American Society of Hematology living guidelines on the use of anticoagulation for thromboprophylaxis in patients with COVID-19: January 2022 update on the use of therapeutic-intensity anticoagulation in acutely ill patients

BACKGROUND

COVID-19-related acute illness is associated with an increased risk of venous thromboembolism (VTE).

OBJECTIVE

These evidence-based guidelines from 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 in patients with COVID-19.

METHODS

ASH formed a multidisciplinary guideline panel that included patient representatives and applied strategies to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process and performed systematic evidence reviews (through November 2021). The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess evidence and make recommendations, which were subject to public comment. This is an update to guidelines published in February 2021 as part of the living phase of these guidelines.

RESULTS

The panel made one additional recommendation. The panel issued a conditional recommendation in favor of therapeutic-intensity over prophylactic-intensity anticoagulation in patients with COVID-19-related acute illness who do not have suspected or confirmed VTE. The panel emphasized the need for an individualized assessment of risk of thrombosis and bleeding. The panel also noted that heparin (unfractionated or low molecular weight) may be preferred because of a preponderance of evidence with this class of anticoagulants.

CONCLUSION

This conditional recommendation was based on very low certainty in the evidence, underscoring the need for additional, high-quality, randomized controlled trials comparing different intensities of anticoagulation in patients with COVID-19-related acute illness.

American Society of Hematology living guidelines on the use of anticoagulation for thromboprophylaxis for patients with COVID-19: March 2022 update on the use of anticoagulation in critically ill patients

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 decisions about the use of anticoagulation for patients with COVID-19.

METHODS

ASH formed a multidisciplinary guideline panel, including 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, including performing systematic evidence reviews (up to January 2022). 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 to guidelines published in February 2021 and May 2021 as part of the living phase of these guidelines.

RESULTS

The panel made 1 additional recommendation: a conditional recommendation for the use of prophylactic-intensity over therapeutic-intensity anticoagulation for patients with COVID-19-related critical illness who do not have suspected or confirmed VTE. The panel emphasized the need for an individualized assessment of thrombotic and bleeding risk.

CONCLUSIONS

This conditional recommendation was based on very low certainty in the evidence, underscoring the need for additional, high-quality, randomized controlled trials comparing different intensities of anticoagulation for patients with COVID-19-related critical illness.

0584 Impact of Obstructive Sleep Apnea on Chronic obstructive pulmonary disease Hospitalizations

Introduction

Obstructive sleep apnea (OSA) is a sleep disorder that has been linked to increase the risk for hypertension, ischemic heart failure, arrhythmia and heart failure. There are multiple similarities between OSA and Chronic Obstructive Pulmonary Disease (COPD); both are associated with hypoxia and hypercapnia, with different mechanisms of hypoxia; in COPD its chronic and slow progression, whereas it is suddenly intermittent hypoxia in OSA. Intermittent hypoxia was hypothesized to enhance the protective effect on subsequent hypoxia resulting in cardioprotective effect [1]. There is little data on rates of in-hospital mortality on patients with OSA and COPD using a nationwide study. In this study, we aim to analyze the impact on mortality and length of hospital stay of obstructive sleep apnea in patients with COPD.

Methods

Adults with principal diagnosis of COPD were selected from the 2019 US National Inpatient Sample, using ICD 10 code primary diagnosis on discharge. We queried the 2019 National Inpatient Sample for OSA, and other secondary diagnoses (hyperlipidemia, hypertension, heart failure, smoking, CKD, electrolytes disturbances). Confounders were adjusted for using multivariable linear regression analysis for other secondary diagnoses.

Results

In a total of 520,624 adult hospitalizations with COPD primary diagnosis on discharge were included from the 2019 national inpatient sample. 73,705 patients had concomitant secondary diagnosis with OSA. On weighted analysis, hospitalizations with primary diagnosis of COPD and secondary diagnosis of OSA had lower in-hospital mortality rates compared to hospitalizations with COPD alone (0.6% vs 1.08%, p= 0.000), .COPD hospitalizations with OSA had statistically significant lower odds for mortality compared to COPD patients without OSA (adjusted OR 0.73, 95% CI 0.57-0.93; p= 0.009).However, COPD hospitalizations with OSA showed increased in the mean length of stay by 0.21 days (95% CI 0.12-0.30, p=0.000) compared to patients without OSA.

Conclusion

Our analysis showed better mortality outcomes for COPD patients with OSA , supporting the protective effect hypothesis of intermittent hypoxia. COPD patients with concomitant secondary OSA diagnosis have increased in-hospital length of stay.

Support (If Any)

1- Murry CE, Jennings RB, Reimer KA (1986) Preconditioning with ischemia: a delay of lethal cell injury in ischemic myocardium. Circulation 74:1124–1136

0589 REM Sleep Behavior Disorder is Associated with Poor Outcomes in Pulmonary Embolism Hospitlizations

Introduction

REM Sleep Behavior Disorder (RBD), is a rare sleep behavior disorder, characterized by loss of skeletal muscle atonia during REM sleep, resulting in prominent motor activity with exhibited behavior mirroring the image of the dreams during sleep. Other sleep disorders were studied before in patients with Pulmonary Embolism (PE). Although, REM sleep behavior disorder association with pulmonary embolism has never been described. In this study we aim to study the prevalence of RBD in patients admitted with PE, and to assess the association between RBD and PE.

Methods

Adults with principal diagnosis of Pulmonary Embolism (PE) on discharge were selected from the 2019 US National Inpatient Sample, using ICD 10 code primary diagnosis. We queried the 2019 National Inpatient Sample for secondary diagnosis of RBD, Obstructive Sleep Apnea (OSA) and other secondary diagnoses (hyperlipidemia,history of old myocardial infarction, atrial fibrillation, Chronic obstructive pulmonary disease, hypertension, heart failure, smoking, chronic kidney disease , electrolytes disturbances). Confounders were adjusted for using multivariable linear regression analysis for other secondary diagnoses.

Results

In a total of 188,355 hospitalizations with PE primary diagnosis on discharge were included from the 2019 national inpatient sample, 25 hospitalizations had concomitant secondary diagnosis with RBD. The overall in-hospital mortality for PE was 3.2%. On weighted analysis, Patients with RBD had statistically significant higher odds for mortality compared to patients without [adjusted odds ratio (OR): 17.15; 95% confidence interval (CI): 2.75-106.8, p= 0.002], 20% mortality rate in patients with RBD compared to 0.03% in patients without RBD (p= 0.03). OSA did not show significant result for mortality when compared to without OSA [adjusted odds ratio (OR): 0.83; 95% confidence interval (CI): 0.67-1.04, p= 0.114].

Conclusion

Our analysis showed a low number of patients with secondary diagnosis of RBD in hospitalizations with primary diagnosis of PE on discharge. However significant association between RBD and mortality in patients with PE primary diagnosis on discharge. The identification of patients with RBD in patients admitted with PE may help decrease mortality rate. Furthermore, our analysis showed that OSA is an independant variable for mortality in PE hospitalization.

Support (If Any)