotic events (RR=1.30, 95 %CI 0.79-2.15, p=0.30, I2=88 %), but increased the risk of any bleeding events (RR=2.16, 95 %CI 1.79-2.60, p<0.01, I2=31 %) and major bleeding events significantly (RR=2.10, 95 %CI 1.77-2.51, p<0.01, I2=11 %) versus prophylactic anticoagulation. Moreover, intermediate-to-therapeutic anticoagulation decreased the incidence of thrombotic events (RR=0.71, 95 %CI 0.56-0.89, p=0.003, I2=0 %) among critically ill COVID-19 patients admitted to intensive care units (ICU), with increased bleeding risk (RR=1.66, 95 %CI 1.37-2.00, p<0.01, I2=0 %) and unchanged in-hospital mortality (RR=0.94, 95 %CI 0.79-1.10, p=0.42, I2=30 %) in such patients. The Grading of Recommendation, Assessment, Development, and Evaluation certainty of evidence ranged from very low to moderate. Conclusions We recommend the use of prophylactic anticoagulation against intermediate-to-therapeutic anticoagulation among unselected hospitalized COVID-19 patients considering insignificant survival benefits but higher risk of bleeding in the escalated thromboprophylaxis strategy. For critically ill COVID-19 patients, the benefits of intermediate-to-therapeutic anticoagulation in reducing thrombotic events should be weighed cautiously because of its association with higher risk of bleeding. Trial registration The protocol was registered at PROSPERO on August 17th 2021 (CRD42021273780). Graphical abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1186/s12959-021-00343-1.
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Affiliation(s)
- Sirui Zhang
- West China School of Medicine, Sichuan University, 610041, Chengdu, China
| | - Yupei Li
- Department of Nephrology, Med+ Biomaterial Institute, West China Hospital, Sichuan University, 610041, Chengdu, China.,Institute for Disaster Management and Reconstruction, Sichuan University, 610207, Chengdu, China
| | - Guina Liu
- West China School of Medicine, Sichuan University, 610041, Chengdu, China
| | - Baihai Su
- West China School of Medicine, Sichuan University, 610041, Chengdu, China. .,Department of Nephrology, Med+ Biomaterial Institute, West China Hospital, Sichuan University, 610041, Chengdu, China. .,Institute for Disaster Management and Reconstruction, Sichuan University, 610207, Chengdu, China. .,The first People's Hospital of Shuangliu District, 610200, Chengdu, China. .,Med-X Center for Materials, Sichuan University, 610041, Chengdu, China.
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16
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American Society of Hematology living guidelines on the use of anticoagulation for thromboprophylaxis in patients with COVID-19: May 2021 update on the use of intermediate-intensity anticoagulation in critically ill patients. Blood Adv 2021; 5:3951-3959. [PMID: 34474482 PMCID: PMC8416320 DOI: 10.1182/bloodadvances.2021005493] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 08/09/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND COVID-19-related critical illness is associated with an increased risk of venous thromboembolism (VTE). OBJECTIVE These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in making decisions about the use of anticoagulation for thromboprophylaxis in patients with COVID-19-related critical illness who do not have confirmed or suspected VTE. METHODS ASH formed a multidisciplinary guideline panel that included 3 patient representatives and applied strategies to minimize potential bias from conflicts of interest. The McMaster University Grading of Recommendations Assessment, Development and Evaluation (GRADE) Centre supported the guideline development process by performing systematic evidence reviews (up to 5 March 2021). The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The panel used the GRADE approach to assess evidence and make recommendations, which were subject to public comment. This is an update on guidelines published in February 2021. RESULTS The panel agreed on 1 additional recommendation. The panel issued a conditional recommendation in favor of prophylactic-intensity over intermediate-intensity anticoagulation in patients with COVID-19-related critical illness who do not have confirmed or suspected VTE. CONCLUSIONS This recommendation was based on low certainty in the evidence, which underscores the need for additional high-quality, randomized, controlled trials comparing different intensities of anticoagulation in critically ill patients. Other key research priorities include better evidence regarding predictors of thrombosis and bleeding risk in critically ill patients with COVID-19 and the impact of nonanticoagulant therapies (eg, antiviral agents, corticosteroids) on thrombotic risk.
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17
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Anderson JJ, Ho FK, Niedzwiedz CL, Katikireddi SV, Celis-Morales C, Iliodromiti S, Welsh P, Pellicori P, Demou E, Hastie CE, Lyall DM, Gray SR, Forbes JF, Gill JMR, Mackay DF, Berry C, Cleland JGF, Sattar N, Pell JP. Remote history of VTE is associated with severe COVID-19 in middle and older age: UK Biobank cohort study. J Thromb Haemost 2021; 19:2533-2538. [PMID: 34242477 PMCID: PMC8420476 DOI: 10.1111/jth.15452] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 06/24/2021] [Accepted: 07/06/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a common, life-threatening complication of COVID-19 infection. COVID-19 risk-prediction models include a history of VTE. However, it is unclear whether remote history (>9 years previously) of VTE also confers increased risk of COVID-19. OBJECTIVES To investigate possible association between VTE and COVID-19 severity, independent of other risk factors. METHODS Cohort study of UK Biobank participants recruited between 2006 and 2010. Baseline data, including history of VTE, were linked to COVID-19 test results, COVID-19-related hospital admissions, and COVID-19 deaths. The risk of COVID-19 hospitalization or death was compared for participants with a remote history VTE versus without. Poisson regression models were run univariately then adjusted stepwise for sociodemographic, lifestyle, and comorbid covariates. RESULTS After adjustment for sociodemographic and lifestyle confounders and comorbid conditions, remote history of VTE was associated with nonfatal community (RR 1.61, 95% CI 1.02-2.54, p = .039), nonfatal hospitalized (RR 1.52, 95% CI 1.06-2.17, p = .024) and severe (hospitalized or fatal) (RR 1.40, 95% CI 1.04-1.89, p = .025) COVID-19. Associations with remote history of VTE were stronger among men (severe COVID-19: RR 1.68, 95% CI 1.14-2.42, p = .009) than for women (severe COVID-19: RR 1.07, 95% CI 0.66-1.74, p = .786). CONCLUSION Our findings support inclusion of remote history of VTE in COVID-19 risk-prediction scores, and consideration of sex-specific risk scores.
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Affiliation(s)
- Jana J Anderson
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Frederick K Ho
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | | | - Srinivasa Vittal Katikireddi
- MRC/CSO Social and Public Health Sciences Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Carlos Celis-Morales
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, BHF Glasgow Cardiovascular Research Centre, Glasgow, UK
| | - Stamatina Iliodromiti
- Centre of Women's Health, Yvonne Carter Building, Queen Mary University of London, London, UK
| | - Paul Welsh
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, BHF Glasgow Cardiovascular Research Centre, Glasgow, UK
| | - Pierpaolo Pellicori
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Evangelia Demou
- MRC/CSO Social and Public Health Sciences Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Claire E Hastie
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Donald M Lyall
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Stuart R Gray
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, BHF Glasgow Cardiovascular Research Centre, Glasgow, UK
| | - John F Forbes
- School of Medicine, University of Limerick, Limerick, Ireland
| | - Jason M R Gill
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, BHF Glasgow Cardiovascular Research Centre, Glasgow, UK
| | - Daniel F Mackay
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Colin Berry
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, BHF Glasgow Cardiovascular Research Centre, Glasgow, UK
| | - John G F Cleland
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, BHF Glasgow Cardiovascular Research Centre, Glasgow, UK
| | - Jill P Pell
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
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18
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Demelo-Rodriguez P, Farfán-Sedano AI, Pedrajas JM, Llamas P, Sigüenza P, Jaras MJ, Quintana-Diaz M, Fernández-Capitán C, Bikdeli B, Jiménez D, Monreal M. Bleeding risk in hospitalized patients with COVID-19 receiving intermediate- or therapeutic doses of thromboprophylaxis. J Thromb Haemost 2021; 19:1981-1989. [PMID: 34018658 PMCID: PMC8237051 DOI: 10.1111/jth.15400] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 05/05/2021] [Accepted: 05/19/2021] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Some local protocols suggest using intermediate or therapeutic doses of anticoagulants for thromboprophylaxis in hospitalized patients with coronavirus disease 2019 (COVID-19). However, the incidence of bleeding, predictors of major bleeding, or the association between bleeding and mortality remain largely unknown. METHODS We performed a cohort study of patients hospitalized for COVID-19 that received intermediate or therapeutic doses of anticoagulants from March 25 to July 22, 2020, to identify those at increased risk for major bleeding. We used bivariate and multivariable logistic regression to explore the risk factors associated with major bleeding. RESULTS During the study period, 1965 patients were enrolled. Of them, 1347 (69%) received intermediate- and 618 (31%) therapeutic-dose anticoagulation, with a median duration of 12 days in both groups. During the hospital stay, 112 patients (5.7%) developed major bleeding and 132 (6.7%) had non-major bleeding. The 30-day all-cause mortality rate for major bleeding was 45% (95% confidence interval [CI]: 36%-54%) and for non-major bleeding 32% (95% CI: 24%-40%). Multivariable analysis showed increased risk for in-hospital major bleeding associated with D-dimer levels >10 times the upper normal range (hazard ratio [HR], 2.23; 95% CI, 1.38-3.59), ferritin levels >500 ng/ml (HR, 2.01; 95% CI, 1.02-3.95), critical illness (HR, 1.91; 95% CI, 1.14-3.18), and therapeutic-intensity anticoagulation (HR, 1.43; 95% CI, 1.01-1.97). CONCLUSIONS Among patients hospitalized with COVID-19 receiving intermediate- or therapeutic-intensity anticoagulation, a major bleeding event occurred in 5.7%. Use of therapeutic-intensity anticoagulation, critical illness, and elevated D-dimer or ferritin levels at admission were associated with increased risk for major bleeding.
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Affiliation(s)
- Pablo Demelo-Rodriguez
- Department of Internal Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | | | - Pilar Llamas
- Department of Hematology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Patricia Sigüenza
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - María Jesús Jaras
- Department of Internal Medicine, Hospital Cantoblanco, Madrid, Spain
| | | | | | - Behnood Bikdeli
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Yale/YNHH Center for Outcomes Research & Evaluation, New Haven, Connecticut, USA
- Cardiovascular Research Foundation, New York, New York, USA
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain
- Universidad de Alcalá (IRYCIS), Madrid, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Germans Trias i Pujol, Badalona, Spain
- Universidad Católica de Murcia, Universidad Autònoma de Barcelona, CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
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