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Godon A, Tacquard CA, Mansour A, Garrigue D, Nguyen P, Lasne D, Testa S, Levy JH, Albaladejo P, Gruel Y, Susen S, Godier A. Prevention of venous thromboembolism and haemostasis monitoring in patients with COVID-19: Updated proposals (April 2021): From the French working group on perioperative haemostasis (GIHP) and the French study group on thrombosis and haemostasis (GFHT), in collaboration with the French society of anaesthesia and intensive care (SFAR). Anaesth Crit Care Pain Med 2021; 40:100919. [PMID: 34182166 PMCID: PMC8233055 DOI: 10.1016/j.accpm.2021.100919] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/16/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Alexandre Godon
- Department of Anaesthesiology and Critical Care, Université Grenoble Alpes, CHU Grenoble Alpes, Grenoble, France.
| | - Charles Ambroise Tacquard
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Alexandre Mansour
- Department of Anaesthesiology Critical Care Medicine and Perioperative Medicine, CHU de Rennes, France
| | | | | | - Dominique Lasne
- Department of Haematology Laboratory, Hôpital Necker, AP-HP, Paris, France
| | | | - Jerrold H Levy
- Department of Anaesthesiology, Critical Care, and Surgery, Duke University Hospital, Durham, NC, USA
| | - Pierre Albaladejo
- Department of Anaesthesiology and Critical Care, Université Grenoble Alpes, CHU Grenoble Alpes, Grenoble, France
| | - Yves Gruel
- Department of Haematology-Haemostasis, Hôpital Universitaire de Tours, France
| | - Sophie Susen
- Department of Haematology and Transfusion, Université de Lille, Lille, France
| | - Anne Godier
- Department of Anaesthesia and Intensive Care, AP-HP, Hôpital Européen Georges Pompidou, and INSERM UMRS-1140, Université de Paris, France
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102
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Hulshof A, Braeken DCW, Ghossein‐Doha C, van Santen S, Sels JEM, Kuiper GJAJM, van der Horst ICC, ten Cate H, van Bussel BCT, Olie RH, Henskens YMC. Hemostasis and fibrinolysis in COVID-19 survivors 6 months after intensive care unit discharge. Res Pract Thromb Haemost 2021; 5:e12579. [PMID: 34595368 PMCID: PMC8463660 DOI: 10.1002/rth2.12579] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 07/08/2021] [Accepted: 07/15/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The prothrombotic phenotype has been extensively described in patients with acute coronavirus disease 2019 (COVID-19). However, potential long-term hemostatic abnormalities are unknown. OBJECTIVE To evaluate the changes in routine hemostasis laboratory parameters and tissue-type plasminogen activator (tPA) rotational thromboelastometry (ROTEM) 6 months after COVID-19 intensive care unit (ICU) discharge in patients with and without venous thromboembolism (VTE) during admission. METHODS Patients with COVID-19 of the Maastricht Intensive Care COVID cohort with tPA ROTEM measurement at ICU and 6-month follow-up were included. TPA ROTEM is a whole blood viscoelastic assay that illustrates both clot development and fibrinolysis due to simultaneous addition of tissue factor and tPA. Analyzed ROTEM parameters include clotting time, maximum clot firmness (MCF), lysis onset time (LOT), and lysis time (LT). RESULTS Twenty-two patients with COVID-19 were included and showed extensive hemostatic abnormalities before ICU discharge. TPA ROTEM MCF (75 mm [interquartile range, 68-78]-59 mm [49-63]; P ≤ .001), LOT (3690 seconds [2963-4418]-1786 seconds [1465-2650]; P ≤ .001), and LT (7200 seconds [6144-7200]-3138 seconds [2591-4389]; P ≤ .001) normalized 6 months after ICU discharge. Of note, eight and four patients still had elevated fibrinogen and D-dimer concentrations at follow-up, respectively. In general, no difference in median hemostasis parameters at 6-month follow-up was observed between patients with (n=14) and without (n=8) VTE, although fibrinogen appeared to be lower in the VTE group (VTE-, 4.3 g/L [3.7-4.7] vs VTE+, 3.4 g/L [3.2-4.2]; P = .05). CONCLUSIONS Six months after COVID-19 ICU discharge, no persisting hypercoagulable or hypofibrinolytic profile was detected by tPA ROTEM. Nevertheless, increased D-dimer and fibrinogen concentrations persist up to 6 months in some patients, warranting further exploration of the role of hemostasis in long-term morbidity after hospital discharge.
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Affiliation(s)
- Anne‐Marije Hulshof
- Central Diagnostic LaboratoryMaastricht University Medical Centre+Maastrichtthe Netherlands
- Cardiovascular Research Institute Maastricht (CARIM)Maastricht UniversityMaastrichtthe Netherlands
| | - Dionne C. W. Braeken
- Thrombosis Expertise Centre MaastrichtMaastricht University Medical Centre+Maastrichtthe Netherlands
| | - Chahinda Ghossein‐Doha
- Department of CardiologyMaastricht University Medical Centre+Maastrichtthe Netherlands
- Department of Intensive Care MedicineMaastricht University Medical Centre+Maastrichtthe Netherlands
| | - Susanne van Santen
- Department of Intensive Care MedicineMaastricht University Medical Centre+Maastrichtthe Netherlands
| | - Jan‐Willem E. M. Sels
- Department of Intensive Care MedicineMaastricht University Medical Centre+Maastrichtthe Netherlands
| | | | - Iwan C. C. van der Horst
- Cardiovascular Research Institute Maastricht (CARIM)Maastricht UniversityMaastrichtthe Netherlands
- Department of Intensive Care MedicineMaastricht University Medical Centre+Maastrichtthe Netherlands
| | - Hugo ten Cate
- Cardiovascular Research Institute Maastricht (CARIM)Maastricht UniversityMaastrichtthe Netherlands
- Thrombosis Expertise Centre MaastrichtMaastricht University Medical Centre+Maastrichtthe Netherlands
- Department of Internal MedicineSection Vascular MedicineMaastricht University Medical Centre+Maastrichtthe Netherlands
| | - Bas C. T. van Bussel
- Department of Intensive Care MedicineMaastricht University Medical Centre+Maastrichtthe Netherlands
- Care and Public Health Research Institute (CAPHRI)Maastricht UniversityMaastrichtthe Netherlands
| | - Renske H. Olie
- Cardiovascular Research Institute Maastricht (CARIM)Maastricht UniversityMaastrichtthe Netherlands
- Thrombosis Expertise Centre MaastrichtMaastricht University Medical Centre+Maastrichtthe Netherlands
- Department of Internal MedicineSection Vascular MedicineMaastricht University Medical Centre+Maastrichtthe Netherlands
| | - Yvonne M. C. Henskens
- Central Diagnostic LaboratoryMaastricht University Medical Centre+Maastrichtthe Netherlands
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103
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COVID-19 Pathogenesis: From Molecular Pathway to Vaccine Administration. Biomedicines 2021; 9:biomedicines9080903. [PMID: 34440107 PMCID: PMC8389702 DOI: 10.3390/biomedicines9080903] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/21/2021] [Accepted: 07/26/2021] [Indexed: 12/19/2022] Open
Abstract
The Coronavirus 2 (SARS-CoV-2) infection is a global pandemic that has affected millions of people worldwide. The advent of vaccines has permitted some restitution. Aside from the respiratory complications of the infection, there is also a thrombotic risk attributed to both the disease and the vaccine. There are no reliable data for the risk of thromboembolism in SARS-CoV-2 infection in patients managed out of the hospital setting. A literature review was performed to identify the pathophysiological mechanism of thrombosis from the SARS-CoV-2 infection including the role of Angiotensin-Converting Enzyme receptors. The impact of the vaccine and likely mechanisms of thrombosis following vaccination were also clarified. Finally, the utility of the vaccines available against the multiple variants is also highlighted. The systemic response to SARS-CoV-2 infection is still relatively poorly understood, but several risk factors have been identified. The roll-out of the vaccines worldwide has also allowed the lifting of lockdown measures and a reduction in the spread of the disease. The experience of the SARS-CoV-2 infection, however, has highlighted the crucial role of epidemiological research and the need for ongoing studies within this field.
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104
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Bristogiannis S, Swan D, Thachil J. Thromboprophylaxis in COVID-19 - Rationale and considerations. Adv Biol Regul 2021; 81:100819. [PMID: 34332403 PMCID: PMC8299150 DOI: 10.1016/j.jbior.2021.100819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/20/2021] [Accepted: 07/21/2021] [Indexed: 12/27/2022]
Abstract
The Corona Virus Disease-2019 (COVID-19) pandemic is associated with a very high incidence of thrombotic complications. The exact mechanisms for this excess risk for clots have not been elucidated although one of the often-quoted pathophysiological entity is immunothrombosis. Recognition of thrombotic complications early on in this pandemic led to an over-explosion of studies which looked at the benefits of anticoagulation to mitigate this risk. In this review, we examine the rationale for thromboprophylaxis in COVID-19 with particular reference to dosing and discuss what may guide the decision-making process to consider anticoagulation. In addition, we explore the rationale for thrombosis prevention measures in special populations including outpatient setting, pregnant females, children, those with high body mass index and those on extracorporeal membrane oxygenation.
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Affiliation(s)
- Sotirios Bristogiannis
- Department of Haematology, NHS Hillingdon Hospital, Pield Health Road, Uxbridge, United Kingdom.
| | - Dawn Swan
- Department of Haematology, University Hospital Galway, Galway, Ireland.
| | - Jecko Thachil
- Department of Haematology, Manchester University Hospitals, Oxford Road, Manchester, United Kingdom.
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105
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Go AS, Reynolds K, Tabada GH, Prasad PA, Sung SH, Garcia E, Portugal C, Fan D, Pai AP, Fang MC. COVID-19 and Risk of VTE in Ethnically Diverse Populations. Chest 2021; 160:1459-1470. [PMID: 34293316 PMCID: PMC8288227 DOI: 10.1016/j.chest.2021.07.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 07/09/2021] [Accepted: 07/10/2021] [Indexed: 12/24/2022] Open
Abstract
Background Limited existing data suggest that the novel COVID-19 may increase risk of VTE, but information from large, ethnically diverse populations with appropriate control participants is lacking. Research Question Does the rate of VTE among adults hospitalized with COVID-19 differ from matched hospitalized control participants without COVID-19? Study Design and Methods We conducted a retrospective study among hospitalized adults with laboratory-confirmed COVID-19 and hospitalized adults without evidence of COVID-19 matched for age, sex, race or ethnicity, acute illness severity, and month of hospitalization between January 2020 and August 2020 from two integrated health care delivery systems with 36 hospitals. Outcomes included VTE (DVT or pulmonary embolism ascertained using diagnosis codes combined with validated natural language processing algorithms applied to electronic health records) and death resulting from any cause at 30 days. Fine and Gray hazards regression was performed to evaluate the association of COVID-19 with VTE after accounting for competing risk of death and residual differences between groups, as well as to identify predictors of VTE in patients with COVID-19. Results We identified 6,319 adults with COVID-19 and 6,319 matched adults without COVID-19, with mean ± SD age of 60.0 ± 17.2 years, 46% women, 53.1% Hispanic, 14.6% Asian/Pacific Islander, and 10.3% Black. During 30-day follow-up, 313 validated cases of VTE (160 COVID-19, 153 control participants) and 1,172 deaths (817 in patients with COVID-19, 355 in control participants) occurred. Adults with COVID-19 showed a more than threefold adjusted risk of VTE (adjusted hazard ratio, 3.48; 95% CI, 2.03-5.98) compared with matched control participants. Predictors of VTE in patients with COVID-19 included age ≥ 55 years, Black race, prior VTE, diagnosed sepsis, prior moderate or severe liver disease, BMI ≥ 40 kg/m2, and platelet count > 217 k/μL. Interpretation Among ethnically diverse hospitalized adults, COVID-19 infection increased the risk of VTE, and selected patient characteristics were associated with higher thromboembolic risk in the setting of COVID-19.
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Affiliation(s)
- Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, CA; Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA; Department of Medicine, University of California, San Francisco, San Francisco, CA; Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA; Departments of Medicine and of Health Research and Policy, Stanford University, Palo Alto, CA.
| | - Kristi Reynolds
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA; Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Grace H Tabada
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Priya A Prasad
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Sue Hee Sung
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Elisha Garcia
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Cecilia Portugal
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Dongjie Fan
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Ashok P Pai
- Department of Hematology/Oncology, Kaiser Permanente Oakland Medical Center, Oakland, CA
| | - Margaret C Fang
- Department of Medicine, University of California, San Francisco, San Francisco, CA
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106
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Ogoina D, James HI, Ogoinja SZ. Post-Discharge Symptoms among Hospitalized COVID-19 Patients in Nigeria: A Single-Center Study. Am J Trop Med Hyg 2021; 105:731-736. [PMID: 34270448 PMCID: PMC8592373 DOI: 10.4269/ajtmh.21-0509] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 06/14/2021] [Indexed: 01/09/2023] Open
Abstract
There is a paucity of studies on post-acute COVID-19 syndrome (PCS) among hospitalized COVID-19 survivors from Nigeria. We describe the frequency, types, and duration of post-discharge symptoms suggestive of PCS among previously hospitalized COVID-19 patients in a treatment center in Nigeria. We conducted a retrospective review of admission and post-discharge follow-up medical records of COVID-19 survivors admitted between April and December 2020. A standardized checklist was used to document post-discharge symptoms. PCS was defined as persisting or new post-discharge symptoms lasting at least 3 weeks after initial COVID-19 symptoms. The relationship between study variables and development of PCS was ascertained by univariate analysis. Thirty of 51 previously hospitalized COVID-19 patients (median age, 46 years; male, 66.7%) were studied. Seventeen (56.7%) of the 30 patients developed features suggestive of PCS. Approximately three post-discharge symptoms were reported per patient over a follow-up period of ranging from 3 weeks to 9 months after initial COVID-19 symptoms. Cough, fatigue, and dyspnea were the most common post-discharge symptoms reported. A few patients had symptoms suggestive of thrombosis and COVID-19 reinfection. Among all study variables, baseline COVID-19 severity was the only significant variable associated with the development of PCS. PCS is common in our setting and is characterized by multisystemic signs and symptoms that require vigilance by clinicians for appropriate diagnosis and treatment. Long-term multicenter prospective studies are needed to characterize fully the burden of PCS among COVID-19 survivors in Nigeria.
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Affiliation(s)
- Dimie Ogoina
- 1Department of Internal Medicine, Niger Delta University Teaching Hospital, Okolobiri, Bayelsa State, Nigeria
| | - Hendris Izibewule James
- 1Department of Internal Medicine, Niger Delta University Teaching Hospital, Okolobiri, Bayelsa State, Nigeria
| | - Stanley Zikeyi Ogoinja
- 2Department of Radiology, Niger Delta University Teaching Hospital, Okolobiri, Bayelsa State, Nigeria
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107
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Ketai LH. Deciphering the Risk of Thromboembolism in COVID-19. Radiology 2021; 301:E436-E437. [PMID: 34254859 PMCID: PMC8294349 DOI: 10.1148/radiol.2021211563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Loren H Ketai
- University of New Mexico Health Science Center, MSC 10 5530, 1 University of New Mexico, Albuquerque NM 87131-0001
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108
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Roubinian NH, Dusendang JR, Mark DG, Vinson DR, Liu VX, Schmittdiel JA, Pai AP. Incidence of 30-Day Venous Thromboembolism in Adults Tested for SARS-CoV-2 Infection in an Integrated Health Care System in Northern California. JAMA Intern Med 2021; 181:997-1000. [PMID: 33818615 PMCID: PMC8022258 DOI: 10.1001/jamainternmed.2021.0488] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 02/01/2021] [Indexed: 01/07/2023]
Affiliation(s)
- Nareg H. Roubinian
- Division of Research, Kaiser Permanente Northern California, Oakland
- The Permanente Medical Group, Kaiser Permanente Northern California
- Vitalant Research Institute, San Francisco, California
| | | | - Dustin G. Mark
- Division of Research, Kaiser Permanente Northern California, Oakland
- The Permanente Medical Group, Kaiser Permanente Northern California
| | - David R. Vinson
- Division of Research, Kaiser Permanente Northern California, Oakland
- The Permanente Medical Group, Kaiser Permanente Northern California
| | - Vincent X. Liu
- Division of Research, Kaiser Permanente Northern California, Oakland
- The Permanente Medical Group, Kaiser Permanente Northern California
| | | | - Ashok P. Pai
- The Permanente Medical Group, Kaiser Permanente Northern California
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109
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Mansory EM, Srigunapalan S, Lazo-Langner A. Venous Thromboembolism in Hospitalized Critical and Noncritical COVID-19 Patients: A Systematic Review and Meta-analysis. TH OPEN 2021; 5:e286-e294. [PMID: 34240001 PMCID: PMC8260281 DOI: 10.1055/s-0041-1730967] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/06/2021] [Indexed: 12/11/2022] Open
Abstract
Introduction Venous thromboembolism (VTE) has been observed as a frequent complication in patients with severe novel coronavirus disease 2019 (COVID-19) infection requiring hospital admission. Aim This study was aimed to evaluate the epidemiology of VTE in hospitalized intensive care unit (ICU) and non-ICU patients. Materials and Methods PubMed was searched up to November 13, 2020, and updated in December 12, 2020. We included studies that evaluated the epidemiology of VTE, including pulmonary embolism (PE) and/or deep vein thrombosis (DVT), in patients with COVID-19. Results A total of 91 studies reporting on 35,017 patients with COVID-19 was included. The overall frequency of VTE in all patients, ICU and non-ICU, was 12.8% (95% confidence interval [CI]: 11.103-14.605), 24.1% (95% CI: 20.070-28.280), and 7.7% (95% CI: 5.956-9.700), respectively. PE occurred in 8.5% (95% CI: 6.911-10.208), and proximal DVT occurred in 8.2% (95% CI: 6.675-9.874) of all hospitalized patients. The relative risk for VTE associated with ICU admission was 2.99 (95% CI: 2.301-3.887, p <0.001). DVT and PE estimated in studies that adopted some form of systematic screening were higher compared with studies with symptom-triggered screening. Analysis restricted to studies in the 5th quintile of sample size reported significantly lower VTE estimates. Conclusion This study confirmed a high risk of VTE in hospitalized COVID-19 patients, especially those admitted to the ICU. Nevertheless, sensitivity analysis suggests that previously reported frequencies of VTE in COVID-19 might have been overestimated.
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Affiliation(s)
- Eman M Mansory
- Division of Hematology, Department of Medicine, Western University, London, Ontario, Canada
- Department of Hematology, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Suthan Srigunapalan
- Division of Hematology, Department of Medicine, Western University, London, Ontario, Canada
| | - Alejandro Lazo-Langner
- Division of Hematology, Department of Medicine, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
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110
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Chakir M, El Jamili M, Boudhar Z, El Hattaoui M. Simultaneous acute myocardial infarction, bilateral pulmonary embolism, and acute ischaemic cerebral stroke, a delayed complication in a patient with COVID-19 infection: case report. Eur Heart J Case Rep 2021; 5:ytab218. [PMID: 34189400 PMCID: PMC8233486 DOI: 10.1093/ehjcr/ytab218] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/03/2021] [Accepted: 05/18/2021] [Indexed: 12/13/2022]
Abstract
Background The simultaneous occurrence of acute myocardial infarction, pulmonary embolism, and acute cerebral stroke is a rare concomitant finding that requires thorough aetiological investigation. Multiple reports note delayed COVID-19 arterial and venous thromboembolic complications. However, to the best of our knowledge, this is the first report of such a simultaneous finding after COVID-19. Case summary A 60-year-old male patient, with a history of Type II diabetes and no risk factors for thromboembolism, experienced simultaneous acute myocardial infarction, bilateral pulmonary embolism, and acute ischaemic stroke. The occurrence of these multi-systemic thromboembolic events made us rule out differential diagnoses of thrombophilia, systemic lupus erythematosus, antiphospholipid syndrome, vasculitis, cancer, disseminated intravascular coagulation, and paradoxical embolism through a patent foramen ovale. On laboratory analysis, the patient was positive for IgG SARS-COV2 antibodies, but negative for IgM antibodies and had two negative nasal polymerase chain reaction swab tests. After thorough aetiological investigation, the most probable diagnosis was thought to be delayed complications of COVID-19 infection. Discussion Multiple mechanisms, such as endothelial dysfunction, complement activation, and virus-induced antiphospholipid syndrome, may explain the hypercoagulable state related to COVID-19. To the best of our knowledge, this is the first case of concomitant multi-systemic thrombosis development, recognized as a delayed complication of COVID-19 infection. This highlights a need among cardiologists for an increased awareness of such late-onset complications. It also emphasizes the importance of identifying the optimal duration and dose of prophylactic anticoagulation as well as the characteristics of the population that would benefit from it after COVID-19.
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Affiliation(s)
- Mariame Chakir
- Department of Cardiology, University Hospital Mohammed the VIth, Marrakesh, Morocco
| | - Mohammed El Jamili
- Department of Cardiology, University Hospital Mohammed the VIth, Marrakesh, Morocco
| | - Zainab Boudhar
- Department of Cardiology, University Hospital Mohammed the VIth, Marrakesh, Morocco
| | - Mustapha El Hattaoui
- Department of Cardiology, University Hospital Mohammed the VIth, Marrakesh, Morocco
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111
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Tan JY, Tan CW, Wong WH, Cheong MA, Lee LH, Kalimuddin S, Low JGH, Ng HJ. Post-hospitalization venous thromboembolism in COVID-19 patients: Evidence against routine post-hospitalization prophylactic anticoagulation. Int J Lab Hematol 2021; 44:e4-e7. [PMID: 34146452 PMCID: PMC8444943 DOI: 10.1111/ijlh.13633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 05/25/2021] [Accepted: 06/02/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Jing Yuan Tan
- SingHealth Internal Medicine Residency, Singapore General Hospital, Singapore, Singapore
| | - Chuen Wen Tan
- Department of Hematology, Singapore General Hospital, Singapore, Singapore
| | - Wan Hui Wong
- Department of Hematology, Singapore General Hospital, Singapore, Singapore
| | - May Anne Cheong
- Department of Hematology, Singapore General Hospital, Singapore, Singapore
| | - Lai Heng Lee
- Department of Hematology, Singapore General Hospital, Singapore, Singapore
| | - Shirin Kalimuddin
- Department of Infectious Diseases, Singapore General Hospital, Singapore, Singapore.,Programme in Emerging Infectious Diseases, Duke NUS Medical School, Singapore, Singapore
| | - Jenny Guek Hong Low
- Department of Infectious Diseases, Singapore General Hospital, Singapore, Singapore.,Programme in Emerging Infectious Diseases, Duke NUS Medical School, Singapore, Singapore
| | - Heng Joo Ng
- Department of Hematology, Singapore General Hospital, Singapore, Singapore
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112
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Lopes RD, de Barros E Silva PGM, Furtado RHM, Macedo AVS, Bronhara B, Damiani LP, Barbosa LM, de Aveiro Morata J, Ramacciotti E, de Aquino Martins P, de Oliveira AL, Nunes VS, Ritt LEF, Rocha AT, Tramujas L, Santos SV, Diaz DRA, Viana LS, Melro LMG, de Alcântara Chaud MS, Figueiredo EL, Neuenschwander FC, Dracoulakis MDA, Lima RGSD, de Souza Dantas VC, Fernandes ACS, Gebara OCE, Hernandes ME, Queiroz DAR, Veiga VC, Canesin MF, de Faria LM, Feitosa-Filho GS, Gazzana MB, Liporace IL, de Oliveira Twardowsky A, Maia LN, Machado FR, de Matos Soeiro A, Conceição-Souza GE, Armaganijan L, Guimarães PO, Rosa RG, Azevedo LCP, Alexander JH, Avezum A, Cavalcanti AB, Berwanger O. Therapeutic versus prophylactic anticoagulation for patients admitted to hospital with COVID-19 and elevated D-dimer concentration (ACTION): an open-label, multicentre, randomised, controlled trial. Lancet 2021; 397:2253-2263. [PMID: 34097856 PMCID: PMC8177770 DOI: 10.1016/s0140-6736(21)01203-4] [Citation(s) in RCA: 317] [Impact Index Per Article: 105.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 05/12/2021] [Accepted: 05/13/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND COVID-19 is associated with a prothrombotic state leading to adverse clinical outcomes. Whether therapeutic anticoagulation improves outcomes in patients hospitalised with COVID-19 is unknown. We aimed to compare the efficacy and safety of therapeutic versus prophylactic anticoagulation in this population. METHODS We did a pragmatic, open-label (with blinded adjudication), multicentre, randomised, controlled trial, at 31 sites in Brazil. Patients (aged ≥18 years) hospitalised with COVID-19 and elevated D-dimer concentration, and who had COVID-19 symptoms for up to 14 days before randomisation, were randomly assigned (1:1) to receive either therapeutic or prophylactic anticoagulation. Therapeutic anticoagulation was in-hospital oral rivaroxaban (20 mg or 15 mg daily) for stable patients, or initial subcutaneous enoxaparin (1 mg/kg twice per day) or intravenous unfractionated heparin (to achieve a 0·3-0·7 IU/mL anti-Xa concentration) for clinically unstable patients, followed by rivaroxaban to day 30. Prophylactic anticoagulation was standard in-hospital enoxaparin or unfractionated heparin. The primary efficacy outcome was a hierarchical analysis of time to death, duration of hospitalisation, or duration of supplemental oxygen to day 30, analysed with the win ratio method (a ratio >1 reflects a better outcome in the therapeutic anticoagulation group) in the intention-to-treat population. The primary safety outcome was major or clinically relevant non-major bleeding through 30 days. This study is registered with ClinicalTrials.gov (NCT04394377) and is completed. FINDINGS From June 24, 2020, to Feb 26, 2021, 3331 patients were screened and 615 were randomly allocated (311 [50%] to the therapeutic anticoagulation group and 304 [50%] to the prophylactic anticoagulation group). 576 (94%) were clinically stable and 39 (6%) clinically unstable. One patient, in the therapeutic group, was lost to follow-up because of withdrawal of consent and was not included in the primary analysis. The primary efficacy outcome was not different between patients assigned therapeutic or prophylactic anticoagulation, with 28 899 (34·8%) wins in the therapeutic group and 34 288 (41·3%) in the prophylactic group (win ratio 0·86 [95% CI 0·59-1·22], p=0·40). Consistent results were seen in clinically stable and clinically unstable patients. The primary safety outcome of major or clinically relevant non-major bleeding occurred in 26 (8%) patients assigned therapeutic anticoagulation and seven (2%) assigned prophylactic anticoagulation (relative risk 3·64 [95% CI 1·61-8·27], p=0·0010). Allergic reaction to the study medication occurred in two (1%) patients in the therapeutic anticoagulation group and three (1%) in the prophylactic anticoagulation group. INTERPRETATION In patients hospitalised with COVID-19 and elevated D-dimer concentration, in-hospital therapeutic anticoagulation with rivaroxaban or enoxaparin followed by rivaroxaban to day 30 did not improve clinical outcomes and increased bleeding compared with prophylactic anticoagulation. Therefore, use of therapeutic-dose rivaroxaban, and other direct oral anticoagulants, should be avoided in these patients in the absence of an evidence-based indication for oral anticoagulation. FUNDING Coalition COVID-19 Brazil, Bayer SA.
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Affiliation(s)
- Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA; Brazilian Clinical Research Institute, São Paulo, Brazil.
| | - Pedro Gabriel Melo de Barros E Silva
- Brazilian Clinical Research Institute, São Paulo, Brazil; HCor Research Institute, São Paulo, Brazil; Hospital Samaritano Paulista, São Paulo, Brazil
| | - Remo H M Furtado
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil; Instituto do Coração, Universidade de São Paulo, São Paulo, Brazil
| | | | - Bruna Bronhara
- Brazilian Clinical Research Institute, São Paulo, Brazil
| | - Lucas Petri Damiani
- Brazilian Clinical Research Institute, São Paulo, Brazil; HCor Research Institute, São Paulo, Brazil
| | | | | | - Eduardo Ramacciotti
- Brazilian Clinical Research Institute, São Paulo, Brazil; Science Valley Research Institute, São Paulo, Brazil; Hemostasis & Thrombosis Research Laboratories at Loyola University Medical Center, Maywood, IL, USA
| | | | | | | | | | - Ana Thereza Rocha
- Hospital Cárdio Pulmonar, Salvador, Brazil; Escola Bahiana de Medicina, Salvador, Brazil; Universidade Federal da Bahia, Salvador, Brazil
| | | | | | | | - Lorena Souza Viana
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil; Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | | | | | | | | | | | | | | | | | | | | | - Viviane C Veiga
- Brazilian Research in Intensive Care Network, São Paulo, Brazil; BP-A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | | | | | - Gilson Soares Feitosa-Filho
- Escola Bahiana de Medicina, Salvador, Brazil; Santa Casa de Misericórdia da Bahia-Hospital Santa Izabel, Salvador, Brazil; Centro Universitário Faculdade de Tecnologia e Ciências, Salvador, Brazil
| | | | | | | | - Lilia Nigro Maia
- Hospital de Base de São José do Rio Preto, São José do Rio Preto, Brazil
| | - Flávia Ribeiro Machado
- Brazilian Research in Intensive Care Network, São Paulo, Brazil; Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, São Paulo, Brazil
| | | | | | | | | | - Regis G Rosa
- Brazilian Research in Intensive Care Network, São Paulo, Brazil; Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Luciano C P Azevedo
- Brazilian Research in Intensive Care Network, São Paulo, Brazil; Hospital Sírio Libanês Research and Education Institute, São Paulo, Brazil
| | - John H Alexander
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Alexandre B Cavalcanti
- HCor Research Institute, São Paulo, Brazil; Brazilian Research in Intensive Care Network, São Paulo, Brazil
| | - Otavio Berwanger
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil
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Simpson G, Rogers M. Real-time collection of data on patients with COVID-19 and thrombosis and/or haemorrhage has aided the development of thromboembolism prophylaxis guidelines at the Royal Surrey County Hospital during the COVID-19 pandemic. Clin Med (Lond) 2021; 21:51-52. [PMID: 34078700 DOI: 10.7861/clinmed.21-2-s51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Goswami J, MacArthur TA, Sridharan M, Pruthi RK, McBane RD, Witzig TE, Park MS. A Review of Pathophysiology, Clinical Features, and Management Options of COVID-19 Associated Coagulopathy. Shock 2021; 55:700-716. [PMID: 33378321 PMCID: PMC8122038 DOI: 10.1097/shk.0000000000001680] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
ABSTRACT There is increasing evidence that novel coronavirus disease 2019 (COVID-19) leads to a significant coagulopathy, a phenomenon termed "COVID-19 associated coagulopathy." COVID-19 has been associated with increased rates of both venous and arterial thromboembolic events, a source of significant morbidity and mortality in this disease. Further evidence suggests a link between the inflammatory response and coagulopathy associated with COVID-19. This presents a unique set of challenges for diagnosis, prevention, and treatment of thrombotic complications. In this review, we summarize and discuss the current literature on laboratory coagulation disruptions associated with COVID-19 and the clinical effects of thromboembolic events including pulmonary embolism, deep vein thrombosis, peripheral arterial thrombosis, and acute ischemic stroke in COVID-19. Endothelial injury and augmented innate immune response are implicated in the development of diffuse macro- and microvascular thrombosis in COVID-19. The pathophysiology of COVID-19 associated coagulopathy is an important determinant of appropriate treatment and monitoring of these complications. We highlight the importance of diagnosis and management of dysregulated coagulation in COVID-19 to improve outcomes in COVID-19 patients with thromboembolic complications.
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Affiliation(s)
- Julie Goswami
- Division of Trauma, Critical Care, and General Surgery, Department of Surgery, Mayo Clinic, 200 1 St. SW, Rochester, MN, 55905
| | - Taleen A. MacArthur
- Division of Trauma, Critical Care, and General Surgery, Department of Surgery, Mayo Clinic, 200 1 St. SW, Rochester, MN, 55905
| | - Meera Sridharan
- Department of Hematology, Mayo Clinic, 200 1 St. SW, Rochester, MN, 55905
| | - Rajiv K. Pruthi
- Department of Hematology, Mayo Clinic, 200 1 St. SW, Rochester, MN, 55905
| | - Robert D. McBane
- Department of Hematology, Mayo Clinic, 200 1 St. SW, Rochester, MN, 55905
- Division of Vascular Cardiology, Department of Cardiovascular Disease, Mayo Clinic, 200 1 St. SW, Rochester, MN, 55905
| | - Thomas E. Witzig
- Department of Hematology, Mayo Clinic, 200 1 St. SW, Rochester, MN, 55905
| | - Myung S. Park
- Division of Trauma, Critical Care, and General Surgery, Department of Surgery, Mayo Clinic, 200 1 St. SW, Rochester, MN, 55905
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Zhang J, Huang X, Ding D, Tao Z. Platelet-driven coagulopathy in COVID-19 patients: in comparison to seasonal influenza cases. Exp Hematol Oncol 2021; 10:34. [PMID: 34059141 PMCID: PMC8165133 DOI: 10.1186/s40164-021-00228-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 05/24/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND One year into the coronavirus diseases 2019 (COVID-19) pandemic we analyzed the blood coagulopathy in severe and non-severe COVID-19 patients and linked to those of influenza patients for a comparative study. METHODS We reported 461 COVID-19 patients and 409 seasonal influenza patients admitted at separated medical centers. With their demographic data and medical history, hematological profiles with coagulation characters were emphasized, and compared between two cohorts before and after treatment. RESULTS For 870 patients included in this study, their median age was (64.0, 51.0-76.0), and among them 511 (58.7%) were male. Hypertension, diabetes, cardiovascular diseases, and bronchitis constituted the leading comorbidities. Upon hospital admission blood test results differentiated COVID-19 patients from influenza cases, and for COVID-19 patients, leukocytosis, neutrophilia, lymphocytopenia, and thrombocytopenia were associated with disease severity and mortality. In addition, COVID-19 cohort demonstrated a prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT), increased INR, shortened thrombin time and decreased fibrinogen, compared to those in influenza cohort, leaving D-dimer levels indistinguishably high between both cohorts. Platelet hyperreactivity in COVID-19 is more evident, associated with worse hyper-inflammatory response and more refractory coagulopathy. For severe COVID-19 patients administered with anticoagulants, bleeding incidence was substantially higher than others with no anticoagulant medications. CONCLUSIONS Comparison of coagulation characteristics between COVID-19 and influenza infections provides an insightful view on SARS-CoV-2 pathogenesis and its coagulopathic mechanism, proposing for therapeutic improvement.
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Affiliation(s)
- Jianguo Zhang
- Jiangsu Province Key Laboratory of Medical Science and Laboratory Medicine, School of Medicine, Jiangsu University, Zhenjiang, 212013, Jiangsu, China
- Department of Critical Care Medicine, The Affiliated Hospital, Jiangsu University, Zhenjiang, 212001, Jiangsu, China
| | - Xing Huang
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Daoyin Ding
- Department of Critical Care Medicine, The First People's Hospital of Jiangxia District, Wuhan, 430200, Hubei, China
| | - Zhimin Tao
- Jiangsu Province Key Laboratory of Medical Science and Laboratory Medicine, School of Medicine, Jiangsu University, Zhenjiang, 212013, Jiangsu, China.
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Postdischarge thromboembolic outcomes and mortality of hospitalized patients with COVID-19: the CORE-19 registry. Blood 2021; 137:2838-2847. [PMID: 33824972 PMCID: PMC8032474 DOI: 10.1182/blood.2020010529] [Citation(s) in RCA: 115] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [Abstract] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 03/11/2021] [Indexed: 12/12/2022] Open
Abstract
In our registry, 90-day postdischarge VTE, ATE, and ACM rates were 1.55%, 1.71%, and 4.83%, respectively. Discharge anticoagulants, mostly prophylactic doses, were associated with 46% decrease in major thromboembolism or ACM composite end point.
Thromboembolic events, including venous thromboembolism (VTE) and arterial thromboembolism (ATE), and mortality from subclinical thrombotic events occur frequently in coronavirus disease 2019 (COVID-19) inpatients. Whether the risk extends postdischarge has been controversial. Our prospective registry included consecutive patients with COVID-19 hospitalized within our multihospital system from 1 March to 31 May 2020. We captured demographics, comorbidities, laboratory parameters, medications, postdischarge thromboprophylaxis, and 90-day outcomes. Data from electronic health records, health informatics exchange, radiology database, and telephonic follow-up were merged. Primary outcome was a composite of adjudicated VTE, ATE, and all-cause mortality (ACM). Principal safety outcome was major bleeding (MB). Among 4906 patients (53.7% male), mean age was 61.7 years. Comorbidities included hypertension (38.6%), diabetes (25.1%), obesity (18.9%), and cancer history (13.1%). Postdischarge thromboprophylaxis was prescribed in 13.2%. VTE rate was 1.55%; ATE, 1.71%; ΑCM, 4.83%; and MB, 1.73%. Composite primary outcome rate was 7.13% and significantly associated with advanced age (odds ratio [OR], 3.66; 95% CI, 2.84-4.71), prior VTE (OR, 2.99; 95% CI, 2.00-4.47), intensive care unit (ICU) stay (OR, 2.22; 95% CI, 1.78-2.93), chronic kidney disease (CKD; OR, 2.10; 95% CI, 1.47-3.0), peripheral arterial disease (OR, 2.04; 95% CI, 1.10-3.80), carotid occlusive disease (OR, 2.02; 95% CI, 1.30-3.14), IMPROVE-DD VTE score ≥4 (OR, 1.51; 95% CI, 1.06-2.14), and coronary artery disease (OR, 1.50; 95% CI, 1.04-2.17). Postdischarge anticoagulation was significantly associated with reduction in primary outcome (OR, 0.54; 95% CI, 0.47-0.81). Postdischarge VTE, ATE, and ACM occurred frequently after COVID-19 hospitalization. Advanced age, cardiovascular risk factors, CKD, IMPROVE-DD VTE score ≥4, and ICU stay increased risk. Postdischarge anticoagulation reduced risk by 46%.
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Korompoki E, Gavriatopoulou M, Hicklen RS, Ntanasis-Stathopoulos I, Kastritis E, Fotiou D, Stamatelopoulos K, Terpos E, Kotanidou A, Hagberg CA, Dimopoulos MA, Kontoyiannis DP. Epidemiology and organ specific sequelae of post-acute COVID19: A narrative review. J Infect 2021; 83:1-16. [PMID: 33992686 PMCID: PMC8118709 DOI: 10.1016/j.jinf.2021.05.004] [Citation(s) in RCA: 93] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 05/06/2021] [Indexed: 02/07/2023]
Abstract
Objectives “Long COVID”, a term coined by COVID-19 survivors, describes persistent or new symptoms in a subset of patients who have recovered from acute illness. Globally, the population of people infected with SARS-CoV-2 continues to expand rapidly, necessitating the need for a more thorough understanding of the array of potential sequelae of COVID-19. The multisystemic aspects of acute COVID-19 have been the subject of intense investigation, but the long–term complications remain poorly understood. Emerging data from lay press, social media, commentaries, and emerging scientific reports suggest that some COVID-19 survivors experience organ impairment and/or debilitating chronic symptoms, at times protean in nature, which impact their quality of life. Methods/Results In this review, by addressing separately each body system, we describe the pleiotropic manifestations reported post COVID-19, their putative pathophysiology and risk factors, and attempt to offer guidance regarding work-up, follow-up and management strategies. Long term sequelae involve all systems with a negative impact on mental health, well-being and quality of life, while a subset of patients, report debilitating chronic fatigue, with or without other fluctuating or persistent symptoms, such as pain or cognitive dysfunction. Although the pathogenesis is unclear, residual damage from acute infection, persistent immune activation, mental factors, or unmasking of underlying co-morbidities are considered as drivers. Comparing long COVID with other post viral chronic syndromes may help to contextualize the complex somatic and emotional sequalae of acute COVID-19. The pace of recovery of different aspects of the syndrome remains unclear as the pandemic began only a year ago. Conclusions Early recognition of long-term effects and thorough follow-up through dedicated multidisciplinary outpatient clinics with a carefully integrated research agenda are essential for treating COVID-19 survivors holistically.
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Affiliation(s)
- Eleni Korompoki
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens 11528, Greece; Divison of Brain Sciences, Imperial College London, London, United Kingdom.
| | - Maria Gavriatopoulou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens 11528, Greece
| | - Rachel S Hicklen
- Research Medical Library, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1460, Houston TX 77030, United States.
| | - Ioannis Ntanasis-Stathopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens 11528, Greece
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens 11528, Greece
| | - Despina Fotiou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens 11528, Greece
| | - Kimon Stamatelopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens 11528, Greece
| | - Evangelos Terpos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens 11528, Greece.
| | - Anastasia Kotanidou
- Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens, Athens 11528, Greece.
| | - Carin A Hagberg
- Division of Anesthesiology, Critical Care and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States.
| | - Meletios A Dimopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens 11528, Greece.
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States.
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Luks AM, Grissom CK. Return to High Altitude After Recovery from Coronavirus Disease 2019. High Alt Med Biol 2021; 22:119-127. [PMID: 33978479 DOI: 10.1089/ham.2021.0049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Luks, Andrew M. and Colin K. Grissom. Return to high altitude after recovery from coronavirus disease 2019. High Alt Med Biol. 22: 119-127, 2021.-With the increasing availability of coronavirus disease 2019 (COVID-19) vaccines and the eventual decline in the burden of the disease, it is anticipated that all forms of tourism, including travel to high altitude, will rebound in the near future. Given the physiologic challenges posed by hypobaric hypoxia at high altitude, it is useful to consider whether high-altitude travel will pose risks to those previously infected with severe acute respiratory syndrome coronavirus 2, particularly those with persistent symptoms after resolution of their infection. Although no studies have specifically examined this question as of yet, available data on the cardiopulmonary sequelae of COVID-19 provide some sense of the problems people may face at high altitude and who warrants evaluation before such endeavors. On average, most individuals who have recovered from COVID-19 have normal or near normal gas exchange, pulmonary function testing, cardiovascular function, and exercise capacity, although a subset of individuals have persistent functional deficits in some or all of these domains when examined up to 5 months after infection. Evaluation is warranted before planned high-altitude travel in individuals with persistent symptoms at least 2 weeks after a positive test or hospital discharge as well as in those who required care in an intensive care unit or suffered from myocarditis or arterial or venous thromboembolism. Depending on the results of this testing, planned high-altitude travel may need to be modified or even deferred pending resolution of the identified abnormalities. As more people travel to high altitude after the pandemic and further studies are conducted, additional data should become available to provide further guidance on these issues.
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Affiliation(s)
- Andrew M Luks
- Division of Pulmonary, Critical Care and Sleep Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Colin K Grissom
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City, Utah, USA
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Kirshblum SC, DeLauter G, Eren F, Pomeranz B, DeLuca R, Hammerman S, Gans BM. Screening for Deep Vein Thrombosis in Persons With COVID-19 Upon Admission to an Inpatient Rehabilitation Hospital. Am J Phys Med Rehabil 2021; 100:419-423. [PMID: 33819922 DOI: 10.1097/phm.0000000000001729] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE The aim of the study was to determine the prevalence of deep venous thrombosis detected by duplex screening and risk factors associated with deep venous thrombosis in patients with COVID-19 upon admission to an inpatient rehabilitation hospital. DESIGN This is a retrospective review. SETTING The setting is three freestanding inpatient rehabilitation hospitals operating as one system. PARTICIPANTS The participants are consecutive patients with a diagnosis of COVID-19 admitted to an inpatient rehabilitation hospital without a diagnosis of deep venous thrombosis or screening duplex ultrasound prior to transfer. INTERVENTIONS A duplex ultrasound of lower limbs was performed upon admission to inpatient rehabilitation hospital. OUTCOME MEASURES Primary outcome was the percentage of admission patients with a lower limb deep venous thrombosis. Secondary factors included potential risk factors for a positive screen for deep venous thrombosis. RESULTS A lower limb deep venous thrombosis was diagnosed in 22% (25/113) of the patients tested, with eight patients (7.1%) having a proximal deep venous thrombosis. Risk factors for screening positive for a deep venous thrombosis included being male, younger, and having been on a ventilator during the acute illness. CONCLUSIONS The high rate of deep venous thrombosis observed in these patients suggests that the risk of venous thromboembolic disorders after severe COVID-19 illness is considerable and surveillance measures of such patients should be undertaken.
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Affiliation(s)
- Steven C Kirshblum
- From the Kessler Institute for Rehabilitation, West Orange, New Jersey (SCK, BP, RD, BMG); Rutgers NJ Medical School, Newark, New Jersey (SCK, FE, BP, BMG); Kessler Foundation, West Orange, New Jersey (SCK, FE, BMG); and Select Medical Corporation, Mechanicsburg, Pennsylvania (SCK, GD, BP, SH, BMG)
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Manral I, Duddu N, Nayan N, Kapoor R, Gupta P, Gupta A. Cerebral Venous Thrombosis in Acute Lymphoblastic Leukemia with Severe COVID-19: a Case Report. ACTA ACUST UNITED AC 2021; 3:1622-1626. [PMID: 33948534 PMCID: PMC8084587 DOI: 10.1007/s42399-021-00932-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2021] [Indexed: 12/24/2022]
Abstract
Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has brought an unprecedented upheaval in our health-care systems. Amongst the many challenges posed by the disease, increased risk of thromboembolism has presented a distinct new front for increased mortality and morbidity. While there are multiple documented evidences for the same, the exact mechanism, knowledge of groups at-risk, and mitigation strategies are evolving. We present a case of a young individual who was diagnosed with acute lymphoblastic leukemia (ALL), was started on appropriate chemotherapy, and subsequently developed severe COVID-19 pneumonia. He was treated for COVID-19 pneumonia and recovered from the illness. However, his recovery from COVID-19 was further complicated by cortical venous sinus thrombosis (CVT). Contrast enhanced magnetic resonance imaging (CEMRI) brain and magnetic resonance venography (MRV) revealed the diagnosis of CVT with hemorrhagic parenchymal changes. He was managed with therapeutic anticoagulation and cerebral decongestants and was subsequently shifted to oral anticoagulant therapy. While the case was managed at a tertiary care setting, it opened up the question of identifying the high-risk groups and to formulate guidelines for extended thromboprophylaxis in these patients.
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Affiliation(s)
- Ishita Manral
- Department of Medicine, Command Hospital, Kolkata, India
| | - Nihar Duddu
- Department of Medicine, Command Hospital, Kolkata, India
| | - Neelabh Nayan
- Department of Medicine, Command Hospital, Kolkata, India
| | - Rajan Kapoor
- Department of Medicine, Command Hospital, Kolkata, India
| | - Preeti Gupta
- Department of Radiodiagnosis, Command Hospital, Kolkata, India
| | - Anirban Gupta
- Department of Medicine, Command Hospital, Kolkata, India
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Leentjens J, van Haaps TF, Wessels PF, Schutgens REG, Middeldorp S. COVID-19-associated coagulopathy and antithrombotic agents-lessons after 1 year. LANCET HAEMATOLOGY 2021; 8:e524-e533. [PMID: 33930350 PMCID: PMC8078884 DOI: 10.1016/s2352-3026(21)00105-8] [Citation(s) in RCA: 147] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 03/26/2021] [Accepted: 03/31/2021] [Indexed: 02/06/2023]
Abstract
COVID-19 is associated with a high incidence of thrombotic complications, which can be explained by the complex and unique interplay between coronaviruses and endothelial cells, the local and systemic inflammatory response, and the coagulation system. Empirically, an intensified dose of thrombosis prophylaxis is being used in patients admitted to hospital with COVID-19 and several guidelines on this topic have been published, although the insufficiency of high quality and direct evidence has led to weak recommendations. In this Viewpoint we summarise the pathophysiology of COVID-19 coagulopathy in the context of patients who are ambulant, admitted to hospital, and critically ill or non-critically ill, and those post-discharge from hospital. We also review data from randomised controlled trials in the past year of antithrombotic therapy in patients who are critically ill. These data provide the first high-quality evidence on optimal use of antithrombotic therapy in patients with COVID-19. Pharmacological thromboprophylaxis is not routinely recommended for patients who are ambulant and post-discharge. A first ever trial in non-critically ill patients who were admitted to hospital has shown that a therapeutic dose of low-molecular-weight heparin might improve clinical outcomes in this population. In critically ill patients, this same treatment does not improve outcomes and prophylactic dose anticoagulant thromboprophylaxis is recommended. In the upcoming months we expect numerous data from the ongoing antithrombotic COVID-19 studies to guide clinicians at different stages of the disease.
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Affiliation(s)
- Jenneke Leentjens
- Department of Internal Medicine, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands.
| | - Thijs F van Haaps
- Department of Vascular Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Pieter F Wessels
- Department of Medical Oncology, University of Pretoria, Pretoria, South Africa; Ampath Laboratories, Pretoria, South Africa
| | - Roger E G Schutgens
- Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, Netherlands
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
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Abstract
Immune-related manifestations are increasingly recognized conditions in patients with COVID-19, with around 3,000 cases reported worldwide comprising more than 70 different systemic and organ-specific disorders. Although the inflammation caused by SARS-CoV-2 infection is predominantly centred on the respiratory system, some patients can develop an abnormal inflammatory reaction involving extrapulmonary tissues. The signs and symptoms associated with this excessive immune response are very diverse and can resemble some autoimmune or inflammatory diseases, with the clinical phenotype that is seemingly influenced by epidemiological factors such as age, sex or ethnicity. The severity of the manifestations is also very varied, ranging from benign and self-limiting features to life-threatening systemic syndromes. Little is known about the pathogenesis of these manifestations, and some tend to emerge within the first 2 weeks of SARS-CoV-2 infection, whereas others tend to appear in a late post-infectious stage or even in asymptomatic patients. As the body of evidence comprises predominantly case series and uncontrolled studies, diagnostic and therapeutic decision-making is unsurprisingly often based on the scarcely reported experience and expert opinion. Additional studies are required to learn about the mechanisms involved in the development of these manifestations and apply that knowledge to achieve early diagnosis and the most suitable therapy.
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123
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Grover P, Gulati S. Highlights from the American society of hematology conference 2020. J Thromb Thrombolysis 2021; 52:354-362. [PMID: 33900522 PMCID: PMC8072747 DOI: 10.1007/s11239-021-02449-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2021] [Indexed: 11/27/2022]
Abstract
American Society of Hematology conducts an annual meeting, where investigators from around the globe presented ground-breaking research in the fields of malignant and non-malignant hematology. We provide a summary of non-malignant hematology abstracts from the 2020 meeting. Topics included range from those related to thrombosis, including thrombotic complications of COVID-19, bleeding and novel therapies such as gene therapies. Readers are encouraged to access meeting materials for a more detailed coverage of the event.
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Affiliation(s)
- Punita Grover
- Division of Hematology and Oncology, University of Cincinnati, Cincinnati, OH, 45267, USA
| | - Shuchi Gulati
- Division of Hematology and Oncology, University of Cincinnati, Cincinnati, OH, 45267, USA.
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124
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Pop C, Ferent I. HIGH D-DIMER VALUES AND POST-DISCHARGE ACUTE PULMONARY EMBOLISM IN YOUNG PATIENTS WITH COVID-19: A CASE SERIES. SANAMED 2021. [DOI: 10.24125/sanamed.v16i1.501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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125
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Engelen MM, Vandenbriele C, Balthazar T, Claeys E, Gunst J, Guler I, Jacquemin M, Janssens S, Lorent N, Liesenborghs L, Peerlinck K, Pieters G, Rex S, Sinonquel P, Van der Linden L, Van Laer C, Vos R, Wauters J, Wilmer A, Verhamme P, Vanassche T. Venous Thromboembolism in Patients Discharged after COVID-19 Hospitalization. Semin Thromb Hemost 2021; 47:362-371. [PMID: 33893631 DOI: 10.1055/s-0041-1727284] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a frequent complication of COVID-19, so that the importance of adequate in-hospital thromboprophylaxis in patients hospitalized with COVID-19 is well established. However, the incidence of VTE after discharge and whether postdischarge thromboprophylaxis is beneficial and safe are unclear. In this prospective observational single-center study, we report the incidence of VTE 6 weeks after hospitalization and the use of postdischarge thromboprophylaxis. METHODS Patients hospitalized with confirmed COVID-19 were invited to a multidisciplinary follow-up clinic 6 weeks after discharge. D-dimer and C-reactive protein were measured, and all patients were screened for deep vein thrombosis with venous duplex-ultrasound. Additionally, selected high-risk patients received computed tomography pulmonary angiogram or ventilation-perfusion (V/Q) scan to screen for incidental pulmonary embolism. RESULTS Of 485 consecutive patients hospitalized from March through June 2020, 146 patients were analyzed, of which 39% had been admitted to the intensive care unit (ICU). Postdischarge thromboprophylaxis was prescribed in 28% of patients, but was used more frequently after ICU stay (61%) and in patients with higher maximal D-dimer and C-reactive protein levels during hospitalization. Six weeks after discharge, elevated D-dimer values were present in 32% of ward and 42% of ICU patients. Only one asymptomatic deep vein thrombosis (0.7%) and one symptomatic pulmonary embolism (0.7%) were diagnosed with systematic screening. No bleedings were reported. CONCLUSION In patients who had been hospitalized with COVID-19, systematic screening for VTE 6 weeks after discharge revealed a low incidence of VTE. A strategy of selectively providing postdischarge thromboprophylaxis in high-risk patients seems safe and potentially effective.
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Affiliation(s)
- Matthias M Engelen
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | | | - Tim Balthazar
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Eveline Claeys
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Jan Gunst
- Clinical Department and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Ipek Guler
- Leuven Biostatistics and Statistical Bioinformatics Centre (L-BioStat), KU Leuven, Leuven, Belgium
| | - Marc Jacquemin
- Department of Cardiovascular Diseases and Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Stefan Janssens
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Natalie Lorent
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Laurens Liesenborghs
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium.,The Outbreak Research Team, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Kathelijne Peerlinck
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Griet Pieters
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Steffen Rex
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Diseases, KU Leuven, Leuven, Belgium
| | - Pieter Sinonquel
- Department of Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Lorenz Van der Linden
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium.,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Christine Van Laer
- Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Robin Vos
- Department of CHROMETA, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
| | - Joost Wauters
- Medical Intensive Care, University Hospitals Leuven, Leuven, Belgium
| | - Alexander Wilmer
- Medical Intensive Care, University Hospitals Leuven, Leuven, Belgium
| | - Peter Verhamme
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Thomas Vanassche
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
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126
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Sisó-Almirall A, Brito-Zerón P, Conangla Ferrín L, Kostov B, Moragas Moreno A, Mestres J, Sellarès J, Galindo G, Morera R, Basora J, Trilla A, Ramos-Casals M. Long Covid-19: Proposed Primary Care Clinical Guidelines for Diagnosis and Disease Management. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:4350. [PMID: 33923972 PMCID: PMC8073248 DOI: 10.3390/ijerph18084350] [Citation(s) in RCA: 97] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/02/2021] [Accepted: 04/16/2021] [Indexed: 01/08/2023]
Abstract
Long COVID-19 may be defined as patients who, four weeks after the diagnosis of SARS-Cov-2 infection, continue to have signs and symptoms not explainable by other causes. The estimated frequency is around 10% and signs and symptoms may last for months. The main long-term manifestations observed in other coronaviruses (Severe Acute Respiratory Syndrome (SARS), Middle East respiratory syndrome (MERS)) are very similar to and have clear clinical parallels with SARS-CoV-2: mainly respiratory, musculoskeletal, and neuropsychiatric. The growing number of patients worldwide will have an impact on health systems. Therefore, the main objective of these clinical practice guidelines is to identify patients with signs and symptoms of long COVID-19 in primary care through a protocolized diagnostic process that studies possible etiologies and establishes an accurate differential diagnosis. The guidelines have been developed pragmatically by compiling the few studies published so far on long COVID-19, editorials and expert opinions, press releases, and the authors' clinical experience. Patients with long COVID-19 should be managed using structured primary care visits based on the time from diagnosis of SARS-CoV-2 infection. Based on the current limited evidence, disease management of long COVID-19 signs and symptoms will require a holistic, longitudinal follow up in primary care, multidisciplinary rehabilitation services, and the empowerment of affected patient groups.
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Affiliation(s)
- Antoni Sisó-Almirall
- Permanent Board of the Catalan Society of Family and Community Medicine (CAMFiC), 08009 Barcelona, Spain; (L.C.F.); (J.M.)
- Primary Care Centre Les Corts, Consorci d’Atenció Primària de Salut Barcelona Esquerra (CAPSBE), 08028 Barcelona, Spain;
- Primary Healthcare Transversal Research Group, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
| | - Pilar Brito-Zerón
- Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, 08036 Barcelona, Spain; (P.B.-Z.); (M.R.-C.)
- Autoimmune Diseases Unit, Department of Medicine, Hospital CIMA-Sanitas, 08034 Barcelona, Spain
- Department of Autoimmune Diseases, ICMiD, Hospital Clínic, 08036 Barcelona, Spain
| | - Laura Conangla Ferrín
- Permanent Board of the Catalan Society of Family and Community Medicine (CAMFiC), 08009 Barcelona, Spain; (L.C.F.); (J.M.)
| | - Belchin Kostov
- Primary Care Centre Les Corts, Consorci d’Atenció Primària de Salut Barcelona Esquerra (CAPSBE), 08028 Barcelona, Spain;
- Primary Healthcare Transversal Research Group, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
- Department of Statistics and Operations Research, Universitat Politècnica de Catalunya (UPC), 08034 Barcelona, Spain
| | - Anna Moragas Moreno
- Jaume I Health Centre, Institut Català de la Salut, Universitat Rovira i Virgili, 43005 Tarragona, Spain;
| | - Jordi Mestres
- Permanent Board of the Catalan Society of Family and Community Medicine (CAMFiC), 08009 Barcelona, Spain; (L.C.F.); (J.M.)
| | | | - Gisela Galindo
- Permanent Board of the Spanish Society of Family and Community Medicine (semFYC), 08009 Barcelona, Spain;
| | - Ramon Morera
- Board of Spanish Society of Managers of Primary Care (SEDAP), 28026 Madrid, Spain;
| | | | - Antoni Trilla
- Faculty of Medicine and Health Sciences, University of Barcelona, 08036 Barcelona, Spain;
| | - Manuel Ramos-Casals
- Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, 08036 Barcelona, Spain; (P.B.-Z.); (M.R.-C.)
- Department of Autoimmune Diseases, ICMiD, Hospital Clínic, 08036 Barcelona, Spain
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127
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Nalbandian A, Sehgal K, Gupta A, Madhavan MV, McGroder C, Stevens JS, Cook JR, Nordvig AS, Shalev D, Sehrawat TS, Ahluwalia N, Bikdeli B, Dietz D, Der-Nigoghossian C, Liyanage-Don N, Rosner GF, Bernstein EJ, Mohan S, Beckley AA, Seres DS, Choueiri TK, Uriel N, Ausiello JC, Accili D, Freedberg DE, Baldwin M, Schwartz A, Brodie D, Garcia CK, Elkind MSV, Connors JM, Bilezikian JP, Landry DW, Wan EY. Post-acute COVID-19 syndrome. Nat Med 2021; 27:601-615. [PMID: 33753937 PMCID: PMC8893149 DOI: 10.1038/s41591-021-01283-z] [Citation(s) in RCA: 2551] [Impact Index Per Article: 850.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 02/09/2021] [Indexed: 02/07/2023]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the pathogen responsible for the coronavirus disease 2019 (COVID-19) pandemic, which has resulted in global healthcare crises and strained health resources. As the population of patients recovering from COVID-19 grows, it is paramount to establish an understanding of the healthcare issues surrounding them. COVID-19 is now recognized as a multi-organ disease with a broad spectrum of manifestations. Similarly to post-acute viral syndromes described in survivors of other virulent coronavirus epidemics, there are increasing reports of persistent and prolonged effects after acute COVID-19. Patient advocacy groups, many members of which identify themselves as long haulers, have helped contribute to the recognition of post-acute COVID-19, a syndrome characterized by persistent symptoms and/or delayed or long-term complications beyond 4 weeks from the onset of symptoms. Here, we provide a comprehensive review of the current literature on post-acute COVID-19, its pathophysiology and its organ-specific sequelae. Finally, we discuss relevant considerations for the multidisciplinary care of COVID-19 survivors and propose a framework for the identification of those at high risk for post-acute COVID-19 and their coordinated management through dedicated COVID-19 clinics.
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Affiliation(s)
- Ani Nalbandian
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Kartik Sehgal
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Correspondence should be addressed to K.S. or E.Y.W. ;
| | - Aakriti Gupta
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA.,Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA.,Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Mahesh V. Madhavan
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA.,Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA
| | - Claire McGroder
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Vagelos College of Physicians and Surgeons, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Jacob S. Stevens
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Joshua R. Cook
- Division of Endocrinology, Department of Medicine, Vagelos College of Physicians and Surgeons, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Anna S. Nordvig
- Department of Neurology, Vagelos College of Physicians and Surgeons, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Daniel Shalev
- Department of Psychiatry, Vagelos College of Physicians and Surgeons, New York-Presbyterian/Columbia University Irving Medical Center, and New York State Psychiatric Institute, New York, New York, USA
| | - Tejasav S. Sehrawat
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Neha Ahluwalia
- Division of Cardiology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Behnood Bikdeli
- Harvard Medical School, Boston, Massachusetts, USA.,Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA.,Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut, USA.,Cardiovascular Division, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Donald Dietz
- Division of Infectious Diseases, Department of Medicine, Vagelos College of Physicians and Surgeons, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Caroline Der-Nigoghossian
- Clinical Pharmacy, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - Nadia Liyanage-Don
- Department of Medicine, Vagelos College of Physicians and Surgeons, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Gregg F. Rosner
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Elana J. Bernstein
- Division of Rheumatology, Department of Medicine, Vagelos College of Physicians and Surgeons, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Akinpelumi A. Beckley
- Department of Rehabilitation and Regenerative Medicine, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - David S. Seres
- Institute of Human Nutrition and Division of Preventive Medicine and Nutrition, Department of Medicine, Vagelos College of Physicians and Surgeons, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Toni K. Choueiri
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Nir Uriel
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - John C. Ausiello
- Division of Endocrinology, Department of Medicine, Vagelos College of Physicians and Surgeons, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Domenico Accili
- Division of Endocrinology, Department of Medicine, Vagelos College of Physicians and Surgeons, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Daniel E. Freedberg
- Division of Digestive and Liver Diseases, Department of Medicine, Vagelos College of Physicians and Surgeons, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Matthew Baldwin
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Vagelos College of Physicians and Surgeons, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Allan Schwartz
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Daniel Brodie
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Vagelos College of Physicians and Surgeons, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Christine Kim Garcia
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Vagelos College of Physicians and Surgeons, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Mitchell S. V. Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Jean M. Connors
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Hematology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - John P. Bilezikian
- Division of Endocrinology, Department of Medicine, Vagelos College of Physicians and Surgeons, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Donald W. Landry
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Elaine Y. Wan
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA.,Correspondence should be addressed to K.S. or E.Y.W. ;
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128
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Martínez-Botía P, Bernardo Á, Acebes-Huerta A, Caro A, Leoz B, Martínez-Carballeira D, Palomo-Antequera C, Soto I, Gutiérrez L. Clinical Management of Hypertension, Inflammation and Thrombosis in Hospitalized COVID-19 Patients: Impact on Survival and Concerns. J Clin Med 2021; 10:jcm10051073. [PMID: 33806709 PMCID: PMC7961450 DOI: 10.3390/jcm10051073] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/13/2021] [Accepted: 02/24/2021] [Indexed: 02/06/2023] Open
Abstract
The most severe clinical manifestations of the Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), are due to an unbalanced immune response and a pro-thrombotic hemostatic disturbance, with arterial hypertension or diabetes as acknowledged risk factors. While waiting for a specific treatment, the clinical management of hospitalized patients is still a matter of debate, and the effectiveness of treatments to manage clinical manifestations and comorbidities has been questioned. In this study, we aim to assess the impact of the clinical management of arterial hypertension, inflammation and thrombosis on the survival of COVID-19 patients. The Spanish cohorts included in this observational retrospective study are from HM Hospitales (2035 patients) and from Hospital Universitario Central de Asturias (72 patients). Kaplan Meier survival curves, Cox regression and propensity score matching analyses were employed, considering demographic variables, comorbidities and treatment arms (when opportune) as covariates. The management of arterial hypertension with angiotensin-converting enzyme 2 (ACE2) inhibitors or angiotensin receptor blockers is not detrimental, as was initially reported, and neither was the use of non-steroidal anti-inflammatory drugs (NSAIDs). On the contrary, our analysis shows that the use on itself of corticosteroids is not beneficial. Importantly, the management of COVID-19 patients with low molecular weight heparin (LMWH) as an anticoagulant significantly improves the survival of hospitalized patients. These results delineate the current treatment options under debate, supporting the effectiveness of thrombosis prophylaxis on COVID-19 patients as a first-line treatment without the need for compromising the treatment of comorbidities, while suggesting cautiousness when administering corticosteroids.
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Affiliation(s)
- Patricia Martínez-Botía
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain; (P.M.-B.); (Á.B.); (A.A.-H.); (A.C.); (D.M.-C.)
| | - Ángel Bernardo
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain; (P.M.-B.); (Á.B.); (A.A.-H.); (A.C.); (D.M.-C.)
- Clinical Diagnosis Laboratory, Department of Hematology, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain
| | - Andrea Acebes-Huerta
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain; (P.M.-B.); (Á.B.); (A.A.-H.); (A.C.); (D.M.-C.)
| | - Alberto Caro
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain; (P.M.-B.); (Á.B.); (A.A.-H.); (A.C.); (D.M.-C.)
- Department of Hematology, Hemostasis Section, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain
| | - Blanca Leoz
- Department of Intensive Medicine, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain;
- Translational Microbiology Group, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain
| | - Daniel Martínez-Carballeira
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain; (P.M.-B.); (Á.B.); (A.A.-H.); (A.C.); (D.M.-C.)
- Department of Hematology, Hemostasis Section, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain
| | - Carmen Palomo-Antequera
- Department of Internal Medicine, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain;
- Bone Metabolism, Vascular Metabolism and Chronic Inflammatory Diseases Group, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain
| | - Inmaculada Soto
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain; (P.M.-B.); (Á.B.); (A.A.-H.); (A.C.); (D.M.-C.)
- Department of Hematology, Hemostasis Section, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain
- Correspondence: (I.S.); (L.G.)
| | - Laura Gutiérrez
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain; (P.M.-B.); (Á.B.); (A.A.-H.); (A.C.); (D.M.-C.)
- Department of Medicine, Faculty of Medicine, University of Oviedo, 33006 Oviedo, Spain
- Correspondence: (I.S.); (L.G.)
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129
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Al Raizah A, Al Askar A, Shaheen N, Aldosari K, Alnahdi M, Luhanga M, Alshuaibi T, Bajhmoum W, Alharbi K, Alsahari G, Algahtani H, Alrayes E, Basendwah A, Abotaleb A, Almegren M. High rate of bleeding and arterial thrombosis in COVID-19: Saudi multicenter study. Thromb J 2021; 19:13. [PMID: 33658062 PMCID: PMC7928187 DOI: 10.1186/s12959-021-00265-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 02/16/2021] [Indexed: 12/23/2022] Open
Abstract
Background Several observational studies have reported the rate of venous and arterial thrombotic events in patients infected with COVID-19, with conflicting results. The aim of this study was to estimate the rate of thrombotic and bleeding events in hospitalized patients diagnosed with Coronavirus disease 2019 (COVID-19). Methods This was a multicenter study of 636 patients admitted between 20 March 2020 and 31 May 2020 with confirmed COVID-19 in four hospitals. Results Over a median length of stay in the non-ICU group of 7 days and of 19 days in the ICU group, twelve patients were diagnosed with Venous thromboembolism (VTE) (1.8 %) (95 % CI, 1.1–3). The rate in the non-ICU group was 0.19 % (95 % CI, 0.04–0.84), and that in the ICU group was 10.3 % (95 % CI, 6.4–16.2). The overall rate of arterial event is 2.2 % (95 % CI, 1.4–3.3). The rates in the non-ICU and ICU groups were 0.94 % (95 % CI, 0.46–0.1.9) and 8.4 % (95 % CI, 5.0–14.0). The overall composite event rate was 2.9 % (95 % CI, 2.0–4.3). The composite event rates in the non-ICU and ICU groups were 0.94 % (95 % CI, 0.46–0.1.9) and 13.2 % (95 % CI, 8.7–19.5). The overall rate of bleeding is 1.7 % (95 % CI, 1.0–2.8). The bleeding rate in the non-ICU group was 0.19 % (95 % CI, 0.04–0.84), and that in the ICU group was 9.4 % (95 % CI, 5.7–15.1). The baseline D-dimer level was a significant risk factor for developing VTE (OR 1.31, 95 % CI, 1.08–1.57, p = 0.005) and composite events (OR 1.32, 95 % CI, 1.12–1.55, p = 0.0007). Conclusions In this study, we found that the VTE rates in hospitalized patients with COVID-19 might not be higher than expected. In contrast to the risk of VTE, we found a high rate of arterial and bleeding complications in patients admitted to the ICU. An elevated D-dimer level at baseline could predict thrombotic complications in COVID-19 patients and may assist in the identification of these patients. Given the high rate of bleeding, the current study suggests that the intensification of anticoagulation therapy in COVID-19 patients beyond the standard of care be pursued with caution and would best be evaluated in a randomized controlled study.
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Affiliation(s)
- Abdulrahman Al Raizah
- Division of Adult Hematology, Department of Oncology, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, PO Box. 22490, 11426, Riyadh, Saudi Arabia. .,King Abdullah International Medical Research Center, Saudi Society for Bone Marrow Transplant, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia. .,King Saud bin Abdulaziz University of Health Sciences, Riyadh, Saudi Arabia.
| | - Ahmed Al Askar
- Division of Adult Hematology, Department of Oncology, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, PO Box. 22490, 11426, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Saudi Society for Bone Marrow Transplant, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.,King Saud bin Abdulaziz University of Health Sciences, Riyadh, Saudi Arabia
| | - Naila Shaheen
- King Saud bin Abdulaziz University of Health Sciences, Riyadh, Saudi Arabia.,Department of Biostatistics and Bioinformatics, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Khalid Aldosari
- Division of Adult Hematology, Department of Oncology, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, PO Box. 22490, 11426, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Saudi Society for Bone Marrow Transplant, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Mohamed Alnahdi
- Division of Adult Hematology, Department of Oncology, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, PO Box. 22490, 11426, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Saudi Society for Bone Marrow Transplant, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Musumadi Luhanga
- Division of Adult Hematology, Department of Oncology, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, PO Box. 22490, 11426, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Saudi Society for Bone Marrow Transplant, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Turki Alshuaibi
- Department of Medicine, King Fahd Hospital, Jeddah, Saudi Arabia
| | - Wail Bajhmoum
- Department of Medicine, King Fahd Hospital, Jeddah, Saudi Arabia
| | - Khaled Alharbi
- Department of Medicine, King Fahd Hospital, Jeddah, Saudi Arabia
| | - Ghaida Alsahari
- Department of Medicine, King Fahd Hospital, Jeddah, Saudi Arabia
| | - Hadeel Algahtani
- Department of Medicine, King Fahd Hospital, Jeddah, Saudi Arabia
| | - Eunice Alrayes
- Department of Medicine, Prince Mohammed Bin Abdulaziz Hospital, Riyadh, Saudi Arabia
| | - Abdulrahim Basendwah
- Oncology Division, Medicine Department, King Fahad Armed Forces Hospital, Jeddah, Mecca, Saudi Arabia
| | - Alia Abotaleb
- Oncology Division, Medicine Department, King Fahad Armed Forces Hospital, Jeddah, Mecca, Saudi Arabia
| | - Mosaad Almegren
- Department of Medicine, College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
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130
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Brem FL, Missaoui Z, Arghal M, Rasras H, Aichouni N, Skiker I, Ouafi NE, Zakaria B. Late-onset of pulmonary embolism following hospitalization for COVID-19 despite thromboprophylaxis: a report of two cases. Pan Afr Med J 2021; 38:226. [PMID: 34046131 PMCID: PMC8140687 DOI: 10.11604/pamj.2021.38.226.28503] [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: 02/22/2021] [Accepted: 02/28/2021] [Indexed: 11/11/2022] Open
Abstract
The global pandemic caused by the SARS-CoV-2 has resulted in an increased incidence of venous thromboembolism among hospitalized COVID-19-patients, especially those who required intensive care, despite thromboprophylaxis. This has resulted in the use of higher doses of thromboprophylaxis or therapeutic anticoagulation therapy even in the absence of thrombotic events. However, after their hospital discharge, authors and current guidelines are not unanimous about extended anticoagulant therapy in patients with COVID-19. Here, we report two pulmonary embolism cases following hospitalization for COVID-19, despite intermediate doses of thromboprophylaxis. These rare cases suggest that there may be a residual thrombotic risk following hospitalization for COVID-19 and highlight questions about extended prophylactic-anticoagulation therapy after hospital discharge of patients with COVID-19.
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Affiliation(s)
- Falmata Laouan Brem
- Department of Cardiology, Mohammed VI University Hospital, Faculty of Medicine and Pharmacy of Oujda, Mohammed First University, Oujda, Morocco
| | - Zakariae Missaoui
- Department of Radiology, Mohammed VI University Hospital, Faculty of Medicine and Pharmacy of Oujda, Mohammed First University, Oujda, Morocco
| | - Mohammed Arghal
- Department of Radiology, Mohammed VI University Hospital, Faculty of Medicine and Pharmacy of Oujda, Mohammed First University, Oujda, Morocco
| | - Hammam Rasras
- Department of Cardiology, Mohammed VI University Hospital, Faculty of Medicine and Pharmacy of Oujda, Mohammed First University, Oujda, Morocco
| | - Narjisse Aichouni
- Department of Radiology, Mohammed VI University Hospital, Faculty of Medicine and Pharmacy of Oujda, Mohammed First University, Oujda, Morocco
| | - Imane Skiker
- Department of Radiology, Mohammed VI University Hospital, Faculty of Medicine and Pharmacy of Oujda, Mohammed First University, Oujda, Morocco
| | - Noha El Ouafi
- Department of Cardiology, Mohammed VI University Hospital, Faculty of Medicine and Pharmacy of Oujda, Mohammed First University, Oujda, Morocco.,Epidemiological Laboratory of Clinical Research and Public Health, Faculty of Medicine and Pharmacy of Oujda, Mohammed First University, Oujda, Morocco
| | - Bazid Zakaria
- Department of Cardiology, Mohammed VI University Hospital, Faculty of Medicine and Pharmacy of Oujda, Mohammed First University, Oujda, Morocco.,Epidemiological Laboratory of Clinical Research and Public Health, Faculty of Medicine and Pharmacy of Oujda, Mohammed First University, Oujda, Morocco
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131
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Rahman A, Niloofa R, Jayarajah U, De Mel S, Abeysuriya V, Seneviratne SL. Hematological Abnormalities in COVID-19: A Narrative Review. Am J Trop Med Hyg 2021; 104:1188-1201. [PMID: 33606667 PMCID: PMC8045618 DOI: 10.4269/ajtmh.20-1536] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 02/08/2021] [Indexed: 01/08/2023] Open
Abstract
COVID-19 is caused by SARS-CoV-2. Although pulmonary manifestations have been identified as the major symptoms, several hematological abnormalities have also been identified. This review summarizes the reported hematological abnormalities (changes in platelet, white blood cell, and hemoglobin, and coagulation/fibrinolytic alterations), explores their patho-mechanisms, and discusses its management. Common hematological abnormalities in COVID-19 are lymphopenia, thrombocytopenia, and elevated D-dimer levels. These alterations are significantly more common/prominent in patients with severe COVID-19 disease, and thus may serve as a possible biomarker for those needing hospitalization and intensive care unit care. Close attention needs to be paid to coagulation abnormalities, and steps should be taken to prevent these occurring or to mitigate their harmful effects. The effect of COVID-19 in patients with hematological abnormalities and recognized hematological drug toxicities of therapies for COVID-19 are also outlined.
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Affiliation(s)
- Asma Rahman
- Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Roshan Niloofa
- Department of Zoology and Environment Sciences, Faculty of Science, University of Colombo, Colombo, Sri Lanka
| | - Umesh Jayarajah
- Postgraduate Institute of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Sanjay De Mel
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System Singapore, Singapore, Singapore
- Nawaloka Hospital Research and Education Foundation, Nawaloka Hospitals, Colombo, Sri Lanka
| | - Visula Abeysuriya
- Nawaloka Hospital Research and Education Foundation, Nawaloka Hospitals, Colombo, Sri Lanka
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132
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Hunt BJ, De Paula EV, McLintock C, Dumantepe M. Prophylactic anticoagulation for patients in hospital with covid-19. BMJ 2021; 372:n487. [PMID: 33608304 DOI: 10.1136/bmj.n487] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Beverley J Hunt
- Thrombosis and Haemophilia Centre, Guy's and St Thomas' NHS Foundation Trust, London SE1 7EH, UK
| | - Erich V De Paula
- School of Medical Sciences, University of Campinas, Campinas, São Paulo, Brazil
| | - Claire McLintock
- Maternal-Fetal Medicine Service, National Women's Health, Auckland City Hospital, Auckland, New Zealand
| | - Mert Dumantepe
- Department of Cardiovascular Surgery, School of Medicine, University of Uskudar, Istanbul, Turkey
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133
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Berkman SA. Post-hospital discharge venous thromboembolism prophylaxis in medically ill patients. Postgrad Med 2021; 133:51-63. [PMID: 33435758 DOI: 10.1080/00325481.2021.1876387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
There is a widely expressed concern about an unmet need for post hospitalization venous thromboembolism (VTE) prophylaxis in medically ill patients, however, physicians and hospitals have been slow to implement this measure. Recommendations against extended VTE prophylaxis in medical patients from the American Society of Hematology (ASH) in 2018 and the withholding of approval of betrixiban by the European Medicines Agency also in 2018 may have been influential in this regard. Furthermore, rivaroxaban the other drug approved for this indication in the U.S has not yet been approved in Europe. In addition, hospital administrators, those monitoring expenses in the U.S, have been reluctant to support a treatment which will mostly involve outpatients. Internal medicine physicians, hospitalists and nursing home physicians have not shared the fervor for post hospital VTE prophylaxis, whether with anticoagulants or aspirin, that their orthopedic surgery colleagues have, particularly in hip and knee arthroplasty. This is despite an increased risk of post hospital discharge thrombosis in both groups of patients. Enter hospitalized patients with COVID-19, a potentially severe medical illness with high hospitalization related thrombosis risk, and questions arise as to whether these medical patients, who are clearly more hypercoagulable during hospitalization than those in previous studies, should warrant post hospital discharge prophylaxis.
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Affiliation(s)
- Samuel A Berkman
- Department of medicine, Division of hematology/Oncology UCLA, California
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134
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Berkman SA, Tapson VF. COVID-19 and Its Implications for Thrombosis and Anticoagulation. Semin Respir Crit Care Med 2021; 42:316-326. [PMID: 33548929 DOI: 10.1055/s-0041-1722992] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Venous thromboembolism, occlusion of dialysis catheters, circuit thrombosis in extracorporeal membrane oxygenation (ECMO) devices, acute limb ischemia, and isolated strokes, all in the face of prophylactic and even therapeutic anticoagulation, are features of novel coronavirus disease 2019 (COVID-19) coagulopathy. It seems well established at this time that a COVID-19 patient deemed sick enough to be hospitalized, should receive at least prophylactic dose anticoagulation. However, should some hospitalized patients have dosage escalation to intermediate dose? Should some be considered for full-dose anticoagulation without a measurable thromboembolic event and how should that anticoagulation be monitored? Should patients receive postdischarge anticoagulation and with what medication and for how long? What thrombotic issues are related to the various medications being used to treat this coagulopathy? Is antiphospholipid antibody part of this syndrome? What is the significance of isolated ischemic stroke and limb ischemia in this disorder and how does this interface with the rest of the clinical and laboratory features of this disorder? The aims of this article are to explore these questions and interpret the available data based on the current evidence.
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Affiliation(s)
- Samuel A Berkman
- Department of Medicine, University of California Los Angeles, Hematology/Oncology, Los Angeles, California
| | - Victor F Tapson
- Department of Medicine, Cedars Sinai Medical Center, Los Angeles, California
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135
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Ortega‐Paz L, Capodanno D, Montalescot G, Angiolillo DJ. Coronavirus Disease 2019-Associated Thrombosis and Coagulopathy: Review of the Pathophysiological Characteristics and Implications for Antithrombotic Management. J Am Heart Assoc 2021; 10:e019650. [PMID: 33228447 PMCID: PMC7955431 DOI: 10.1161/jaha.120.019650] [Citation(s) in RCA: 99] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus-2, which has posed a significant threat to global health. Although the infection is frequently asymptomatic or associated with mild symptoms, in a small proportion of patients it can produce an intense inflammatory and prothrombotic state that can lead to acute respiratory distress syndrome, multiple organ failure, and death. Angiotensin-converting enzyme 2, highly expressed in the respiratory system, has been identified as a functional receptor for severe acute respiratory syndrome coronavirus-2. Notably, angiotensin-converting enzyme 2 is also expressed in the cardiovascular system, and there are multiple cardiovascular implications of COVID-19. Cardiovascular risk factors and cardiovascular disease have been associated with severe manifestations and poor prognosis in patients with COVID-19. More important, patients with COVID-19 may have thrombotic and coagulation abnormalities, promoting a hypercoagulable state and resulting in an increased rate of thrombotic and thromboembolic events. This review will describe the pathophysiological characteristics of the cardiovascular involvement following infection by severe acute respiratory syndrome coronavirus-2, with a focus on thrombotic and thromboembolic manifestations and implications for antithrombotic management.
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Affiliation(s)
- Luis Ortega‐Paz
- Cardiovascular InstituteInstitut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)BarcelonaSpain
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria "Policlinico‐Vittorio Emanuele"University of CataniaCataniaItaly
| | - Gilles Montalescot
- ACTION Study GroupInstitut de CardiologieAssistance Publique ‐ Hôpitaux de ParisHôpital Pitié‐SalpêtrièreUniversity Paris 6INSERM UMRS 1166ParisFrance
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136
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Rashidi F, Barco S, Kamangar F, Heresi GA, Emadi A, Kaymaz C, Jansa P, Reis A, Rashidi A, Taghizadieh A, Rezaeifar P, Moghimi M, Ghodrati S, Mozafari A, Foumani AA, Tahamtan O, Rafiee E, Abbaspour Z, Khodadadi K, Alamdari G, Boodaghi Y, Rezaei M, Muhammadi MJ, Abbasi M, Movaseghi F, Koohi A, Shakourzad L, Ebrahimi F, Radvar S, Amoozadeh M, Fereidooni F, Naseari H, Movalled K, Ghorbani O, Ansarin K. Incidence of symptomatic venous thromboembolism following hospitalization for coronavirus disease 2019: Prospective results from a multi-center study. Thromb Res 2021; 198:135-138. [PMID: 33338976 PMCID: PMC7836837 DOI: 10.1016/j.thromres.2020.12.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/29/2020] [Accepted: 12/04/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Thrombosis and pulmonary embolism appear to be major causes of mortality in hospitalized coronavirus disease 2019 (COVID-19) patients. However, few studies have focused on the incidence of venous thromboembolism (VTE) after hospitalization for COVID-19. METHODS In this multi-center study, we followed 1529 COVID-19 patients for at least 45 days after hospital discharge, who underwent routine telephone follow-up. In case of signs or symptoms of pulmonary embolism (PE) or deep vein thrombosis (DVT), they were invited for an in-hospital visit with a pulmonologist. The primary outcome was symptomatic VTE within 45 days of hospital discharge. RESULTS Of 1529 COVID-19 patients discharged from hospital, a total of 228 (14.9%) reported potential signs or symptoms of PE or DVT and were seen for an in-hospital visit. Of these, 13 and 12 received Doppler ultrasounds or pulmonary CT angiography, respectively, of whom only one patient was diagnosed with symptomatic PE. Of 51 (3.3%) patients who died after discharge, two deaths were attributed to VTE corresponding to a 45-day cumulative rate of symptomatic VTE of 0.2% (95%CI 0.1%-0.6%; n = 3). There was no evidence of acute respiratory distress syndrome (ARDS) in these patients. Other deaths after hospital discharge included myocardial infarction (n = 13), heart failure (n = 9), and stroke (n = 9). CONCLUSIONS We did not observe a high rate of symptomatic VTE in COVID-19 patients after hospital discharge. Routine extended thromboprophylaxis after hospitalization for COVID-19 may not have a net clinical benefit. Randomized trials may be warranted.
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Affiliation(s)
- Farid Rashidi
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, Johannes Gutenberg University Mainz, Mainz, Germany; Clinic of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Farin Kamangar
- Department of Biology, School of Computer, Mathematical, and Natural Sciences, Morgan State University, Baltimore, MD, USA
| | - Gustavo A Heresi
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, OH, USA
| | - Ashkan Emadi
- Department of Medicine, School of Medicine, University of Maryland, Baltimore, USA; Greenebaum Comprehensive Cancer Center, University of Maryland, Baltimore, MD, USA
| | - Cihangir Kaymaz
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, 34844 Istanbul, Turkey
| | - Pavel Jansa
- 2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Abilio Reis
- Pulmonary Vascular Disease Unit, Medicine Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Arash Rashidi
- Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center Cleveland, OH, USA
| | - Ali Taghizadieh
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Parisa Rezaeifar
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Minoosh Moghimi
- Department of Hematology & Medical Oncology, Vali-e-Asr Hospital, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Samad Ghodrati
- Department of Pulmonology, Vali-e-Asr Hospital, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Abolfazl Mozafari
- Department of Internal Medical, Qom Branch, Islamic Azad University, Qom, Iran
| | - Ali Alavi Foumani
- Inflammatory Lung Disease Research Center, Department of Internal Medicine, Razi Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Ouria Tahamtan
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Effat Rafiee
- Department of Pulmonology, Vali-e-Asr Hospital, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Zahra Abbaspour
- Department of Endocrinology, Vali-e-Asr Hospital, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Kasra Khodadadi
- Department of Internal Medicine, Vali-e-Asr Hospital, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Golsa Alamdari
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Yasman Boodaghi
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Maryam Rezaei
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Meysam Abbasi
- Student Research Center, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Fatemeh Movaseghi
- Department of Internal Medical, Qom Branch, Islamic Azad University, Qom, Iran
| | - Ata Koohi
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Leila Shakourzad
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Fatemeh Ebrahimi
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sarvin Radvar
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Maryam Amoozadeh
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Fatemeh Fereidooni
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hanieh Naseari
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Kobra Movalled
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ozra Ghorbani
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Khalil Ansarin
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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137
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Eswaran H, Jarmul JA, Shaheen AW, Meaux D, Long T, Saccoccio D, Moll S. Vascular thromboembolic events following COVID-19 hospital discharge: Incidence and risk factors. Res Pract Thromb Haemost 2021; 5:292-295. [PMID: 33733027 PMCID: PMC7938613 DOI: 10.1002/rth2.12485] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/03/2021] [Accepted: 01/08/2021] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) is associated with high rates of thromboembolic events in hospitalized patients. It remains to be determined if this risk persists following hospital discharge. METHODS We conducted a retrospective cohort study of outpatients recently hospitalized for COVID-19 to determine the incidence of vascular thromboembolic events within 30 days of discharge. We investigated the risk factors associated with these events, including intensive care admission, age, and anticoagulation. RESULTS Among 447 patients hospitalized for COVID-19, 2.0% experienced a vascular thromboembolic event within 30 days of discharge. No risk factor variable was significantly associated with an increased risk for these events. CONCLUSIONS The incidence of vascular thromboembolic events following hospital discharge for COVID-19 is low. These findings suggest against the routine use of postdischarge thromboprophylaxis in patients with COVID-19.
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Affiliation(s)
- Harish Eswaran
- Department of MedicineUniversity of North Carolina School of MedicineChapel HillNCUSA
| | | | - Amy W. Shaheen
- Department of MedicineDivision of General Medicine and Clinical EpidemiologyUniversity of North Carolina School of MedicineChapel HillNCUSA
| | | | | | | | - Stephan Moll
- Department of MedicineDivision of HematologyUniversity of North Carolina School of MedicineChapel HillNCUSA
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138
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El-Goly AMM. Lines of Treatment of COVID-19 Infection. COVID-19 INFECTIONS AND PREGNANCY 2021. [PMCID: PMC8298380 DOI: 10.1016/b978-0-323-90595-4.00002-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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139
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Affiliation(s)
- Gregory Piazza
- Vascular Medicine, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David A Morrow
- Critical Care Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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140
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Salisbury R, Iotchkova V, Jaafar S, Morton J, Sangha G, Shah A, Untiveros P, Curry N, Shapiro S. Incidence of symptomatic, image-confirmed venous thromboembolism following hospitalization for COVID-19 with 90-day follow-up. Blood Adv 2020; 4:6230-6239. [PMID: 33351117 PMCID: PMC7757009 DOI: 10.1182/bloodadvances.2020003349] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 11/03/2020] [Indexed: 01/02/2023] Open
Abstract
Although COVID-19 has been reported to be associated with high rates of venous thromboembolism (VTE), the risk of VTE and bleeding after hospitalization for COVID-19 remains unclear, and the optimal hospital VTE prevention strategy is not known. We collected retrospective observational data on thrombosis and bleeding in 303 consecutive adult patients admitted to the hospital for at least 24 hours for COVID-19. Patients presenting with VTE on admission were excluded. Data were collected until 90 days after admission or known death by using medical records and an established national VTE network. Maximal level of care was ward based in 78% of patients, with 22% requiring higher dependency care (12% noninvasive ventilation, 10% invasive ventilation). Almost all patients (97.0%) received standard thromboprophylaxis or were already receiving therapeutic anticoagulation (17.5%). Symptomatic image-confirmed VTE occurred in 5.9% of patients during index hospitalization, and in 7.2% at 90 days after admission (23.9% in patients requiring higher dependency care); half the events were isolated segmental or subsegmental defects on lung imaging. Bleeding occurred in 13 patients (4.3%) during index hospitalization (1.3% had major bleeding). The majority of bleeds occurred in patients on the general ward, and 6 patients were receiving treatment-dose anticoagulation, highlighting the need for caution in intensifying standard thromboprophylaxis strategies. Of 152 patients discharged from the hospital without an indication for anticoagulation, 97% did not receive thromboprophylaxis after discharge, and 3% received 7 days of treatment with low molecular weight heparin after discharge. The rate of symptomatic VTE in this group at 42 days after discharge was 2.6%, highlighting the need for large prospective randomized controlled trials of extended thromboprophylaxis after discharge in COVID-19.
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Affiliation(s)
- Richard Salisbury
- Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, United Kingdom; and
| | - Valentina Iotchkova
- Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
| | - Sarah Jaafar
- Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
| | - Joshua Morton
- Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
| | - Gavinda Sangha
- Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
| | - Akshay Shah
- Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Paraskevi Untiveros
- Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
- National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, United Kingdom; and
| | - Nicola Curry
- Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, United Kingdom; and
| | - Susan Shapiro
- Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, United Kingdom; and
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141
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Frequency of venous thromboembolism in 6513 patients with COVID-19: a retrospective study. Blood Adv 2020; 4:5373-5377. [PMID: 33137202 PMCID: PMC7656921 DOI: 10.1182/bloodadvances.2020003083] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 09/17/2020] [Indexed: 12/28/2022] Open
Abstract
VTE incidence for a large cohort in New Orleans, LA, does not differ from previous hospitalized populations matched for acuity. Noted large subpopulation of dialysis thrombosis may account for high incidence of thrombosis not related to typical VTE.
Patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) appear to be at increased risk for venous thromboembolism (VTE), especially if they become critically ill with COVID-19. Some centers have reported very high rates of thrombosis despite anticoagulant prophylaxis. The electronic health record (EHR) of a New Orleans–based health system was searched for all patients with polymerase chain reaction–confirmed SARS-CoV-2 infection who were either admitted to hospital or treated and discharged from an emergency department between 1 March 2020 and 1 May 2020. From this cohort, patients with confirmed VTE (either during or after their hospital encounter) were identified by administrative query of the EHR.: Between 1 March 2020 and 1 May 2020, 6153 patients with COVID-19 were identified; 2748 of these patients were admitted, while 3405 received care exclusively through the emergency department. In total, 637 patients required mechanical ventilation and 206 required renal replacement therapy. Within the hospitalized cohort, the overall mortality rate was 24.5% and VTE occurred in 86 patients (3.1%). In the 637 patients who required mechanical ventilation at some point during their hospital stay, 45 developed VTE (7.2%). After a median follow-up of 14.6 days, VTE had been diagnosed in 3 of the 2075 admitted who were discharged alive (0.14%). Among 6153 patients with COVID-19 who were hospitalized or treated in emergency departments, we did not find evidence of unusually high VTE risk. Pending further evidence from prospective, controlled trials, our findings support a traditional approach to primary VTE prevention in patients with COVID-19.
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142
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Schulman S, Hu Y, Konstantinides S. Venous Thromboembolism in COVID-19. Thromb Haemost 2020; 120:1642-1653. [PMID: 33099284 PMCID: PMC7869046 DOI: 10.1055/s-0040-1718532] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 09/04/2020] [Indexed: 02/08/2023]
Abstract
The coronavirus disease 2019 (COVID-19) is our latest pandemic, preceded by the H1N1 swine flu in 2009, which lasted approximately 19 months. One of the special characteristics of COVID-19 is the propensity to cause venous thromboembolism (VTE). Thromboinflammation seems to play a prominent role in the pathogenesis. We will here review some mechanisms in the pathogenesis and discuss some hematological biomarkers, and also whether they serve as useful risk factors for VTE. The role of general risk assessment models for medically ill patients specifically in COVID-19 is appraised. The type of prophylaxis and particularly whether standard or augmented doses of chemoprophylaxis should be used is reviewed based on available evidence. We are also comparing recommendations from 10 different guidance or position/consensus statements. Treatment recommendations for patients with COVID-19 and pulmonary embolism are discussed with current general treatment guidelines as reference. Specifics for patients with COVID-19 are pointed out and the potential role of thrombolytic treatment is explored.
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Affiliation(s)
- Sam Schulman
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
- Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Yu Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Thrace, Greece
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143
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Amenta EM, Spallone A, Rodriguez-Barradas MC, El Sahly HM, Atmar RL, Kulkarni PA. Postacute COVID-19: An Overview and Approach to Classification. Open Forum Infect Dis 2020; 7:ofaa509. [PMID: 33403218 PMCID: PMC7665635 DOI: 10.1093/ofid/ofaa509] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 10/19/2020] [Indexed: 01/10/2023] Open
Abstract
As the coronavirus disease 2019 (COVID-19) pandemic has progressed, a large volume of literature has developed delineating the clinical manifestations of acute infection. Recent reports have also started to describe persistent symptoms extending beyond the period of initial illness or hospitalization. Anecdotes of different signs and symptoms occurring after acute infection have also arisen in the lay press. Here we describe the current existing medical literature on the emerging concept of postacute COVID-19 and suggest an approach to classifying different manifestations of the syndrome. We also review long-term clinical manifestations observed in patients who recovered from infection due to other epidemic coronaviruses and briefly discuss potential mechanisms driving the phenomenon of postacute COVID-19.
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Affiliation(s)
- Eva M Amenta
- General Internal Medicine, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Amy Spallone
- Infectious Diseases Section, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Maria C Rodriguez-Barradas
- Infectious Diseases Section, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Medical Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Hana M El Sahly
- Infectious Diseases Section, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas, USA
| | - Robert L Atmar
- Infectious Diseases Section, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Prathit A Kulkarni
- Infectious Diseases Section, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Medical Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
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144
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Gomez K, Laffan M, Bradbury C. Debate: Should the dose or duration of anticoagulants for the prevention of venous thrombosis be increased in patients with COVID-19 while we are awaiting the results of clinical trials? Br J Haematol 2020; 192:459-466. [PMID: 33236402 PMCID: PMC7753713 DOI: 10.1111/bjh.17241] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 10/26/2020] [Indexed: 01/09/2023]
Affiliation(s)
- Keith Gomez
- Haemophilia Centre and Thrombosis Unit, Royal Free Hospital London NHS Foundation Trust, London, UK
| | - Mike Laffan
- Department of Immunity and Inflammation, Centre for Haematology, Faculty of Medicine, Imperial College London, London, UK
| | - Charlotte Bradbury
- Faculty of Translational Health Sciences, University of Bristol, Bristol, UK.,University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
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145
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Piazza G, Campia U, Hurwitz S, Snyder JE, Rizzo SM, Pfeferman MB, Morrison RB, Leiva O, Fanikos J, Nauffal V, Almarzooq Z, Goldhaber SZ. Registry of Arterial and Venous Thromboembolic Complications in Patients With COVID-19. J Am Coll Cardiol 2020; 76:2060-2072. [PMID: 33121712 PMCID: PMC7588178 DOI: 10.1016/j.jacc.2020.08.070] [Citation(s) in RCA: 195] [Impact Index Per Article: 48.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/26/2020] [Accepted: 08/29/2020] [Indexed: 12/11/2022]
Abstract
Background Cardiovascular complications, including myocardial infarction, ischemic stroke, and pulmonary embolism, represent an important source of adverse outcomes in coronavirus disease-2019 (COVID-19). Objectives To assess the frequency of arterial and venous thromboembolic disease, risk factors, prevention and management patterns, and outcomes in patients with COVID-19, the authors designed a multicenter, observational cohort study. Methods We analyzed a retrospective cohort of 1,114 patients with COVID-19 diagnosed through our Mass General Brigham integrated health network. The total cohort was analyzed by site of care: intensive care (n = 170); hospitalized nonintensive care (n = 229); and outpatient (n = 715). The primary study outcome was a composite of adjudicated major arterial or venous thromboembolism. Results Patients with COVID-19 were 22.3% Hispanic/Latinx and 44.2% non-White. Cardiovascular risk factors of hypertension (35.8%), hyperlipidemia (28.6%), and diabetes (18.0%) were common. Prophylactic anticoagulation was prescribed in 89.4% of patients with COVID-19 in the intensive care cohort and 84.7% of those in the hospitalized nonintensive care setting. Frequencies of major arterial or venous thromboembolism, major cardiovascular adverse events, and symptomatic venous thromboembolism were highest in the intensive care cohort (35.3%, 45.9%, and 27.0 %, respectively) followed by the hospitalized nonintensive care cohort (2.6%, 6.1%, and 2.2%, respectively) and the outpatient cohort (0% for all). Conclusions Major arterial or venous thromboembolism, major adverse cardiovascular events, and symptomatic venous thromboembolism occurred with high frequency in patients with COVID-19, especially in the intensive care setting, despite a high utilization rate of thromboprophylaxis.
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Affiliation(s)
- Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Umberto Campia
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shelley Hurwitz
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Julia E Snyder
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Samantha M Rizzo
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mariana B Pfeferman
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ruth B Morrison
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Orly Leiva
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - John Fanikos
- Department of Pharmacy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Victor Nauffal
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Zaid Almarzooq
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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146
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Affiliation(s)
- Robert D McBane
- Department of Cardiovascular Medicine, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota.
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147
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148
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Doyle AJ, Thomas W, Retter A, Besser M, MacDonald S, Breen KA, Desborough MJR, Hunt BJ. Updated hospital associated venous thromboembolism outcomes with 90-days follow-up after hospitalisation for severe COVID-19 in two UK critical care units. Thromb Res 2020; 196:454-456. [PMID: 33065410 PMCID: PMC7543947 DOI: 10.1016/j.thromres.2020.10.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 09/30/2020] [Accepted: 10/01/2020] [Indexed: 01/14/2023]
Affiliation(s)
- Andrew J Doyle
- Centre for Thrombosis and Haemostasis, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Will Thomas
- Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Andrew Retter
- Department of Critical Care, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Martin Besser
- Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Stephen MacDonald
- Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Karen A Breen
- Centre for Thrombosis and Haemostasis, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Michael J R Desborough
- Centre for Thrombosis and Haemostasis, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Beverley J Hunt
- Centre for Thrombosis and Haemostasis, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom.
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