A Systematic Review and a Meta-Analysis Comparing Prophylactic and Therapeutic Low Molecular Weight Heparins for Mortality Reduction in 32,688 COVID-19 Patients

Anticoagulant therapy in adult with COVID-19: a systematic review and meta-analysis of randomized controlled trial

Background

Blood coagulation dysfunction is a risk factor for adverse outcomes in patients with coronavirus disease 2019 (COVID-19), especially in severe cases. The evidence for the effects of anticoagulation therapy on prognosis of COVID-19 patients and its risk of causing bleeding events is accumulating. Here we conducted a meta-analysis to assess the efficacy and safety of anticoagulants in COVID-19 patients of different severity.

Methods

We searched PubMed, Embase databases, Cochrane Trials, OVID MEDLINE from December 2019 to April 2023. We included randomized controlled trials (RCTs) involving COVID-19 patients over 18 years of age, which explored the effect of anticoagulant and its dose on outcomes including all-cause mortality, bleeding events or thrombotic events. We calculated the risk ratio (RR) and its 95% confidence interval (CI) for each outcome. We also performed subgroup analyses to assess the impact of disease severity, using a fixed-effect model to test for heterogeneity. The risk of bias, publication bias, and the quality of evidence were also evaluated.

Results

A total of 20 RCTs were included for final analysis. When compared with standard care, anticoagulation treatment reduced all-cause mortality (RR 0.47, 95% CI: 0.29-0.76) and thrombotic events (RR 0.35, 95% CI: 0.15-0.83) in the whole population with COVID-19 (n=2,365), without increase in bleeding events (total: RR 1.47, 95% CI: 0.54-4.00). Most of the studies only enrolled non-severe patients (n=2,329), while the number of severe patients (n=36) was scarce. In RCTs compared therapeutical and prophylactic doses of anticoagulants, no significant difference in on all-cause mortality was found in the whole population and non-severe and severe subgroups (total: RR 1.01, 95% CI: 0.92-1.10; non-severe: RR 1.03, 95% CI: 0.81-1.32; severe: RR 1.00, 95% CI: 0.91-1.11). Therapeutical dose reduced risk of thrombotic events (total: RR 0.59, 95% CI: 0.48-0.73; subtotal of non-severe: RR 0.57, 95% CI: 0.39-0.84; Subtotal of severe: RR 0.61, 95% CI: 0.47-0.78), while risk of bleeding was increased (total: RR 1.98, 95% CI: 1.47-2.66; non-severe: RR 2.38, 95% CI: 1.56-3.62; severe: RR 1.63, 95% CI: 1.07-2.47). Study heterogeneity was found only in the analysis of effects of anticoagulants on risk of thrombotic events.

Conclusions

Anticoagulant therapy reduces all-cause mortality and risk of thrombosis in non-severe COVID-19 patients. Therapeutic dose of anticoagulant therapy can be considered in both non-severe and severe COVID-19 patients to reduce thrombosis, but may be associated with increased bleeding events.

Acute and Post-Acute COVID-19 Cardiovascular Complications: A Comprehensive Review

PURPOSE OF REVIEW

The risk of cardiovascular complications due to SARS-CoV-2 are significantly increased within the first 6 months of the infection. Patients with COVID-19 have an increased risk of death, and there is evidence that many may experience a wide range of post-acute cardiovascular complications. Our work aims to provide an update on current clinical aspects of diagnosis and treatment of cardiovascular manifestations during acute and long-term COVID-19.

RECENT FINDINGS

SARS-CoV-2 has been shown to be associated with increased incidence of cardiovascular complications such as myocardial injury, heart failure, and dysrhythmias, as well as coagulation abnormalities not only during the acute phase but also beyond the first 30 days of the infection, associated with high mortality and poor outcomes. Cardiovascular complications during long-COVID-19 were found regardless of comorbidities such as age, hypertension, and diabetes; nevertheless, these populations remain at high risk for the worst outcomes during post-acute COVID-19. Emphasis should be given to the management of these patients. Treatment with low-dose oral propranolol, a beta blocker, for heart rate management may be considered, since it was found to significantly attenuate tachycardia and improve symptoms in postural tachycardia syndrome, while for patients on ACE inhibitors or angiotensin-receptor blockers (ARBs), under no circumstances should these medications be withdrawn. In addition, in patients at high risk after hospitalization due to COVID-19, thromboprophylaxis with rivaroxaban 10 mg/day for 35 days improved clinical outcomes compared with no extended thromboprophylaxis. In this work we provide a comprehensive review on acute and post-acute COVID-19 cardiovascular complications, symptomatology, and pathophysiology mechanisms. We also discuss therapeutic strategies for these patients during acute and long-term care and highlight populations at risk. Our findings suggest that older patients with risk factors such as hypertension, diabetes, and medical history of vascular disease have worse outcomes during acute SARS-CoV-2 infection and are more likely to develop cardiovascular complications during long-COVID-19.

COVID-19 related peripheral arterial thrombotic events in intensive care unit and non-intensive care unit patients: A retrospective case series

OBJECTIVES

COVID-19 associated arterial thrombosis has been attributed to multiple inflammation and coagulation mechanisms. The aim of this study was to report the experience of a tertiary center on COVID-19 patients managed for acute peripheral arterial thrombosis.

METHODS

A single-center case series was conducted, including retrospectively collected data from all COVID-19 patients presenting arterial thrombosis, from March 2020 to February 2022. Intensive care unit (ICU) and non-ICU cases were included. The primary outcomes were mortality, successful revascularization, and amputation at 30 days.

RESULTS

Twenty patients presented peripheral arterial thrombosis (90% males, mean age 65 years (16-82 years)). Eighteen were diagnosed with the Delta variant and none was previously vaccinated. All cases presented acute lower limb ischemia; in 20% with bilateral involvement. Nine patients were hospitalized in the ward while 11 in the ICU. From the non-ICU cases, five presented Rutherford IIb and four cases, Rutherford's IIa ischemia. Six cases underwent revascularization (67%). Two of them were finally amputated (33%) and two died during hospitalization (33%). Two revascularizations were considered successful (33%). The ICU group presented mainly with Rutherford's III ischemia (54.5%). The mortality in the ICU cohort was 72.7%. Only one patient underwent successful revascularization and two were amputated in this subgroup. Early mortality was 50% for the total cohort while the type of management was not related to mortality.

CONCLUSIONS

Covid-19 related arterial thrombosis in non-vaccinated population is associated with 50% early mortality; increased up to 72% in the ICU patients. The amputation rate was 20% while only 40% of the revascularizations were considered successful.

Multisite spontaneous hematomas and bleeding in critically ill Chinese patients with COVID-19: two case reports and a literature review

BACKGROUND

Anticoagulation is recommended as a standardized therapy for COVID-19 patients according to the WHO guidelines. However, bleeding events have also been reported. Hemorrhage or hematoma was observed in sites including the retroperitoneum, brain, alimentary tract, muscles, and soft tissues. Reduction or suspension of anticoagulants is a common intervention. Transfusion, endoscopic hemostasis, and vascular interventional therapy have been used to improve the condition.

CASE PRESENTATION

In this article, we present two cases of concurrent multisite hematomas and bleeding at other sites in patients with SARS-CoV-2 infection. Both patients were treated with heparins and experienced bleeding after the anticoagulation therapy. Both patients were older with more than two comorbidities, and critical COVID-19. Laboratory tests revealed a considerable decrease in hemoglobin levels and alterations in the coagulation system. In the first patient, the main intervention was embolization using angiography. However, we only adjusted the anticoagulation strategy in the second case. The first patient recovered and was discharged; however, the second died of other causes. This study provides a retrospective review of typical hemorrhagic cases during anticoagulation in COVID-19 patients over the course of four years. A relatively comprehensive search was performed in Pubmed by constructing MeSH subject terms on limiting the search period and specific contents. It summarizes and synthesizes the research related to heparins and other novel anticoagulants in the context of COVID-19 from the onset of the pandemic to the present disseminated phase. This study aimed to offer valuable insights and reference points for developing anticoagulation treatment strategies for patients with COVID-19.

CONCLUSIONS

Anticoagulation is a crucial treatment option for patients with COVID-19. The difference in anticoagulant effects is related to the severity of COVID-19. Nafamostat can reduce thrombosis in the extracorporeal circuits in critically ill patients with COVID-19. The efficacy and safety of novel anticoagulants require further clinical data. Routine bedside assessments and real-time laboratory monitoring are essential for early identification of bleeding events during anticoagulant therapy and administering intervention.

Therapeutic-dose anticoagulation or thromboprophylaxis with low-molecular-weight heparin for moderate Covid-19: meta-analysis of randomized controlled trials

BACKGROUND

We carried out a meta-analysis since there is not enough evidence to recommend for or against therapeutic-dose anticoagulation compared with thromboprophylaxis in noncritically ill patients hospitalized with Covid-19.

METHODS

We performed a systematic literature search using PubMed, Embase, Cochrane Library, and MedRxiv for randomized trials that included therapeutic-dose with low-molecular-weight heparin (LMW) or thromboprophylaxis with LMW heparin in noncritically ill patients admitted to the hospital with Covid-19. We identified five open-label studies for analysis with a total of 3220 patients. Two independent researchers selected, assessed, and extracted the data in duplicate. The outcomes evaluated were all-cause mortality, progression to invasive mechanical ventilation, incidence of venous thromboembolism, and major bleeding. The studies did not show risk for selection, detection, attrition, or reporting bias.

RESULTS

Therapeutic-dose anticoagulation with LMW heparin compared with thromboprophylaxis with LMW heparin had no significant effect of all-cause death (risk ratio [RR] 0.85; 95% confidence interval [CI] 0.67-1.07; P = 0.16; I2 = 48%), or progression to invasive mechanical ventilation (RR 0.89; CI 0.73-1.08; P = 0.24; I2: 0%). Therapeutic-dose anticoagulation significantly reduced the risk of venous thromboembolic disease (RR 0.42; 95% CI 0.28-0.62; P = 0.0001; I2 = 0%) [Number needed to treat = 37]. Major bleeding occurred in 1.79% of the patients receiving therapeutic-dose anticoagulation and in 0.97% of those receiving thromboprophylaxis [Number needed to harm 125].

CONCLUSION

Therapeutic-dose anticoagulation in noncritically ill patients with Covid-19 could be indicated for patients at high risk of venous thromboembolic disease and low risk of bleeding.

Protein structure-based in-silico approaches to drug discovery: Guide to COVID-19 therapeutics

With more than 5 million fatalities and close to 300 million reported cases, COVID-19 is the first documented pandemic due to a coronavirus that continues to be a major health challenge. Despite being rapid, uncontrollable, and highly infectious in its spread, it also created incentives for technology development and redefined public health needs and research agendas to fast-track innovations to be translated. Breakthroughs in computational biology peaked during the pandemic with renewed attention to making all cutting-edge technology deliver agents to combat the disease. The demand to develop effective treatments yielded surprising collaborations from previously segregated fields of science and technology. The long-standing pharmaceutical industry's aversion to repurposing existing drugs due to a lack of exponential financial gain was overrun by the health crisis and pressures created by front-line researchers and providers. Effective vaccine development even at an unprecedented pace took more than a year to develop and commence trials. Now the emergence of variants and waning protections during the booster shots is resulting in breakthrough infections that continue to strain health care systems. As of now, every protein of SARS-CoV-2 has been structurally characterized and related host pathways have been extensively mapped out. The research community has addressed the druggability of a multitude of possible targets. This has been made possible due to existing technology for virtual computer-assisted drug development as well as new tools and technologies such as artificial intelligence to deliver new leads. Here in this article, we are discussing advances in the drug discovery field related to target-based drug discovery and exploring the implications of known target-specific agents on COVID-19 therapeutic management. The current scenario calls for more personalized medicine efforts and stratifying patient populations early on for their need for different combinations of prognosis-specific therapeutics. We intend to highlight target hotspots and their potential agents, with the ultimate goal of using rational design of new therapeutics to not only end this pandemic but also uncover a generalizable platform for use in future pandemics.

The Effect of Heparin Full-Dose Anticoagulation on Survival of Hospitalized, Non-critically Ill COVID-19 Patients: A Meta-analysis of High Quality Studies

BACKGROUND

International COVID-19 guidelines recommend thromboprophylaxis for non-critically ill inpatients to prevent thrombotic complications. It is still debated whether full-dose thromboprophylaxis reduces all-cause mortality. The main aim of this updated systematic review and meta-analysis is to evaluate the effect of full-dose heparin-based thromboprophylaxis on survival in hospitalized non-critically ill COVID-19 patients.

METHODS

A systematic review was performed across Pubmed/Medline, EMBASE, Cochrane Central Register of clinical trials, Clinicaltrials.gov, and medRxiv.org from inception to November 2022. We conducted a meta-analysis of randomized clinical trials (RCTs) comparing full-dose heparin-based anticoagulation to prophylactic or intermediate dose anticoagulation or standard treatment in hospitalized non-critically ill COVID-19 patients. The risk of bias was assessed using the Cochrane risk-of-bias tool for randomized trials and Grading of Recommendations Assessment, Development and Evaluation was applied. The primary outcome was all-cause mortality at the longest follow-up available.

RESULTS

We identified 6 multicenter RCTs involving 3297 patients from 13 countries across 4 continents. The rate of all-cause mortality was 6.2% (103/1662) in the full-dose group vs 7.7% (126/1635) in the prophylactic or intermediate dose group (Risk Ratio [RR] = 0.76; 95% confidence interval [CI] = 0.59-0.98; P = 0.037). The probabilities of any mortality difference and of NNT ≤ 100 were estimated at 98.2% and 84.5%, respectively. The risk of bias was low for all included RCTs and the strength of the evidence was "moderate."

CONCLUSION

Our meta-analysis of high-quality multicenter RCTs suggests that full-dose anticoagulation with heparin or low molecular weight heparin reduces all-cause mortality in hospitalized non-critically ill COVID-19 patients.

STUDY REGISTRATION

PROSPERO, review no. CRD42022348993.

Polypharmacy and Drug Interactions in the COVID-19 Pandemic

The COVID-19 pandemic generated a great impact on health systems. We compared evolution, polypharmacy, and potential drug-drug interactions (P-DDIs) in COVID-19 and non-COVID-19 hospitalizations during first wave of pandemic. Prescriptions for hospitalized patients ≥ 18 years (COVID-19 and non-COVID-19 rooms) between April and September 2020 were included. The computerized medical decision support system SIMDA and the physician order entry system Hdc.DrApp.la were used. Patients in COVID-19 rooms were divided into detectable and non-detectable, according to real-time reverse transcription polymerase chain reaction (RT-PCR). Number of drugs, prescribed on day 1, after day 1, and total; polypharmacy, excessive polypharmacy, and P-DDIs were compared. 1,623 admissions were evaluated: 881 COVID-19, 538 detectable and 343 non-detectable, and 742 non-COVID-19. Mortality was 15% in COVID-19 and 13% in non-COVID-19 (RR [non-COVID-19 vs. COVID-19]: 0.84 [95% CI] [0.66-1.07]). In COVID-19, mortality was 19% in detectable and 9% in non-detectable (RR: 2.07 [1.42-3.00]). Average number of drugs was 4.54/patient (SD ± 3.06) in COVID-19 and 5.92/patient (±3.24) in non-COVID-19 (p<0.001) on day 1 and 5.57/patient (±3.93) in COVID-19 and 9.17/patient (±5.27) in non-COVID-19 (p<0.001) throughout the hospitalization. 45% received polypharmacy in COVID-19 and 62% in non-COVID-19 (RR: 1.38 [1.25-1.51]) and excessive polypharmacy 7% in COVID-19 and 14% in non-COVID-19 (RR: 2.09 [1.54-2.83]). The frequency of total P-DDIs was 0.31/patient (±0.67) in COVID-19 and 0.40/patient (±0.94) in non-COVID-19 (p=0.022). Hospitalizations in the COVID-19 setting are associated with less use of drugs, less polypharmacy and less P-DDIs. Detectable patients had higher mortality.

The diverse role of heparan sulfate and other GAGs in SARS-CoV-2 infections and therapeutics

In December 2019, the global coronavirus disease 2019 (COVID-19) pandemic began in Wuhan, China. COVID-19 is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which infects host cells primarily through the angiotensin-converting enzyme 2 (ACE2) receptor. In addition to ACE2, several studies have shown the importance of heparan sulfate (HS) on the host cell surface as a co-receptor for SARS-CoV-2-binding. This insight has driven research into antiviral therapies, aimed at inhibiting the HS co-receptor-binding, e.g., by glycosaminoglycans (GAGs), a family of sulfated polysaccharides that includes HS. Several GAGs, such as heparin (a highly sulfated analog of HS), are used to treat various health indications, including COVID-19. This review is focused on current research on the involvement of HS in SARS-CoV-2 infection, implications of viral mutations, as well as the use of GAGs and other sulfated polysaccharides as antiviral agents.

Outcomes in Severe COVID-19 Patients Following Percutaneous Versus Open Surgical Tracheostomy: An Analysis of Clinical and Prognostic Indicators

Background and objective Tracheostomy in coronavirus disease 2019 (COVID-19) patients can be performed in cases of prolonged intubation or in patients with a known difficult airway. Tracheostomy is usually performed by two main approaches: open surgery or percutaneous endoscopic insertion. However, few studies have compared these two techniques in severe COVID-19 patients. The objective of the present study was to compare the efficacy of the two main methods of tracheostomy among patients with severe COVID-19 infection. We also aimed to investigate the impact of various lab data and medications on patient outcomes. Materials and methods We included all symptomatic severe COVID-19 patients in need of prolonged mechanical ventilation. We examined the patients' past medical history, arterial blood gas (ABG) analysis, laboratory workups, and medication history. We calculated the PaO₂/FiO₂ ratio as an index to evaluate the severity of acute respiratory distress syndrome (ARDS). Results During the study period, 72 patients with severe COVID-19 underwent tracheostomy tube insertion. The average age of participants was 58.93 ±15.27 years; 44 (61.1%) were male and 28 (38.9%) were female. Of note, 54 (75.0%) patients passed away and only 18 (25.0%) survived. Among the survivors, 13 (29.5%) were men and five (17.9%) were women. The study showed a significantly higher mortality rate (23, 92.0%) among patients who underwent open surgery compared to those who received percutaneous surgery (31, 65.9%) (p=0.01). Conclusion Based on our findings, percutaneous endoscopic tracheostomy seems to be the superior approach compared to open tracheostomy. Other predictive factors associated with patient outcomes included levels of HCO₃, FiO₂, PaCO₂, and PaO₂/FiO₂ ratio.

Therapeutic Applications of Fucoidans and their Potential to Act Against COVID-19

In this review article, we present the updated evidence of therapeutic applications of fucoidan (a seaweed polysaccharide) and its novel potential to treat infectious diseases such as coronavirus disease (COVID-19). Because of their many biological activities, seaweeds have been identified as a rich and useful source of bioactive chemicals. Sulfated polysaccharides from the sea are considered a source of physiologically active chemicals that might be used in medication development. Antitumor, antiviral, antioxidant, antibacterial, anticoagulant, and immune-inflammatory properties have all been described for these compounds. By interfering at various phases of viral infection, marine sulfated polysaccharide has a virucidal effect. As a result, it opens the door to the development of antiviral treatments. Virus entry into host cells is an initial process, avoiding this type of entry makes any precautionary measure effective. The inhibitory action of certain marine sulfated polysaccharides against coronavirus was tested, and fucoidan, iota-carrageenan, and sea cucumber sulfated polysaccharides all showed a substantial antiviral impact. Fucoidan is one of the useful sulfated polysaccharides that has been widely studied and explored in various research. There are different sources of fucoidans, which have been used in the treatment of viral infection. Additionally, we highlight the mechanism of action of fuocidan against COVID-19. Hence, we could suggest that COVID-19 might be prevented and treated using these sulfated polysaccharides. This review thus highlights ample evidence to support the hypothesis that a large number of drugs have been developed from powerful compounds isolated from marine seaweeds.

Challenges in evaluating treatments for COVID-19: The case of in-hospital anticoagulant use and the risk of adverse outcomes

Anticoagulants are a potential treatment for the thrombotic complications resulting from COVID-19. We aimed to determine the association between anticoagulant use and adverse outcomes among hospitalized patients with COVID-19. We used data from the COVID-19 International Collaborative Research Project in South Korea from January to June 2020. We defined exposure using an intention-to-treat approach, with person-time classified as use or non-use of anticoagulants at cohort entry, and a time-varying approach. The primary outcome was all-cause, in-hospital mortality; the secondary outcome was a composite including respiratory outcomes, cardiovascular outcomes, venous thromboembolism, major bleeding, and intensive care unit admission. Cox proportional hazards models estimated adjusted hazard ratios (HRs) of the outcomes comparing use versus non-use of anticoagulants. Our cohort included 2,677 hospitalized COVID-19 patients, of whom 24 received anticoagulants at cohort entry. Users were older and had more comorbidities. The crude incidence rate (per 1,000 person-days) of mortality was 5.83 (95% CI: 2.80, 10.72) among anticoagulant users and 1.36 (95% CI: 1.14, 1.59) for non-users. Crude rates of the composite outcome were 3.20 (95% CI: 1.04, 7.47) and 1.80 (95% CI: 1.54, 2.08), respectively. Adjusted HRs for mortality (HR: 1.12, 95% CI: 0.48, 2.64) and the composite outcome (HR: 0.79, 95% CI: 0.28, 2.18) were inconclusive. Although our study was not able to draw conclusions on anticoagulant effectiveness for COVID-19 outcomes, these results can contribute to future knowledge syntheses of this important question. Our study demonstrated that the dynamic pandemic environment may have important implications for observational studies of COVID-19 treatment effectiveness.

The Comparison of Therapeutic With Prophylactic Anticoagulation on Mortality, Risk of Bleeding, and Thromboembolism in Hospitalized Patients With COVID-19: A Systematic Review

Thromboembolism is one of the most severe manifestations of coronavirus disease 2019 (COVID-19). Thrombotic complications have been reported even with the administration of thromboprophylaxis. This has led many experts to have variable opinions on the most effective prophylactic strategy and to anticipate the discovery of the ideal dosing of anticoagulation to reduce thromboembolic events and related mortality. We performed a systematic review to evaluate whether therapeutic-dose anticoagulation is superior to prophylactic-dose anticoagulation by comparing mortality rates, bleeding risks, and rates of thromboembolism. We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to create our systematic review. Twenty-two records were collected from PubMed, PubMed Central (PMC), and Medical Literature Analysis and Retrieval System Online (MEDLINE), after which they undertook quality appraisals. A total of 124 studies were analyzed in six systematic reviews and meta-analyses, one pooled analysis, two multicenter retrospective cohort studies, one observational study, one retrospective chart review, one evidence-based protocol, and four narrative reviews.

The optimal anticoagulation strategy for COVID-19, prophylactic or therapeutic?: a meta-analysis, trial sequential analysis, and meta-regression of more than 27,000 participants

Background

Anticoagulants are promising regimens for treating coronavirus disease 2019 (COVID-19). However, whether prophylactic or intermediate-to-therapeutic dosage is optimal remains under active discussion.

Methods

We comprehensively searched PubMed, Embase, Scopus, Web of Science, Cochrane Library, ClinicalTrials, and MedRxiv databases on April 26, 2022. Two independent researchers conducted literature selection and data extraction separately according to predetermined criteria. Notably, this is the first meta-analysis on COVID-19, taking serious consideration regarding the dosage overlap between the 2 comparison groups of prophylactic anticoagulation (PA) and intermediate-to-therapeutic anticoagulation (I-TA).

Results

We included 11 randomized controlled trials (RCTs) and 36 cohort studies with 27,051 COVID-19 patients. By analyzing all the RCTs, there was no significant difference in mortality between the PA and I-TA groups, which was further confirmed by trial sequential analysis (TSA) (odds ratio [OR]: 0.93; 95% confidence interval [CI]: 0.71–1.22; P = 0.61; TSA adjusted CI: 0.71–1.26). The rate of major bleeding was remarkably higher in the I-TA group than in the PA group, despite adjusting for TSA (OR: 1.73; 95% CI: 1.15–2.60; P = 0.009; TSA adjusted CI: 1.09–2.58). RCTs have supported the beneficial effect of I-TA in reducing thrombotic events. After including all studies, mortality in the I-TA group was significantly higher than in the PA group (OR: 1.38; 95% CI: 1.15–1.66; P = 0.0005). The rate of major bleeding was similar to the analysis from RCTs (OR: 2.24; 95% CI: 1.86–2.69; P < 0.00001). There was no distinct difference in the rate of thrombotic events between the 2 regimen groups. In addition, in both critical and noncritical subgroups, I-TA failed to reduce mortality but increased major bleeding rate compared with PA, as shown in meta-analysis of all studies, as well as RCTs only. Meta-regression of all studies suggested that there was no relationship between the treatment effect and the overall risk of mortality or major bleeding (P = 0.14, P = 0.09, respectively).

Conclusion

I-TA is not superior to PA for treating COVID-19 because it fails to lower the mortality rate but increases the major bleeding rate in both critical and noncritical patients.

Effect of therapeutic versus prophylactic anticoagulation therapy on clinical outcomes in COVID-19 patients: a systematic review with an updated meta-analysis

BACKGROUND

Previous studies demonstrate a reduced risk of thrombosis and mortality with anticoagulant treatment in patients with COVID-19 than in those without anticoagulation treatment. However, an open question regarding the efficacy and safety of therapeutic anticoagulation (T-AC) versus a lower dose, prophylaxis anticoagulation (P-AC) in COVID-19 patients is still controversial.

METHODS

We systematically reviewed currently available randomized clinical trials (RCTs) and observational studies (OBs) from January 8, 2019, to January 8, 2022, and compared prophylactic and therapeutic anticoagulant treatment in COVID-19 patients. The primary outcomes were risk of mortality, major bleeding, and the secondary outcomes included venous and arterial thromboembolism. Subgroup analysis was also performed between critically ill and non-critically ill patients with COVID-19 and between patients with higher and lower levels of D-dimer. Sensitivity analysis was performed to decrease the bias and the impact of population heterogeneity.

RESULTS

We identified 11 RCTs and 17 OBs fulfilling our inclusion criteria. In the RCTs analyses, there was no statistically significant difference in the relative risk of mortality between COVID-19 patients with T-AC treatment and those treated with P-AC (RR 0.95, 95% CI, 0.78-1.15, P = 0.60). Similar results were also found in the OBs analyses (RR 1.21, 95% CI, 0.98-1.49, P = 0.08). The pooling meta-analysis using a random-effects model combined with effect sizes showed that in the RCTs and OBs analyses, patients with COVID-19 who received T-AC treatment had a significantly higher relative risk of the major bleeding event than those with P-AC treatment in COVID-19 patients (RCTs: RR 1.76, 95% CI, 1.19-2.62, P = 0.005; OBs: RR 2.39, 95% CI, 1.56-3.68, P < 0.0001). Compared with P-AC treatment in COVID-19 patients, patients with T-AC treatment significantly reduced the incidence of venous thromboembolism (RR 0.51, 95% CI, 0.39-0.67, P<0.00001), but it is not associated with arterial thrombosis events (RR 0.97, 95% CI, 0.66-1.42, P = 0.87). The subgroup analysis of OBs shows that the mortality risk significantly reduces in critically ill COVID-19 patients treated with T-AC compared with those with P-AC treatment (RR 0.58, 95% CI, 0.39-0.86, P = 0.007), while the mortality risk significantly increases in non-critically ill COVID-19 patients treated with T-AC (RR 1.56, 95% CI, 1.34-1.80, P < 0.00001). In addition, T-AC treatment does not reduce the risk of mortality in COVID-19 patients with high d-dimer levels in RCTs. Finally, the overall sensitivity analysis after excluding two RCTs studies remains consistent with the previous results.

CONCLUSIONS

In our integrated analysis of included RCTs and OBs, there is no significant difference between the mortality of T-AC and P-AC treatment in unselected patients with COVID-19. T-AC treatment in COVID-19 patients significantly reduced the incidence of venous thromboembolism but showed a higher risk of bleeding than those with P-AC treatment. In addition, P-AC treatment was superior to T-AC treatment in non-critically ill COVID-19 patients, the evidence supporting the necessity for T-AC treatment in critically ill COVID-19 patients came only from OBs.

TRIAL REGISTRATION

Protocol registration: The protocol was registered at PROSPERO (CRD42021293294).

The Role of Heparin in COVID-19: An Update after Two Years of Pandemics

Coronavirus disease 2019 (COVID-19) is associated with an increased risk of venous thromboembolism (VTE) and coagulopathy, especially in critically ill patients. Endothelial damage induced by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is emerging as a crucial pathogenetic mechanism for the development of complications in an acute phase of the illness and for several postdischarge sequalae. Heparin has been shown to have a positive impact on COVID-19 due to its anticoagulant function. Moreover, several other biological actions of heparin were postulated: a potential anti-inflammatory and antiviral effect through the main protease (Mpro) and heparansulfate (HS) binding and a protection from the damage of vascular endothelial cells. In this paper, we reviewed available evidence on heparin treatment in COVID-19 acute illness and chronic sequalae, focusing on the difference between prophylactic and therapeutic dosage.

Low Molecular Weight Heparin Doses and Ventilator Airway Necessity in the COVID-19 Patients: Systematic Review and Meta-analysis

BACKGROUND: Anticoagulant therapy is recommendation for COVID-19 infection. However, the mechanical ventilation needed for COVID-19 is still high. AIM: The aim of the study was to determine comparison therapeutic and prophylactic dose LMWH for mechanical necessity in COVID-19 infection. METHODS: A systematic literature search articles online from studies published between 2020 and 2021 that met our inclusion criteria and were retrieved from scientific databases such as Cochrane, ProQuest, and PubMed. The primary measure was a composite bad outcome, which included mechanical ventilation, mortality. and bleeding risk. RESULTS: There were 3432 patients from seven study included in this meta-analysis for necessity of mechanical ventilation in COVID-19 patients that used prophylactic and therapeutic anticoagulants. Prophylactic dose of anticoagulant showed no difference for the need for mechanical ventilation necessity for COVID-19 patients (RR = 0.54; 95% CI = 0.20–1.48; p = 0.23). However, prophylactic anticoagulant showed more safe for bleeding incidence (RR = 0.27; 95% CI = 0.18–0.39; p = <0.00001) and reduce mortality (RR = 0.52; 95% CI = 0.46-0.58; p = <0.00001). CONCLUSION: LMWH anticoagulant dose not associated with reduce mechanical ventilation necessity but prophylactic dose prefers rather than therapeutic dose for reduce mortality and risk of bleeding.