Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy

COVID-19 as a Vascular Disease: Lesson Learned from Imaging and Blood Biomarkers

COVID-19, a disease initially thought to be prominently an interstitial pneumonia with varying degrees of severity, can be considered a vascular disease with regards to serious complications and causes of mortality. Quite recently, blood clots have emerged as the common factor unifying many of the symptoms initially attributed without an explanation to COVID-19. Cardiovascular biomarkers and particularly, D-dimer and troponin appear to be very powerful prognostic markers, signaling the need for earlier and more aggressive interventions and treatments in order to avoid and/or minimize arterial/venous thromboembolism and myocardial infarct. The ultrasound imaging patterns at both the lung and peripheral vascular level can also be very useful weapons that have the advantage of being able to monitor longitudinally the clinical picture, something that real-time PCR/nasopharyngeal swab is not able to do and that CT can only pursue with significant radiation exposure. A lesson learned in the early phase of the COVID-19 pandemic suggests quitting and starting again with targeted imaging and blood vascular biomarkers.

COVID-19: Off-label therapies based on mechanism of action while waiting for evidence-based medicine recommendations

The world pandemic due to coronavirus disease 2019, known as COVID-19, embodies a high rate of disease transmission that causes a critical hospitalization overload. As of May 15, 2020, the disease has been the cause of more than 4 million infections and more than 280000 deaths all over the world. At the beginning, we underestimated the disease; now, we have sufficient information and it is clear that it is not just a respiratory disease. In fact, if a prompt treatment is not initiated, the disease may evolve towards an abnormal immune response and cytokine storm with an important thrombophilic pattern. Therefore, we think that while waiting for certainties to be established by evidence-based medicine, it is not ethical to not try off-label therapies for some of the well-known drugs, as they could have some efficacy based on their mechanisms of action.

Indicators of Critical Illness and Predictors of Mortality in COVID-19 Patients

COVID-19 is an emerging disease all over the world and spreading at an unpredicted rate, resulting in significant influences on global economies and public health. Clinical, laboratory, and imaging characteristics have been partially described in some observational studies. Not enough systematic reviews on predictors of critical illness and mortality in COVID 19 have been published to date. In this review, we had illustrated the prognostic predictors of COVID-19 by gathering published information on the risk factors related to the outcomes of SARS-CoV-2 infections.

COVID-19: progression of disease and intravascular coagulation - present status and future perspectives

The timely and accurate diagnosis of infection with severe acute respiratory syndrome (SARS) coronavirus 2 (SARS-CoV-2), the cause of coronavirus disease 2019 (COVID-19), remains the cornerstone of efforts to provide appropriated treatment for patients, to limit further spread of the virus and ultimately to eliminate the virus from the human society. We focus this article on (a) developments for improvement of diagnosis of specific SARS-CoV-2 virus, (b) laboratory changes in the immunologic and coagulation system, (c) therapeutic options for anticoagulant treatment of seriously affected patients and (d) on the perspectives through improvement of diagnostic and therapeutic medical procedures.

Overview: Systemic Inflammatory Response Derived From Lung Injury Caused by SARS-CoV-2 Infection Explains Severe Outcomes in COVID-19

Most SARS-CoV2 infections will not develop into severe COVID-19. However, in some patients, lung infection leads to the activation of alveolar macrophages and lung epithelial cells that will release proinflammatory cytokines. IL-6, TNF, and IL-1β increase expression of cell adhesion molecules (CAMs) and VEGF, thereby increasing permeability of the lung endothelium and reducing barrier protection, allowing viral dissemination and infiltration of neutrophils and inflammatory monocytes. In the blood, these cytokines will stimulate the bone marrow to produce and release immature granulocytes, that return to the lung and further increase inflammation, leading to acute respiratory distress syndrome (ARDS). This lung-systemic loop leads to cytokine storm syndrome (CSS). Concurrently, the acute phase response increases the production of platelets, fibrinogen and other pro-thrombotic factors. Systemic decrease in ACE2 function impacts the Renin-Angiotensin-Kallikrein-Kinin systems (RAS-KKS) increasing clotting. The combination of acute lung injury with RAS-KKS unbalance is herein called COVID-19 Associated Lung Injury (CALI). This conservative two-hit model of systemic inflammation due to the lung injury allows new intervention windows and is more consistent with the current knowledge.

A Case of COVID-19 Infection With Delayed Thromboembolic Complication on Warfarin

Novel coronavirus disease 2019 (COVID-19) pandemic has posed an unprecedented threat to humanity with more than eight million infections and 450,000 deaths reported worldwide so far. The spectrum of the disease varies from mild asymptomatic infection to severe disease with rapid progression to acute respiratory distress syndrome and multiorgan failure. It is associated with a prothrombotic state and hence there is a risk of thromboembolic complications in critically ill patients, even after recovery. However, the duration of prothrombotic risk after recovery is yet to be determined. We present the case of a 78-year-old man with a history of atrial fibrillation on warfarin who had been recently discharged to a nursing home after recovering from COVID-19 pneumonia and presented to the emergency department a month later with worsening shortness of breath and cough. He was found to have worsening respiratory failure with multiple segmental pulmonary emboli, despite being on warfarin, and supratherapeutic international normalized ratio (INR). He required mechanical ventilation and was started on steroids and therapeutic enoxaparin anticoagulation. This case highlights the risk of delayed thromboembolic complications in patients with COVID-19 infection and the need to identify the subgroup of patients with a higher risk of thromboembolism, such as discharges to nursing homes and those in need of oxygen requirement; and those with underlying comorbid conditions that may require anticoagulation for a longer duration. The role of heparin is being increasingly investigated in patients with COVID-19 infection; however, the role of other anticoagulants such as warfarin is yet to be defined.

Assisted reproduction and thromboembolic risk in the COVID-19 pandemic

The COVID-19 pandemic has significantly increased mortality in many countries, with the number of infected cases increasing exponentially worldwide. One of the main determining factors of the poor prognosis in these patients is the development of coagulopathy. Moreover, it is well known that assisted reproductive technology procedures confer a risk of thromboembolic complications. This commentary analyses specific aspects coexisting between the thrombotic risk described during virus infection and that reported in the context of assisted reproduction treatments. Based on known pathophysiological aspects of virus infection and of ovarian stimulation, there are common elements that deserve to be taken into account. In the present context, any risk of hyperstimulation should be avoided. Gonadotrophin-releasing hormone agonist triggering should be mandatory in high-responder patients and/or those with COVID-19 infection. In both cases, the cycle should be segmented. A proposal is made for the use of prophylactic low molecular weight heparin not only in those cases in which oocyte retrieval has been performed, but also in those in which cancellation has been decided. In addition, endometrial preparation for frozen-thawed embryo transfers should use the transdermal route in order to minimize the higher thrombotic risk associated with the oral route.

Entangling COVID-19 associated thrombosis into a secondary antiphospholipid antibody syndrome: Diagnostic and therapeutic perspectives (Review)

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel β coronavirus that is the etiological agent of the pandemic coronavirus disease 2019 (COVID-19) that at the time of writing (June 16, 2020) has infected almost 6 million people with some 450,000 deaths. These numbers are still rising daily. Most (some 80%) cases of COVID-19 infection are asymptomatic, a substantial number of cases (15%) require hospitalization and an additional fraction of patients (5%) need recovery in intensive care units. Mortality for COVID-19 infection appears to occur globally between 0.1 and 0.5% of infected patients although the frequency of lethality is significantly augmented in the elderly and in patients with other comorbidities. The development of acute respiratory distress syndrome and episodes of thromboembolism that may lead to disseminated intravascular coagulation (DIC) represent the primary causes of lethality during COVID-19 infection. Increasing evidence suggests that thrombotic diathesis is due to multiple derangements of the coagulation system including marked elevation of D-dimer that correlate negatively with survival. We propose here that the thromboembolic events and eventually the development of DIC provoked by SARS-CoV-2 infection may represent a secondary anti-phospholipid antibody syndrome (APS). We will apply both Baconian inductivism and Cartesian deductivism to prove that secondary APS is likely responsible for coagulopathy during the course of COVID-19 infection. Diagnostic and therapeutic implications of this are also discussed.

COVID-19-related strokes in adults below 55 years of age: a case series

BACKGROUND

Coronavirus infection is a novel respiratory disease affecting people across the world. Although the majority of patients present with fever, dyspnea, cough, or myalgia, various signs and symptoms have been reported for this disease. Recently, neurological symptoms have been noticed in patients with COVID-19 with unknown etiology. However, the occurrence of strokes in young and middle aged patients with COVID-19 is not fully explained.

METHODS

In this series, six patients younger than 55 years of age with diagnosis of stroke and a confirmed diagnosis of COVID-19 were evaluated for symptoms, lab data, imaging findings, and outcomes from March 2020 to the end of April 2020 from all stroke cases in a tertiary academic hospital. Patients older than 55 and all others who had evidence of cardiac abnormalities (arrhythmia/valvular) were excluded.

RESULTS

Fever, myalgia, cough, and dyspnea were the most common clinical symptoms noted in 66.66% (4/6), 66.66% (4/6), 50% (3/6), and 50% (3/6) of the patients, respectively. The mean ± standard deviation (SD) of National Institutes of Health Stroke Scale (NIHSS) for the patient was 10.16 ± 7.13 (ranged 5-24). The most involved area was middle cerebral artery (MCA) (five in MCA versus one in basal ganglia) and the majority of our patients had a low lung involvement score (mean ± SD: 13.16 ± 6.49 out of 24). Finally, one patient was deceased and rest discharged.

CONCLUSION

Stroke may be unrelated to age and the extent of lung involvement. However, different factors may play roles in co-occurrence of stroke and COVID-19 and its outcome. Future studies with long-term follow-up and more cases are needed to assess prognostic factors.

Thrombosis Risk Assessment In The COVID-19 Era

The appearance of the coronavirus pandemic has prompted a renewed interest in thrombosis risk assessment, particularly since this disease is associated with a high risk of thrombotic events. It is known that the number one preventable cause of death in hospitalized patients including those having surgical procedures is fatal pulmonary emboli. There is also high-quality data that the use of anticoagulant drugs in the proper dose, and for the period of time shown to be efficacious, will prevent most fatal events. It is true that even with the use of the best anticoagulant regimes venous thromboembolic events (VTE) can still occur but are rarely fatal. We also realize that providing adequate anticoagulant prophylaxis for the entire period of risk is the key to preventing these deaths.  Thrombosis risk scoring identifies who's at risk for these emboli and guides physician choices for appropriate preventive measures.

Intracranial hemorrhage complicating anticoagulant prophylactic therapy in three hospitalized COVID-19 patients

SARS-CoV2 has led to a global pandemic affecting almost 3 million people in almost over 3 months. Various clinical presentations have been reported so far and no definite therapy is established. Anticoagulation is recommended by several experts to address the potential prothrombotic complications from COVID-19, but its safety and regimen need further clinical trials and safety and efficacy profile. Here, we present three cases of intracranial hemorrhage in three critically ill patients with COVID-19 and discuss their course in relation to various regimens of anticoagulation used.

Deaths in SARS-Cov-2 Positive Patients in Italy: The Influence of Underlying Health Conditions on Lethality

This study aims to underline the clinical characteristics of patients who died after testing positive for SARS-CoV-2 infection in one region of Italian and to evaluate the influence of underlying health conditions on the fatal outcome. A matched case-control study was designed by analyzing the data regarding positive subjects observed up to April 21, 2020. The case fatality rate was 7.9%, with a higher proportion of deaths in men than women. The specific standardized mortality ratio was 0.15-0.13 for males and 0.2 for females, showing that mortality is much lower than expected. Cardiovascular diseases, chronic lung diseases and diabetes mellitus showed a significant association with the outcome. Although the case fatality rate in Sardinia in regard to age and gender patterns seems to be similar to that for Italy as a whole, its quantitative value was far lower than the national one and possible explanations might include the genetic characteristics of the Sardinian population or the immediate closure of its borders as soon as the epidemic started. Our results highlighted that lethality is strongly dependent on the presence of multiple concomitant serious diseases. It is important to have epidemiological strategies for effective guidance on public health actions in order to improve chances of survival.

Approaching COVID-19: Bedside strategies for intensive care

The spread of novel coronavirus disease (COVID‐19) urged a never‐seen coordinated global response to prepare the health system, including primary care, hospital facilities and intensive care units (ICUs). Lessons have been learned from countries who suffered the pandemic at the beginning, helping the ones which are on different phases of the spreading curve. Currently, optimizing intensive care resources is mandatory as admittance to the ICUs remains rising exponentially. While public and private health system struggle for changing the slope of the curve, intensivists prepare the facilities for a tsunami of respiratory failure patients with COVID‐19.1

Systematic assessment of venous thromboembolism in COVID-19 patients receiving thromboprophylaxis: incidence and role of D-dimer as predictive factors

Coagulopathy in COVID-19 is a burning issue and strategies to prevent thromboembolic events are debated and highly heterogeneous. The objective was to determine incidence and risk factors of venous thromboembolism (VTE) in COVID-19 inpatients receiving thromboprophylaxis. In this retrospective French cohort study, patients hospitalized in medical wards non-ICU with confirmed COVID-19 and adequate thromboprophylaxis were included. A systematic low limb venous duplex ultrasonography was performed at hospital discharge or earlier if deep venous thrombosis (DVT) was clinically suspected. Chest angio-CT scan was performed when pulmonary embolism (PE) was suspected. Of 71 patients, 16 developed VTE (22.5%) and 7 PE (10%) despite adequate thromboprophylaxis. D-dimers at baseline were significantly higher in patients with DVT (p < 0.001). Demographics, comorbidities, disease manifestations, severity score, and other biological parameters, including inflammatory markers, were similar in patients with and without VTE. The negative predictive value of a baseline D-dimer level < 1.0 µg/ml was 90% for VTE and 98% for PE. The positive predictive value for VTE was 44% and 67% for D-dimer level ≥ 1.0 µg/ml and ≥ 3 µg/ml, respectively. The association between D-dimer level and VTE risk increased by taking into account the latest available D-dimer level prior to venous duplex ultrasonography for the patients with monitoring of D-dimer. Despite thromboprophylaxis, the risk of VTE is high in COVID-19 non-ICU inpatients. Increased D-dimer concentrations of more than 1.0 μg/ml predict the risk of venous thromboembolism. D-dimer level-guided aggressive thromboprophylaxis regimens using higher doses of heparin should be evaluated in prospective studies.

"War to the knife" against thromboinflammation to protect endothelial function of COVID-19 patients

In this viewpoint, we summarize the relevance of thromboinflammation in COVID-19 and discuss potential mechanisms of endothelial injury as a key point for the development of lung and distant organ dysfunction, with a focus on direct viral infection and cytokine-mediated injury. Entanglement between inflammation and coagulation and resistance to heparin provide a rationale to consider other therapeutic approaches in order to preserve endothelial function and limit microthrombosis, especially in severe forms. These strategies include nebulized heparin, N-acetylcysteine, plasma exchange and/or fresh frozen plasma, plasma derivatives to increase the level of endogenous anticoagulants (tissue factor pathway inhibitor, activated protein C, thrombomodulin, antithrombin), dipyridamole, complement blockers, different types of stem cells, and extracellular vesicles. An integrated therapy including these drugs has the potential to improve outcomes in COVID-19.

COVID-19 and Headache: A Primer for Trainees

Objective

To summarize for the trainee audience the possible mechanisms of headache in patients with COVID‐19 as well as to outline the impact of the pandemic on patients with headache disorders and headache medicine in clinical practice.

Background

COVID‐19 is a global pandemic caused by the novel coronavirus severe acute respiratory syndrome coronavirus 2, of which a large subset of patients features neurological symptoms, commonly headache. The virus is highly contagious and is, therefore, changing clinical practice by forcing limitations on in‐person visits and procedural treatments, more quickly shifting toward the widespread adaptation of telemedicine services.

Design/Results

We review what is currently known about the pathophysiology of COVID‐19 and how it relates to possible mechanisms of headache, including indirect, potential direct, and secondary causes. Alternative options for the treatment of patients with headache disorders and the use of telemedicine are also explored.

Conclusions

Limited information exists regarding the mechanisms and timing of headache in patients with COVID‐19, though causes relate to plausible direct viral invasion of the nervous system as well as the cytokine release syndrome. Though headache care in the COVID‐19 era requires alterations, the improved preventive treatment options now available and evidence for feasibility and safety of telemedicine well positions clinicians to take care of such patients, especially in the COVID‐19 epicenter of New York City.

The unique characteristics of COVID-19 coagulopathy

Thrombotic complications and coagulopathy frequently occur in COVID-19. However, the characteristics of COVID-19-associated coagulopathy (CAC) are distinct from those seen with bacterial sepsis-induced coagulopathy (SIC) and disseminated intravascular coagulation (DIC), with CAC usually showing increased D-dimer and fibrinogen levels but initially minimal abnormalities in prothrombin time and platelet count. Venous thromboembolism and arterial thrombosis are more frequent in CAC compared to SIC/DIC. Clinical and laboratory features of CAC overlap somewhat with a hemophagocytic syndrome, antiphospholipid syndrome, and thrombotic microangiopathy. We summarize the key characteristics of representative coagulopathies, discussing similarities and differences so as to define the unique character of CAC.

Factor VIII and Functional Protein C Activity in Critically Ill Patients With Coronavirus Disease 2019: A Case Series

Critically ill patients with coronavirus disease 2019 (COVID-19) have been observed to be hypercoagulable, but the mechanisms for this remain poorly described. Factor VIII is a procoagulant factor that increases during inflammation and is cleaved by activated protein C. To our knowledge, there is only 1 prior study of factor VIII and functional protein C activity in critically ill patients with COVID-19. Here, we present a case series of 10 critically ill patients with COVID-19 who had severe elevations in factor VIII activity and low normal functional protein C activity, which may have contributed to hypercoagulability.

New onset neurologic events in people with COVID-19 in 3 regions in China

OBJECTIVE

To investigate new-onset neurologic impairments associated with coronavirus disease 2019 (COVID-19).

METHODS

A retrospective multicenter cohort study was conducted between January 18 and March 20, 2020, including people with confirmed COVID-19 from 56 hospitals officially designated in 3 Chinese regions; data were extracted from medical records. New-onset neurologic events as assessed by neurology consultants based on manifestations, clinical examination, and investigations were noted, in which critical events included disorders of consciousness, stroke, CNS infection, seizures, and status epilepticus.

RESULTS

We enrolled 917 people with average age 48.7 years and 55% were male. The frequency of new-onset critical neurologic events was 3.5% (32/917) overall and 9.4% (30/319) among those with severe or critical COVID-19. These were impaired consciousness (n = 25) or stroke (n = 10). The risk of critical neurologic events was highly associated with age above 60 years and previous history of neurologic conditions. Noncritical events were seen in fewer than 1% (7/917), including muscle cramp, unexplained headache, occipital neuralgia, tic, and tremor. Brain CT in 28 people led to new findings in 9. Findings from lumbar puncture in 3 with suspected CNS infection, unexplained headache, or severe occipital neuralgia were unremarkable.

CONCLUSIONS

People with COVID-19 aged over 60 and with neurologic comorbidities were at higher risk of developing critical neurologic impairment, mainly impaired consciousness and cerebrovascular accidents. Brain CT should be considered when new-onset brain injury is suspected, especially in people under sedation or showing an unexplained decline in consciousness. Evidence of direct acute insult of severe acute respiratory syndrome coronavirus 2 to the CNS is lacking.

The Role of Anticoagulation in COVID-19-Induced Hypercoagulability

PURPOSE OF REVIEW

We aim to provide a comprehensive analysis of hypercoagulability in individuals affected by COVID-19. Our goal is to describe the hypercoagulable state related to the infection and provide guidance regarding the possible benefits of anti-coagulation with the support of evidence from current literature.

RECENT FINDINGS

The incidence of thrombotic disease in individuals affected by COVID-19 is reported as high as 31%. A significant mortality benefit has been observed with the use of therapeutic anticoagulation in high-risk individuals. Literature supports the use of scoring systems, such as the sepsis-induced coagulopathy score, to risk-stratify individuals who might benefit from anticoagulation. COVID-19-induced hypercoagulability has been demonstrated to play a significant role in overall COVID-19 outcomes. Current literature shows promising evidence with the use of therapeutic anticoagulation in high-risk individuals. Further studies are needed to better analyze the risks and benefits of anticoagulation in this specific patient population.

Arterial thromboembolism associated with COVID-19 and elevated D-dimer levels

The novel coronavirus 2019 (SARS-CoV-2) was first identified in January 2020 and has since evolved into a pandemic affecting >200 countries. The severity of presentation is variable and carries a mortality between 1% and 3%. We continue to learn about the virus and the resulting acute respiratory illness and hypercoagulability; however, much remains unknown. In our early experience in a high-volume center, we report a series of four cases of acute peripheral artery ischemia in patients with COVID-19 in the setting of elevated D-dimer levels.

The vascular endothelium: the cornerstone of organ dysfunction in severe SARS-CoV-2 infection

In severe SARS-CoV-2 infections, emerging data including recent histopathological studies have emphasized the crucial role of endothelial cells (ECs) in vascular dysfunction, immunothrombosis, and inflammation.Histopathological studies have evidenced direct viral infection of ECs, endotheliitis with diffuse endothelial inflammation, and micro- and macrovascular thrombosis both in the venous and arterial circulations. Venous thrombotic events, particularly pulmonary embolism, with elevated D-dimer and coagulation activation are highly prevalent in COVID-19 patients. The pro-inflammatory cytokine storm, with elevated levels of interleukin-6 (IL-6), IL-2 receptor, and tumor necrosis factor-α, could also participate in endothelial dysfunction and leukocyte recruitment in the microvasculature. COVID-19-induced endotheliitis may explain the systemic impaired microcirculatory function in different organs in COVID-19 patients. Ongoing trials directly and indirectly target COVID-19-related endothelial dysfunctions: i.e., a virus-cell entry using recombinant angiotensin-converting enzyme 2 (ACE2) and transmembrane protease serine 2 (TMPRSS-2) blockade, coagulation activation, and immunomodulatory therapies, such as anti-IL-6 strategies. Studies focusing on endothelial dysfunction in COVID-19 patients are warranted as to decipher their precise role in severe SARS-CoV-2 infection and organ dysfunction and to identify targets for further interventions.

COVID-19 and Thrombotic or Thromboembolic Disease: Implications for Prevention, Antithrombotic Therapy, and Follow-Up: JACC State-of-the-Art Review

Coronavirus disease-2019 (COVID-19), a viral respiratory illness caused by the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), may predispose patients to thrombotic disease, both in the venous and arterial circulations, because of excessive inflammation, platelet activation, endothelial dysfunction, and stasis. In addition, many patients receiving antithrombotic therapy for thrombotic disease may develop COVID-19, which can have implications for choice, dosing, and laboratory monitoring of antithrombotic therapy. Moreover, during a time with much focus on COVID-19, it is critical to consider how to optimize the available technology to care for patients without COVID-19 who have thrombotic disease. Herein, the authors review the current understanding of the pathogenesis, epidemiology, management, and outcomes of patients with COVID-19 who develop venous or arterial thrombosis, of those with pre-existing thrombotic disease who develop COVID-19, or those who need prevention or care for their thrombotic disease during the COVID-19 pandemic.

COVID-19 and Thrombotic or Thromboembolic Disease: Implications for Prevention, Antithrombotic Therapy, and Follow-Up: JACC State-of-the-Art Review

Coronavirus disease-2019 (COVID-19), a viral respiratory illness caused by the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), may predispose patients to thrombotic disease, both in the venous and arterial circulations, because of excessive inflammation, platelet activation, endothelial dysfunction, and stasis. In addition, many patients receiving antithrombotic therapy for thrombotic disease may develop COVID-19, which can have implications for choice, dosing, and laboratory monitoring of antithrombotic therapy. Moreover, during a time with much focus on COVID-19, it is critical to consider how to optimize the available technology to care for patients without COVID-19 who have thrombotic disease. Herein, the authors review the current understanding of the pathogenesis, epidemiology, management, and outcomes of patients with COVID-19 who develop venous or arterial thrombosis, of those with pre-existing thrombotic disease who develop COVID-19, or those who need prevention or care for their thrombotic disease during the COVID-19 pandemic.

Current Perspectives on Coronavirus Disease 2019 and Cardiovascular Disease: A White Paper by the JAHA Editors

Coronavirus Disease 2019 (COVID-19) has infected more than 3.0 million people worldwide and killed more than 200,000 as of April 27, 2020. In this White Paper, we address the cardiovascular co-morbidities of COVID-19 infection; the diagnosis and treatment of standard cardiovascular conditions during the pandemic; and the diagnosis and treatment of the cardiovascular consequences of COVID-19 infection. In addition, we will also address various issues related to the safety of healthcare workers and the ethical issues related to patient care in this pandemic.

From the trenches: inpatient management of coronavirus disease 2019 in pregnancy

The novel coronavirus disease 2019 caused by the severe acute respiratory syndrome coronavirus 2 has become a pandemic. It has quickly swept across the globe, leaving many clinicians to care for infected patients with limited information about the disease and best practices for care. Our goal is to share our experiences of caring for pregnant and postpartum women with novel coronavirus disease 2019 in New York, which is the coronavirus disease 2019 epicenter in the United States, and review current guidelines. We offer a guide, focusing on inpatient management, including testing policies, admission criteria, medical management, care for the decompensating patient, and practical tips for inpatient antepartum service management.

Profil clinique, biologique et radiologique des patients Algériens hospitalisés pour COVID-19: données préliminaires

INTRODUCTION

Aucune étude antérieure n'a élaboré le profil des patients Algériens hospitalisés pour COVID-19. L'objectif de cette étude était de déterminer le profil clinique, biologique et tomodensitométrique des patients Algériens hospitalisés pour COVID-19.

MÉTHODES

Une étude prospective était menée auprès des patients hospitalisés pour COVID-19 (période: 19 mars-30 avril 2020). Les données cliniques, biologiques et radiologiques, le type de traitement reçu et la durée de l'hospitalisation étaient notés.

RÉSULTATS

Le profil clinique des 86 patients atteints de COVID-19 était un homme non-fumeur, âgé de 53 ans, qui était dans 42% des cas en contact avec un cas suspect/confirmé de COVID-19 et ayant une comorbidité dans 70% des cas (hypertension artérielle, diabète sucré, pathologie respiratoire chronique et allergie, cardiopathie). Les plaintes cliniques étaient dominées par la triade «asthénie-fièvre-toux» dans plus de 70% des cas. Les anomalies biologiques les plus fréquentes étaient: syndrome inflammatoire biologique (90,1%), basocytémie (70,8%), lymphopénie (53,3%), augmentation de la lactico-deshydrogénase (52,2%), anémie (38,7%), augmentation de la phosphokinase (28,8%) et cytolyse hépatique (27,6%). Les signes tomodensitométriques les plus fréquents étaient: verre dépoli (91,8%), condensations alvéolaires (61,2%), verre dépoli en plage (60,0%), et verre dépoli nodulaire (55,3%). Un traitement à base de «chloroquine, azithromycine, zinc, vitamine C, enoxaparine, double antibiothérapie et ± corticoïdes» était prescrit chez 34,9% des patients. La moyenne de la durée d'hospitalisation était de 7±3 jours.

CONCLUSION

La connaissance des profils des formes modérées et sévères du COVID-19 contribuerait à faire progresser les stratégies de contrôle de l'infection en Algérie.

The novel coronavirus disease (COVID-19) complicated by pulmonary embolism and acute respiratory distress syndrome

Acute respiratory distress syndrome and coagulopathy played an important role in morbidity and mortality of severe COVID-19 patients. A higher frequency of pulmonary embolism (PE) than expected in COVID-19 patients was recently reported. The presenting symptoms for PE were untypical including dyspnea, which is one of the major symptoms in severe COVID-19, especially in those patients with acute respiratory distress syndrome (ARDS). We reported two COVID-19 cases with coexisting complications of PE and ARDS, aiming to consolidate the emerging knowledge of this global health emergency and raise the awareness that the hypoxemia or severe dyspnea in COVID-19 may be related to PE and not necessarily always due to the parenchymal disease.

Coronavirus Disease 2019 (COVID-19)-Associated Thromboembolic Disease: A Report of Three Patients With Pulmonary Embolism

Coagulopathy and thromboembolic disease, including pulmonary embolism (PE), are reported complications of coronavirus disease 2019 (COVID-19). The mechanism is not fully understood. We present three patients with COVID-19 and concurrent PE.

Coronavirus Disease 2019 in Pregnancy: A Clinical Management Protocol and Considerations for Practice

The coronavirus disease 2019 (COVID-19) pandemic has represented a major impact to health systems and societies worldwide. The generation of knowledge about the disease has occurred almost as fast as its global expansion. The mother and fetus do not seem to be at particularly high risk. Nevertheless, obstetrics and maternal-fetal medicine practice have suffered profound changes to adapt to the pandemic. In addition, there are aspects specific to COVID-19 and gestation that should be known by specialists in order to correctly diagnose the disease, classify the severity, distinguish specific signs of COVID-19 from those of obstetric complications, and take the most appropriate management decisions. In this review we present in a highly concise manner an evidence-based protocol for the management of COVID-19 in pregnancy. We briefly contemplate all relevant aspects that we believe a specialist in obstetrics and maternal medicine should know, ranging from basic concepts about the disease and protection measures in the obstetric setting to more specific aspects related to maternal-fetal management and childbirth.

Venous Thromboembolism in COVID-19: Towards an Ideal Approach to Thromboprophylaxis, Screening, and Treatment

Purpose of Review

Novel coronavirus disease 2019 (COVID-19) has been associated with an increased risk of arterial and venous thromboembolic (VTE) diseases. However, there is a limited amount of data regarding the prevention and management of VTE in severe hospitalized COVID-19 patients.

Recent Findings

In this article, we review currently available clinical data, and mechanisms for COVID-associated coagulopathy, and propose algorithms for screening, prevention (including extended-duration prophylaxis), and treatment of these patients.

Summary

Although these recommendations are subject to change given rapidly evolving data, we provide a framework that can guide clinicians in managing thrombotic complications in this challenging condition.

Acute Limb Ischemia Due to Arterial Thrombosis Associated With Coronavirus Disease 2019

Objectives:

To describe a case of acute limb ischemia caused by arterial thrombosis due to coronavirus disease 2019.

Design:

Clinical observation of a patient.

Setting:

Academic medical center.

Patient:

A 59-year-old female with history of hypertension, hyperlipidemia, and prior smoking.

Intervention:

Clinical observation and data extraction from electronic medical records.

Measurements and Main Results:

We report a case of peripheral arterial thrombosis associated with coronavirus disease 2019, resulting in acute limb ischemia of the right lower extremity. This event was heralded by a sudden and significant elevation in d-dimer levels. At the time of surgery, a long, gelatinous clot was retrieved from the right popliteal artery. Perioperatively, she continued to have absent pedal Doppler signals and after multiple embolectomy attempts, required distal arterial cut down with removal of additional thrombi and resultant improvement of distal arterial flow.

Conclusions:

This case demonstrates the importance of regularly checking d-dimer levels and vigilant monitoring for arterial thrombotic events, as they can rapidly become catastrophic.