251
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Goldin M, Giannis D, Diab W, Wang J, Khanijo S, Sharifova G, Cohen M, Lund JM, Mignatti A, Gianos E, Tafur A, Lewis PA, Cohoon K, Kittelson JM, Lesser ML, Sison CP, Rahman H, Ochani K, Hiatt WR, Dale RA, Anderson VE, Bonaca M, Halperin JL, Weitz JI, Spyropoulos AC. Treatment-Dose LMWH versus Prophylactic/Intermediate Dose Heparins in High-Risk COVID-19 Inpatients: Rationale and Design of the HEP-COVID Trial. Thromb Haemost 2021; 121:1684-1695. [PMID: 33823560 DOI: 10.1055/a-1475-2351] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Coronavirus disease-2019 (COVID-19) has been associated with significant risk of venous thromboembolism (VTE), arterial thromboembolism (ATE), and mortality particularly among hospitalized patients with critical illness and elevated D-dimer (Dd) levels. Conflicting data have yet to elucidate optimal thromboprophylaxis dosing. HEP-COVID (NCT04401293) is a phase 3, multicenter, pragmatic, prospective, randomized, pseudo-blinded, active control trial to evaluate efficacy and safety of therapeutic-dose low-molecular-weight heparin (LMWH) versus prophylactic-/intermediate-dose LMWH or unfractionated heparin (UFH) for prevention of a primary efficacy composite outcome of VTE, ATE, and all-cause mortality 30 ± 2 days post-enrollment. Eligible patients have COVID-19 diagnosis by nasal swab or serologic testing, requirement for supplemental oxygen per investigator judgment, and Dd >4 × upper limit of normal (ULN) or sepsis-induced coagulopathy score ≥4. Subjects are randomized to enoxaparin 1 mg/kg subcutaneous (SQ)/two times a day (BID) (creatinine clearance [CrCl] ≥ 30 mL/min) or 0.5 mg/kg (CrCl 15-30 mL/min) versus local institutional prophylactic regimens including (1) UFH up to 22,500 IU (international unit) daily (divided BID or three times a day), (2) enoxaparin 30 and 40 mg SQ QD (once daily) or BID, or (3) dalteparin 2,500 IU or 5,000 IU QD. The principal safety outcome is major bleeding. Events are adjudicated locally. Based on expected 40% relative risk reduction with treatment-dose compared with prophylactic-dose prophylaxis, 308 subjects will be enrolled (assuming 20% drop-out) to achieve 80% power. Distinguishing design features include an enriched population for the composite endpoint anchored on Dd >4 × ULN, stratification by intensive care unit (ICU) versus non-ICU, and the ability to capture asymptomatic proximal deep venous thrombosis via screening ultrasonography prior to discharge.
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Affiliation(s)
- Mark Goldin
- Institute of Health Innovations and Outcomes Research, The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States.,Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - Dimitrios Giannis
- Institute of Health Innovations and Outcomes Research, The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States
| | - Wassim Diab
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - Janice Wang
- Institute of Health Innovations and Outcomes Research, The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States.,Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - Sameer Khanijo
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - Gulru Sharifova
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - Marc Cohen
- Department of Medicine, Newark Beth Israel Medical Center, Newark, New Jersey, United States
| | - Jeet M Lund
- Wellspan York Hospital, York, Pennsylvania, United States
| | - Andrea Mignatti
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States.,Department of Cardiology, Lenox Hill Hospital, Northwell Health, New York, New York, United States
| | - Eugenia Gianos
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States.,Department of Cardiology, Lenox Hill Hospital, Northwell Health, New York, New York, United States
| | - Alfonso Tafur
- Department of Medicine and Vascular Medicine, NorthShore University Health System, Evanston, Illinois, United States.,Division of Cardiology, University of Chicago, Pritzker School of Medicine, Chicago, Illinois, United States
| | - Paul A Lewis
- Evidence Based Medicine, Baycare Health System, Clearwater, Florida, United States
| | - Kevin Cohoon
- Division of Cardiovascular Medicine, Department of Medicine, Froedtert and Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - John M Kittelson
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
| | - Martin L Lesser
- Institute of Health Innovations and Outcomes Research, The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States.,Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - Cristina P Sison
- Institute of Health Innovations and Outcomes Research, The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States.,Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - Husneara Rahman
- Institute of Health Innovations and Outcomes Research, The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States
| | - Kanta Ochani
- Institute of Health Innovations and Outcomes Research, The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States
| | - William R Hiatt
- Biostatistics, Colorado Prevention Center (CPC) Clinical Research, Aurora, Colorado, United States.,Division of Cardiology, University of Colorado, School of Medicine, Aurora, Colorado, United States
| | - Rita A Dale
- Biostatistics, Colorado Prevention Center (CPC) Clinical Research, Aurora, Colorado, United States
| | - Victoria E Anderson
- Biostatistics, Colorado Prevention Center (CPC) Clinical Research, Aurora, Colorado, United States
| | - Marc Bonaca
- Biostatistics, Colorado Prevention Center (CPC) Clinical Research, Aurora, Colorado, United States.,Division of Cardiology, University of Colorado, School of Medicine, Aurora, Colorado, United States
| | - Jonathan L Halperin
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Mount Sinai Medical Center, New York, New York, United States
| | - Jeffrey I Weitz
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Alex C Spyropoulos
- Institute of Health Innovations and Outcomes Research, The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States.,Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
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252
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Endothelial dysfunction and immunothrombosis as key pathogenic mechanisms in COVID-19. Nat Rev Immunol 2021; 21:319-329. [PMID: 33824483 PMCID: PMC8023349 DOI: 10.1038/s41577-021-00536-9] [Citation(s) in RCA: 536] [Impact Index Per Article: 178.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2021] [Indexed: 02/07/2023]
Abstract
Coronavirus disease 2019 (COVID-19) is a clinical syndrome caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Patients with severe disease show hyperactivation of the immune system, which can affect multiple organs besides the lungs. Here, we propose that SARS-CoV-2 infection induces a process known as immunothrombosis, in which activated neutrophils and monocytes interact with platelets and the coagulation cascade, leading to intravascular clot formation in small and larger vessels. Microthrombotic complications may contribute to acute respiratory distress syndrome (ARDS) and other organ dysfunctions. Therapeutic strategies aimed at reducing immunothrombosis may therefore be useful. Several antithrombotic and immunomodulating drugs have been proposed as candidates to treat patients with SARS-CoV-2 infection. The growing understanding of SARS-CoV-2 infection pathogenesis and how it contributes to critical illness and its complications may help to improve risk stratification and develop targeted therapies to reduce the acute and long-term consequences of this disease. Here, the authors propose that SARS-CoV-2 induces a prothrombotic state, with dysregulated immunothrombosis in lung microvessels and endothelial injury, which drive the clinical manifestations of severe COVID-19. They discuss potential antithrombotic and immunomodulating drugs that are being considered in the treatment of patients with COVID-19.
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253
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Grote U, Arvand M, Brinkwirth S, Brunke M, Buchholz U, Eckmanns T, von Kleist M, Niebank M, Ruehe B, Schulze K, Stoliaroff-Pépin A, Thanheiser M, Schaade L, Said D, Haas W. [Measures to cope with the COVID-19 pandemic in Germany: nonpharmaceutical and pharmaceutical interventions]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2021; 64:435-445. [PMID: 33787944 PMCID: PMC8010780 DOI: 10.1007/s00103-021-03306-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2021] [Indexed: 12/15/2022]
Abstract
When the emerging novel SARS-CoV‑2 virus first appeared in December 2019, neither specific therapeutic options nor vaccinations were available. The role of nonpharmaceutical interventions (NPIs) became of central importance. At the Robert Koch Institute, a multilayer strategy consisting of population-based and individual preventive measures to control the pandemic was developed, which built upon existing influenza pandemic plans as well as generic plans. This paper explains the recommended NPIs and illustrates the pharmaceutical approaches developed in parallel.Among others, general contact bans, providing material for infection prevention and control, ban of events, closing educational institutions, and restricting travel are counted among population-based measures. Additional individual preventive measures are necessary, e.g., keeping a minimum distance, reducing contacts, and wearing a mouth-nose covering as well as quarantine and isolation. Measures within the health system are based on recommendations of the Commission on Hospital Hygiene and Infection Protection (Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO)) and specified and implemented by professional societies. Since November 2020, an antiviral therapy with remdesivir and treatment with the glucocorticoid dexamethasone have been available as pharmaceutical interventions. Monoclonal antibodies are at this time not approved. Therapeutic anticoagulation is recommended.Recommendations are constantly adapted to the increasing knowledge on the pathogen and its means of transmission. A challenge is to strengthen the trust of the population. Many measures have to be applied on an individual basis in order to work together.
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Affiliation(s)
- Ulrike Grote
- Abteilung für Infektionsepidemiologie, Robert Koch-Institut, Berlin, Deutschland.
- ÖGD Kontaktstelle: Infektionsepidemiologisches Krisenmanagement, Ausbruchsuntersuchungen und Trainingsprogramme (Fachgebiet 38), Abteilung für Infektionsepidemiologie, Robert Koch-Institut, Seestraße 10, 13353, Berlin, Deutschland.
| | - Mardjan Arvand
- Abteilung für Infektionskrankheiten, Robert Koch-Institut, Berlin, Deutschland
| | - Simon Brinkwirth
- Abteilung für Infektionsepidemiologie, Robert Koch-Institut, Berlin, Deutschland
| | - Melanie Brunke
- Abteilung für Infektionskrankheiten, Robert Koch-Institut, Berlin, Deutschland
| | - Udo Buchholz
- Abteilung für Infektionsepidemiologie, Robert Koch-Institut, Berlin, Deutschland
| | - Tim Eckmanns
- Abteilung für Infektionsepidemiologie, Robert Koch-Institut, Berlin, Deutschland
| | - Max von Kleist
- MF Methodenentwicklung und Forschungsinfrastruktur, Robert Koch-Institut, Berlin, Deutschland
| | - Michaela Niebank
- Zentrum für Biologische Gefahren und Spezielle Pathogene (ZBS), Robert Koch-Institut, Berlin, Deutschland
| | - Bettina Ruehe
- Zentrum für Biologische Gefahren und Spezielle Pathogene (ZBS), Robert Koch-Institut, Berlin, Deutschland
| | - Kai Schulze
- Abteilung für Infektionsepidemiologie, Robert Koch-Institut, Berlin, Deutschland
| | | | - Marc Thanheiser
- Abteilung für Infektionskrankheiten, Robert Koch-Institut, Berlin, Deutschland
| | - Lars Schaade
- Zentrum für Biologische Gefahren und Spezielle Pathogene (ZBS), Robert Koch-Institut, Berlin, Deutschland
| | - Dunja Said
- Abteilung für Infektionsepidemiologie, Robert Koch-Institut, Berlin, Deutschland
| | - Walter Haas
- Abteilung für Infektionsepidemiologie, Robert Koch-Institut, Berlin, Deutschland
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254
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Meizlish ML, Goshua G, Liu Y, Fine R, Amin K, Chang E, DeFilippo N, Keating C, Liu Y, Mankbadi M, McManus D, Wang SY, Price C, Bona RD, Ochoa Chaar CI, Chun HJ, Pine AB, Rinder HM, Siner JM, Neuberg DS, Owusu KA, Lee AI. Intermediate-dose anticoagulation, aspirin, and in-hospital mortality in COVID-19: A propensity score-matched analysis. Am J Hematol 2021; 96:471-479. [PMID: 33476420 PMCID: PMC8013588 DOI: 10.1002/ajh.26102] [Citation(s) in RCA: 108] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 01/18/2021] [Indexed: 02/06/2023]
Abstract
Thrombotic complications occur at high rates in hospitalized patients with COVID-19, yet the impact of intensive antithrombotic therapy on mortality is uncertain. We examined in-hospital mortality with intermediate- compared to prophylactic-dose anticoagulation, and separately with in-hospital aspirin compared to no antiplatelet therapy, in a large, retrospective study of 2785 hospitalized adult COVID-19 patients. In this analysis, we established two separate, nested cohorts of patients (a) who received intermediate- or prophylactic-dose anticoagulation ("anticoagulation cohort", N = 1624), or (b) who were not on home antiplatelet therapy and received either in-hospital aspirin or no antiplatelet therapy ("aspirin cohort", N = 1956). To minimize bias and adjust for confounding factors, we incorporated propensity score matching and multivariable regression utilizing various markers of illness severity and other patient-specific covariates, yielding treatment groups with well-balanced covariates in each cohort. The primary outcome was cumulative incidence of in-hospital death. Among propensity score-matched patients in the anticoagulation cohort (N = 382), in a multivariable regression model, intermediate- compared to prophylactic-dose anticoagulation was associated with a significantly lower cumulative incidence of in-hospital death (hazard ratio 0.518 [0.308-0.872]). Among propensity-score matched patients in the aspirin cohort (N = 638), in a multivariable regression model, in-hospital aspirin compared to no antiplatelet therapy was associated with a significantly lower cumulative incidence of in-hospital death (hazard ratio 0.522 [0.336-0.812]). In this propensity score-matched, observational study of COVID-19, intermediate-dose anticoagulation and aspirin were each associated with a lower cumulative incidence of in-hospital death.
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Affiliation(s)
| | - George Goshua
- Section of Hematology, Department of MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Yiwen Liu
- Dana‐Farber Cancer InstituteBostonMassachusettsUSA
| | - Rebecca Fine
- Department of MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Kejal Amin
- Department of PharmacyYale‐New Haven HospitalNew HavenConnecticutUSA
| | - Eric Chang
- Section of Hematology, Department of MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Nicholas DeFilippo
- Department of PharmacyYale‐New Haven HospitalNew HavenConnecticutUSA
- School of PharmacyUniversity of ConnecticutStorrsConnecticutUSA
| | - Craig Keating
- Joint Data Analytics TeamYale New Haven HospitalNew HavenConnecticutUSA
| | - Yuxin Liu
- Section of Hematology, Department of MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Michael Mankbadi
- Department of MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Dayna McManus
- Department of PharmacyYale‐New Haven HospitalNew HavenConnecticutUSA
| | - Stephen Y. Wang
- Department of MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Christina Price
- Section of Allergy and Immunology, Department of MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Robert D. Bona
- Section of Hematology, Department of MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Cassius Iyad Ochoa Chaar
- Section of Vascular Surgery, Department of SurgeryYale School of MedicineNew HavenConnecticutUSA
| | - Hyung J. Chun
- Section of Cardiology, Department of MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Alexander B. Pine
- Section of Hematology, Department of MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Henry M. Rinder
- Section of Hematology, Department of MedicineYale School of MedicineNew HavenConnecticutUSA
- Department of Laboratory MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Jonathan M. Siner
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of MedicineYale School of MedicineNew HavenConnecticutUSA
| | | | - Kent A. Owusu
- Department of PharmacyYale‐New Haven HospitalNew HavenConnecticutUSA
- Clinical RedesignYale New Haven HealthNew HavenConnecticutUSA
| | - Alfred Ian Lee
- Section of Hematology, Department of MedicineYale School of MedicineNew HavenConnecticutUSA
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255
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Melegari G, Rivi V, Zelent G, Nasillo V, De Santis E, Melegari A, Bevilacqua C, Zoli M, Meletti S, Barbieri A. Mild to Severe Neurological Manifestations of COVID-19: Cases Reports. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18073673. [PMID: 33915937 PMCID: PMC8036948 DOI: 10.3390/ijerph18073673] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 03/28/2021] [Accepted: 03/29/2021] [Indexed: 02/07/2023]
Abstract
The main focus of Coronavirus disease 2019 (COVID-19) infection is pulmonary complications through virus-related neurological manifestations, ranging from mild to severe, such as encephalitis, cerebral thrombosis, neurocognitive (dementia-like) syndrome, and delirium. The hospital screening procedures for quickly recognizing neurological manifestations of COVID-19 are often complicated by other coexisting symptoms and can be obscured by the deep sedation procedures required for critically ill patients. Here, we present two different case-reports of COVID-19 patients, describing neurological complications, diagnostic imaging such as olfactory bulb damage (a mild and unclear underestimated complication) and a severe and sudden thrombotic stroke complicated with hemorrhage with a low-level cytokine storm and respiratory symptom resolution. We discuss the possible mechanisms of virus entrance, together with the causes of COVID-19-related encephalitis, olfactory bulb damage, ischemic stroke, and intracranial hemorrhage.
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Affiliation(s)
- Gabriele Melegari
- Anaesthesia and Intensive Care, Azienda Ospedaliero-Universitaria di Modena, 41125 Modena, Italy
- Correspondence: ; Tel.: +39-0593961536
| | - Veronica Rivi
- Department of Biomedical, Metabolic and Neural Sciences, Neuroscience Post Graduate School, University of Modena and Reggio Emilia, 41125 Modena, Italy; (V.R.); (M.Z.)
| | - Gabriele Zelent
- Neuroradiology, Azienda Ospedaliero-Universitaria di Modena, 41125 Modena, Italy;
| | - Vincenzo Nasillo
- Department of Laboratory Medicine, Azienda Unità Sanitaria Locale, 41125 Modena, Italy; (V.N.); (E.D.S.); (A.M.)
| | - Elena De Santis
- Department of Laboratory Medicine, Azienda Unità Sanitaria Locale, 41125 Modena, Italy; (V.N.); (E.D.S.); (A.M.)
| | - Alessandra Melegari
- Department of Laboratory Medicine, Azienda Unità Sanitaria Locale, 41125 Modena, Italy; (V.N.); (E.D.S.); (A.M.)
| | - Claudia Bevilacqua
- School of Anaesthesia and Intensive Care, University of Modena and Reggio Emilia, 41125 Modena, Italy; (C.B.); (A.B.)
| | - Michele Zoli
- Department of Biomedical, Metabolic and Neural Sciences, Neuroscience Post Graduate School, University of Modena and Reggio Emilia, 41125 Modena, Italy; (V.R.); (M.Z.)
| | - Stefano Meletti
- Neurology, Azienda Ospedaliera Universitaria di Modena, 41125 Modena, Italy;
| | - Alberto Barbieri
- School of Anaesthesia and Intensive Care, University of Modena and Reggio Emilia, 41125 Modena, Italy; (C.B.); (A.B.)
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256
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Ranjeva S, Pinciroli R, Hodell E, Mueller A, Hardin CC, Thompson BT, Berra L. Identifying clinical and biochemical phenotypes in acute respiratory distress syndrome secondary to coronavirus disease-2019. EClinicalMedicine 2021; 34:100829. [PMID: 33875978 PMCID: PMC8047387 DOI: 10.1016/j.eclinm.2021.100829] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 03/12/2021] [Accepted: 03/23/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) secondary to coronavirus disease-2019 (COVID-19) is characterized by substantial heterogeneity in clinical, biochemical, and physiological characteristics. However, the pathophysiology of severe COVID-19 infection is poorly understood. Previous studies established clinical and biological phenotypes among classical ARDS cohorts, with important therapeutic implications. The phenotypic profile of COVID-19 associated ARDS remains unknown. METHODS We used latent class modeling via a multivariate mixture model to identify phenotypes from clinical and biochemical data collected from 263 patients admitted to Massachusetts General Hospital intensive care unit with COVID-19-associated ARDS between March 13 and August 2, 2020. FINDINGS We identified two distinct phenotypes of COVID-19-associated ARDS, with substantial differences in biochemical profiles despite minimal differences in respiratory dynamics. The minority phenotype (class 2, n = 70, 26·6%) demonstrated increased markers of coagulopathy, with mild relative hyper-inflammation and dramatically increased markers of end-organ dysfunction (e.g., creatinine, troponin). The odds of 28-day mortality among the class 2 phenotype was more than double that of the class 1 phenotype (40·0% vs.· 23·3%, OR = 2·2, 95% CI [1·2, 3·9]). INTERPRETATION We identified distinct phenotypic profiles in COVID-19 associated ARDS, with little variation according to respiratory physiology but with important variation according to systemic and extra-pulmonary markers. Phenotypic identity was highly associated with short-term mortality. The class 2 phenotype exhibited prominent signatures of coagulopathy, suggesting that vascular dysfunction may play an important role in the clinical progression of severe COVID-19-related disease.
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Affiliation(s)
- Sylvia Ranjeva
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston MA 02114, USA
| | - Riccardo Pinciroli
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston MA 02114, USA
| | - Evan Hodell
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston MA 02114, USA
| | - Ariel Mueller
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston MA 02114, USA
| | - C. Corey Hardin
- Pulmonary Critical Care Division, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston MA 02114, USA
| | - B. Taylor Thompson
- Pulmonary Critical Care Division, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston MA 02114, USA
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston MA 02114, USA
- Correspondence author.
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257
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Coopersmith CM, Antonelli M, Bauer SR, Deutschman CS, Evans LE, Ferrer R, Hellman J, Jog S, Kesecioglu J, Kissoon N, Martin-Loeches I, Nunnally ME, Prescott HC, Rhodes A, Talmor D, Tissieres P, De Backer D. The Surviving Sepsis Campaign: Research Priorities for Coronavirus Disease 2019 in Critical Illness. Crit Care Med 2021; 49:598-622. [PMID: 33591008 DOI: 10.1097/ccm.0000000000004895] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To identify research priorities in the management, pathophysiology, and host response of coronavirus disease 2019 in critically ill patients. DESIGN The Surviving Sepsis Research Committee, a multiprofessional group of 17 international experts representing the European Society of Intensive Care Medicine and Society of Critical Care Medicine, was virtually convened during the coronavirus disease 2019 pandemic. The committee iteratively developed the recommendations and subsequent document. METHODS Each committee member submitted a list of what they believed were the most important priorities for coronavirus disease 2019 research. The entire committee voted on 58 submitted questions to determine top priorities for coronavirus disease 2019 research. RESULTS The Surviving Sepsis Research Committee provides 13 priorities for coronavirus disease 2019. Of these, the top six priorities were identified and include the following questions: 1) Should the approach to ventilator management differ from the standard approach in patients with acute hypoxic respiratory failure?, 2) Can the host response be modulated for therapeutic benefit?, 3) What specific cells are directly targeted by severe acute respiratory syndrome coronavirus 2, and how do these cells respond?, 4) Can early data be used to predict outcomes of coronavirus disease 2019 and, by extension, to guide therapies?, 5) What is the role of prone positioning and noninvasive ventilation in nonventilated patients with coronavirus disease?, and 6) Which interventions are best to use for viral load modulation and when should they be given? CONCLUSIONS Although knowledge of both biology and treatment has increased exponentially in the first year of the coronavirus disease 2019 pandemic, significant knowledge gaps remain. The research priorities identified represent a roadmap for investigation in coronavirus disease 2019.
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Affiliation(s)
- Craig M Coopersmith
- Department of Surgery and Emory Critical Care Center, Emory University, Atlanta, GA
| | - Massimo Antonelli
- Department of Anesthesiology Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Italy
| | - Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH
| | - Clifford S Deutschman
- Department of Pediatrics, Cohen Children's Medical center, Northwell Health, New Hyde Park, NY
- Feinstein Institute for Medical Research/Elmezzi Graduate School of Molecular Medicine, Manhasset, NY
| | - Laura E Evans
- Department of Medicine, University of Washington, Seattle, WA
| | - Ricard Ferrer
- Department of Intensive Care, SODIR-VHIR Research Group, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Judith Hellman
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA
| | - Sameer Jog
- Department of Intensive Care Medicine, Deenanath Mangeshkar Hospital, Pune, India
| | - Jozef Kesecioglu
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Niranjan Kissoon
- Department of Pediatrics and Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Ignacio Martin-Loeches
- Multidisciplinary Intensive Care Research Organization (MICRO), Department of Intensive Care Medicine, St. James's University Hospital, Trinity Centre for Health Sciences, Dublin, Ireland
- Hospital Clinic, IDIBAPS, Universided de Barcelona, CIBERes, Barcelona, Spain
| | - Mark E Nunnally
- Departments of Anesthesiology, Perioperative Care and Pain Medicine, Neurology, Surgery and Medicine, New York University, New York, NY
| | - Hallie C Prescott
- Department of Medicine, University of Michigan and VA Center for Clinical Management Research, Ann Arbor, MI
| | - Andrew Rhodes
- St George's University Hospitals NHS Foundation Trust and St George's University of London, London, United Kingdom
| | - Daniel Talmor
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Pierre Tissieres
- Pediatric Intensive Care, AP-HP Paris Saclay University, Le Kremlin-Bicetre and Institute of Integrative Biology of the Cell, CNRS, CEA, Paris-Saclay University, Gif-sur-Yvette, France
| | - Daniel De Backer
- Chirec Hospitals, Université Libre de Bruxelles, Brussels, Belgium
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258
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Meizoso JP, Moore HB, Moore EE. Fibrinolysis Shutdown in COVID-19: Clinical Manifestations, Molecular Mechanisms, and Therapeutic Implications. J Am Coll Surg 2021; 232:995-1003. [PMID: 33766727 PMCID: PMC7982779 DOI: 10.1016/j.jamcollsurg.2021.02.019] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/18/2021] [Accepted: 02/19/2021] [Indexed: 02/06/2023]
Abstract
The COVID-19 pandemic has introduced a global public health threat unparalleled in our history. The most severe cases are marked by ARDS attributed to microvascular thrombosis. Hypercoagulability, resulting in a profoundly prothrombotic state, is a distinct feature of COVID-19 and is accentuated by a high incidence of fibrinolysis shutdown. The aims of this review were to describe the manifestations of fibrinolysis shutdown in COVID-19 and its associated outcomes, review the molecular mechanisms of dysregulated fibrinolysis associated with COVID-19, and discuss potential implications and therapeutic targets for patients with severe COVID-19.
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Affiliation(s)
- Jonathan P Meizoso
- Ernest E Moore Shock Trauma Center, Denver Health Medical Center, University of Colorado, Denver, CO.
| | - Hunter B Moore
- Division of Transplant Surgery, University of Colorado, Denver, CO
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center, Denver Health Medical Center, University of Colorado, Denver, CO
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259
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Welte T, Ambrose LJ, Sibbring GC, Sheikh S, Müllerová H, Sabir I. Current evidence for COVID-19 therapies: a systematic literature review. Eur Respir Rev 2021; 30:30/159/200384. [PMID: 33731328 PMCID: PMC9489065 DOI: 10.1183/16000617.0384-2020] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 02/10/2021] [Indexed: 01/09/2023] Open
Abstract
Effective therapeutic interventions for the treatment and prevention of coronavirus disease 2019 (COVID-19) are urgently needed. A systematic review was conducted to identify clinical trials of pharmacological interventions for COVID-19 published between 1 December 2019 and 14 October 2020. Data regarding efficacy of interventions, in terms of mortality, hospitalisation and need for ventilation, were extracted from identified studies and synthesised qualitatively. In total, 42 clinical trials were included. Interventions assessed included antiviral, mucolytic, antimalarial, anti-inflammatory and immunomodulatory therapies. Some reductions in mortality, hospitalisation and need for ventilation were seen with interferons and remdesivir, particularly when administered early, and with the mucolytic drug, bromhexine. Most studies of lopinavir/ritonavir and hydroxychloroquine did not show significant efficacy over standard care/placebo. Dexamethasone significantly reduced mortality, hospitalisation and need for ventilation versus standard care, particularly in patients with severe disease. Evidence for other classes of interventions was limited. Many trials had a moderate-to-high risk of bias, particularly in terms of blinding; most were short-term and some included low patient numbers.This review highlights the need for well-designed clinical trials of therapeutic interventions for COVID-19 to increase the quality of available evidence. It also emphasises the importance of tailoring interventions to disease stage and severity for maximum efficacy.
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Affiliation(s)
- Tobias Welte
- Dept of Pulmonary and Infectious Diseases, Hannover University School of Medicine, Germany
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260
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Talasaz AH, Sadeghipour P, Kakavand H, Aghakouchakzadeh M, Kordzadeh-Kermani E, Van Tassell BW, Gheymati A, Ariannejad H, Hosseini SH, Jamalkhani S, Sholzberg M, Monreal M, Jimenez D, Piazza G, Parikh SA, Kirtane AJ, Eikelboom JW, Connors JM, Hunt BJ, Konstantinides SV, Cushman M, Weitz JI, Stone GW, Krumholz HM, Lip GYH, Goldhaber SZ, Bikdeli B. Recent Randomized Trials of Antithrombotic Therapy for Patients With COVID-19: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 77:1903-1921. [PMID: 33741176 PMCID: PMC7963001 DOI: 10.1016/j.jacc.2021.02.035] [Citation(s) in RCA: 131] [Impact Index Per Article: 43.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 02/05/2021] [Indexed: 12/15/2022]
Abstract
Endothelial injury and microvascular/macrovascular thrombosis are common pathophysiological features of coronavirus disease-2019 (COVID-19). However, the optimal thromboprophylactic regimens remain unknown across the spectrum of illness severity of COVID-19. A variety of antithrombotic agents, doses, and durations of therapy are being assessed in ongoing randomized controlled trials (RCTs) that focus on outpatients, hospitalized patients in medical wards, and patients critically ill with COVID-19. This paper provides a perspective of the ongoing or completed RCTs related to antithrombotic strategies used in COVID-19, the opportunities and challenges for the clinical trial enterprise, and areas of existing knowledge, as well as data gaps that may motivate the design of future RCTs.
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Affiliation(s)
- Azita H Talasaz
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran; Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran. https://twitter.com/AzitaTalasaz
| | - Parham Sadeghipour
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Hessam Kakavand
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran; Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Aghakouchakzadeh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Elaheh Kordzadeh-Kermani
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Benjamin W Van Tassell
- Department of Pharmacotherapy and Outcome Science, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia, USA; Pauley Heart Center, Division of Cardiology, Department of Internal Medicine, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Azin Gheymati
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamid Ariannejad
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Hossein Hosseini
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Sepehr Jamalkhani
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Michelle Sholzberg
- Departments of Medicine and Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trials i Pujol, Universidad Católica San Antonio de Murcia, Barcelona, Spain
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (Instituto de Ramón y Cajal de Investigación Sanitaria), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Madrid, Spain
| | - Gregory Piazza
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sahil A Parikh
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA; NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - Ajay J Kirtane
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA; NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Jean M Connors
- Hematology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Beverley J Hunt
- Haemostasis and Thrombosis Centre, St. Thomas' Hospital, London, United Kingdom
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis, Johannes Gutenberg University of Mainz, Mainz, Germany; Department of Cardiology, Democritus University of Thrace, Komotini, Greece
| | - Mary Cushman
- Department of Medicine, University of Vermont Larner College of Medicine and University of Vermont Medical Center, Burlington, Vermont, USA; Department of Pathology and Laboratory Medicine, University of Vermont Larner College of Medicine and University of Vermont Medical Center, Burlington, Vermont, USA
| | - Jeffrey I Weitz
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Gregg W Stone
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA; Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation (CORE), Yale School of Medicine, New Haven, Connecticut, USA; Department of Health Policy and Administration, Yale School of Public Health, New Haven, Connecticut, USA; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool, United Kingdom; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Samuel Z Goldhaber
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA; Center for Outcomes Research and Evaluation (CORE), Yale School of Medicine, New Haven, Connecticut, USA.
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261
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Quek E, Tahir H, Kumar P, Hastings R, Jha R. Treatment of COVID-19: a review of current and prospective pharmacotherapies. Br J Hosp Med (Lond) 2021; 82:1-9. [PMID: 33792391 DOI: 10.12968/hmed.2021.0112] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continues to spread and have grave health and socioeconomic consequences worldwide. Researchers have raced to understand the pathophysiological mechanisms underpinning the disease caused by SARS-CoV-2 so that effective therapeutic targets can be discovered. This review summarises the key pharmacotherapies that are being investigated for treatment of COVID-19, including antiviral, immunomodulator and anticoagulation strategies.
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Affiliation(s)
- Eleanor Quek
- Department of General Medicine, Barnet Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Hasan Tahir
- Department of Rheumatology and General Medicine, Barnet Hospital, Royal Free London NHS Foundation Trust, London, UK.,Division of Medicine, University College London, London, UK
| | - Poornima Kumar
- Department of Clinical Haematology, Barnet Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Robert Hastings
- Department of Respiratory Medicine, Barnet Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Rajeev Jha
- Department of Intensive Care, Barnet Hospital, Royal Free London NHS Foundation Trust, London, UK
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262
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El-Solh AA, Meduri UG, Lawson Y, Carter M, Mergenhagen KA. Clinical Course and Outcome of COVID-19 Acute Respiratory Distress Syndrome: Data From a National Repository. J Intensive Care Med 2021; 36:664-672. [PMID: 33685275 DOI: 10.1177/0885066621994476] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Mortality attributable to coronavirus disease-19 (COVID-19) 2 infection occurs mainly through the development of viral pneumonia-induced acute respiratory distress syndrome (ARDS). RESEARCH QUESTION The objective of the study is to delineate the clinical profile, predictors of disease progression, and 30-day mortality from ARDS using the Veterans Affairs Corporate Data Warehouse. STUDY DESIGN AND METHODS Analysis of a historical cohort of 7,816 hospitalized patients with confirmed COVID-19 infection between January 1, 2020, and August 1, 2020. Main outcomes were progression to ARDS and 30-day mortality from ARDS, respectively. RESULTS The cohort was comprised predominantly of men (94.5%) with a median age of 69 years (interquartile range [IQR] 60-74 years). 2,184 (28%) were admitted to the intensive care unit and 643 (29.4%) were diagnosed with ARDS. The median Charlson Index was 3 (IQR 1-5). Independent predictors of progression to ARDS were body mass index (BMI) ≥40 kg/m2, diabetes, lymphocyte counts <700 × 109/L, LDH >450 U/L, ferritin >862 ng/ml, C-reactive protein >11 mg/dL, and D-dimer >1.5 ug/ml. In contrast, the use of an anticoagulant lowered the risk of developing ARDS (OR 0.66 [95% CI 0.49-0.89]. Crude 30-day mortality rate from ARDS was 41% (95% CI 38%-45%). Risk of death from ARDS was significantly higher in those who developed acute renal failure and septic shock. Use of an anticoagulant was associated with 2-fold reduction in mortality. Survival benefit was observed in patients who received corticosteroids and/or remdesivir but there was no advantage of combination therapy over either agent alone. CONCLUSIONS Among those hospitalized for COVID-19, nearly 1 in 10 progressed to ARDS. Septic shock, and acute renal failure are the leading causes of death in these patients. Treatment with either remdesivir and corticosteroids reduced the risk of mortality from ARDS. All hospitalized patients with COVID-19 should be placed at a minimum on prophylactic doses of anticoagulation.
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Affiliation(s)
- Ali A El-Solh
- 20073VA Western New York Healthcare System, Buffalo, NY, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Buffalo, NY, USA.,Department of Epidemiology and Environmental Health, School of Medicine and Biomedical Sciences, School of Public Health and Health Professions, State University of New York, Buffalo, NY, USA
| | | | - Yolanda Lawson
- 20073VA Western New York Healthcare System, Buffalo, NY, USA
| | - Michael Carter
- 20073VA Western New York Healthcare System, Buffalo, NY, USA
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263
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Alfonso F, Gonzalo N, Rivero F, Escaned J. The year in cardiovascular medicine 2020: interventional cardiology. Eur Heart J 2021; 42:985-1003. [PMID: 33448291 PMCID: PMC7928953 DOI: 10.1093/eurheartj/ehaa1096] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/11/2020] [Accepted: 12/23/2020] [Indexed: 12/11/2022] Open
Affiliation(s)
- Fernando Alfonso
- Cardiology Department, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria IIS-IP, Universidad Autónoma de Madrid, CIBERCV, C/Diego de León 62, Madrid 28006, Spain
| | - Nieves Gonzalo
- Cardiology Department, Hospital Clinico San Carlos, IdISSC, Universidad Complutense de Madrid. C/ Martín Lagos s/n 28042 Madrid, Spain
| | - Fernando Rivero
- Cardiology Department, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria IIS-IP, Universidad Autónoma de Madrid, CIBERCV, C/Diego de León 62, Madrid 28006, Spain
| | - Javier Escaned
- Cardiology Department, Hospital Clinico San Carlos, IdISSC, Universidad Complutense de Madrid. C/ Martín Lagos s/n 28042 Madrid, Spain
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264
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The impact of different prophylactic anticoagulation doses on the outcomes of patients with COVID-19. Thromb Res 2021; 202:14-16. [PMID: 33711753 DOI: 10.1016/j.thromres.2021.02.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 02/23/2021] [Accepted: 02/25/2021] [Indexed: 01/08/2023]
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265
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Napoli C, Benincasa G, Criscuolo C, Faenza M, Liberato C, Rusciano M. Immune reactivity during COVID-19: Implications for treatment. Immunol Lett 2021; 231:28-34. [PMID: 33421440 PMCID: PMC7787505 DOI: 10.1016/j.imlet.2021.01.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 01/03/2021] [Indexed: 01/08/2023]
Abstract
Clinical symptoms of COVID-19 include fever, cough, and fatigue which may progress to acute respiratory distress syndrome (ARDS). The main hematological laboratory findings associated with the severe form of disease are represented by lymphopenia and eosinopenia which mostly occur in the elderly population characterized by cardiovascular comorbidities and immunosenescence. Besides, increased levels of D-dimer, procalcitonin, and C reactive protein (CRP) seem to be powerful prognostic biomarkers helping to predict the onset of coagulopathy. The host immune response to SARS-CoV-2 can lead to an aberrant inflammatory response or "cytokine storm" which contributes to the severity of illness. At immunological level, patients affected by a severe form of COVID-19 show poor clinical trajectories characterized by differential "immunotypes" for which T cell response seems to play a critical role in understanding pathogenic mechanisms of disease. Also, patients with mild to severe COVID-19 displayed macrophage activation syndrome (MAS), very low human leukocyte antigen D related (HLA-DR) expression with a parallel reduction of CD04+ lymphocytes, CD19 lymphocytes, and natural killer (NK) cells. Corticosteroids resulted the best therapy for the immune dysregulation whereas repurposing of tocilizumab (IL-6 receptor antagonist) appears to have mixed results in patients with COVID-19. Besides, anticoagulative therapy was associated with reduced in-hospital mortality and need of intubation among COVID-19 patients. Furthermore, the beneficial use of intravenous immunoglobulin (IVIG) and passive immunotherapy with convalescent plasma needs to be validated in large controlled clinical trials. In this review, we summarize the main hematological parameters with a prognostic value in COVID-19 and the basis of immunological reactivity during COVID-19, with a focus on ongoing clinical trials evaluating immune targets as possible therapeutic strategies.
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Affiliation(s)
- Claudio Napoli
- Clinical Department of Internal Medicine and Specialistic Units, Department of Advanced Medical and Surgical Sciences (DAMSS), University of Campania "Luigi Vanvitelli", Naples, Italy; Clinical Department of Internal Medicine and Specialistics, Division of Clinical Immunology, Transfusion Medicine and Transplant Immunology, AOU University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Giuditta Benincasa
- Department of Advanced Medical and Surgical Sciences (DAMSS), University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - Clelia Criscuolo
- Division of Hematology, Hospital of Aversa (ASLCE), Aversa, Italy
| | - Mario Faenza
- Multidisciplinary Department of Medical, Surgical and Dental Sciences, Plastic Surgery Unit, Universityof Campania "Luigi Vanvitelli", Naples, Italy
| | - Cinzia Liberato
- Clinical Department of Internal Medicine and Specialistics, Division of Clinical Immunology, Transfusion Medicine and Transplant Immunology, AOU University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Mariangela Rusciano
- Clinical Department of Internal Medicine and Specialistics, Division of Clinical Immunology, Transfusion Medicine and Transplant Immunology, AOU University of Campania "Luigi Vanvitelli", Naples, Italy
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266
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Fuster V. Editor-in-Chief's Top Picks From 2020. J Am Coll Cardiol 2021; 77:937-997. [PMID: 33602476 DOI: 10.1016/j.jacc.2020.12.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Each week, I record audio summaries for every paper in JACC, as well as an issue summary. Although this process is quite time-consuming, I have become familiar with every paper that we publish. Thus, I have personally selected the top 100 papers (both Original Investigations and Review Articles) from the distinct specialties each year. In addition to my personal choices, I have included papers that have been the most accessed or downloaded on our websites, as well as those selected by the JACC Editorial Board members. In order to present the full breadth of this important research in a consumable fashion, we will present these abstracts in this issue of JACC, as well as their Central Illustrations. The highlights comprise the following sections: Basic & Translational Research, Cardiac Failure & Myocarditis, Cardiomyopathies & Genetics, Cardio-Oncology, Congenital Heart Disease, Coronary Disease & Interventions, Coronavirus (as a NEW section), Hypertension, Imaging, Metabolic & Lipid Disorders, Neurovascular Disease & Dementia, Promoting Health & Prevention, Rhythm Disorders & Thromboembolism, Valvular Heart Disease, and Vascular Medicine (1-100).
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267
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Mussini C, Falcone M, Nozza S, Sagnelli C, Parrella R, Meschiari M, Petrosillo N, Mastroianni C, Cascio A, Iaria C, Galli M, Chirianni A, Sagnelli E, Iacobello C, Di Perri G, Mazzotta F, Carosi G, Tinelli M, Grossi P, Armignacco O, Portelli V, Andreoni M, Tavio M. Therapeutic strategies for severe COVID-19: a position paper from the Italian Society of Infectious and Tropical Diseases (SIMIT). Clin Microbiol Infect 2021; 27:389-395. [PMID: 33359375 PMCID: PMC7833273 DOI: 10.1016/j.cmi.2020.12.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 11/29/2020] [Accepted: 12/10/2020] [Indexed: 02/07/2023]
Abstract
SCOPE Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has become pandemic, reaching almost one million death worldwide. At present standard treatment for coronavirus disease 2019 (COVID-19) is not well defined because the evidence, either from randomized or observational studies, with conflicting results, has led to rapid changes in treatment guidelines. Our aim was to narratively summarize the available literature on the management of COVID-19 in order to combine current evidence and interpretation of the data by experts who are treating patients in the frontline setting. METHODS The panel conducted a detailed review of the literature and eventual press releases from randomized clinical trials for each possible available treatment. Inductive PubMed search waws performed for publications relevant to the topic, including all clinical trials conducted. The result was a flowchart with treatment indications for patients with COVID-19. IMPLICATIONS After 6 months of a pandemic situation and before a possible second coronavirus wave descends on Europe, it is important to evaluate which drugs proved to be effective while also considering that results from many randomized clinical trials are still awaited. Indeed, among treatments for COVID-19, only glucocorticoids have resulted in an association with a significant decrease in mortality in published randomized controlled trials. New therapeutic strategies are urgently needed.
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Affiliation(s)
- Cristina Mussini
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy.
| | - Marco Falcone
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, Pisa University, Pisa, Italy
| | - Silvia Nozza
- Department of Infectious and Tropical Diseases, San Raffaele Hospital, Milan, Italy
| | - Caterina Sagnelli
- Department of Mental Health and Public Medicine, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Roberto Parrella
- Respiratory Infectious Diseases Unit, Cotugno Hospital, AORN dei Colli, Naples, Italy
| | - Marianna Meschiari
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - Nicola Petrosillo
- Clinical and Research Department of Infectious Diseases, National Institute for Infectious Diseases 'L. Spallanzani', IRCCS, Rome, Italy
| | - Claudio Mastroianni
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Antonio Cascio
- Infectious and Tropical Diseases Unit, Department of Health Promotion Sciences Maternal and Infantile Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Chiara Iaria
- Infectious Disease Unit, ARNAS Civico - Di Cristina-Benfratelli Hospital, Palermo, Italy
| | - Massimo Galli
- Infectious Diseases Unit, Department of Biomedical and Clinical Sciences Luigi Sacco, University of Milan, Milan, Italy
| | | | | | | | | | | | | | - Marco Tinelli
- Istituto Auxologico Italiano, IRCCS, San Luca Hospital, Milan, Italy
| | - Paolo Grossi
- Unit of Infectious and Tropical Diseases, ASST dei Sette Laghi, Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | | | | | - Massimo Andreoni
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy; Infectious Diseases Clinic, University Hospital "Tor Vergata", Rome, Italy
| | - Marcello Tavio
- Unit of Emerging and Immunosuppressed Infectious Diseases, Department of Gastroenterology and Transplantation, Polytechnic University of Marche, Ancona, Italy
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268
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Ng TSB, Leblanc K, Yeung DF, Tsang TSM. Medication use during COVID-19: Review of recent evidence. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2021; 67:171-179. [PMID: 33727376 PMCID: PMC7963004 DOI: 10.46747/cfp.6703171] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To keep health care providers, in response to the ongoing coronavirus disease 2019 (COVID-19) pandemic, informed about the medications that have been proposed to treat the disease and the evidence supporting their use. QUALITY OF EVIDENCE A narrative review of medications most widely used to treat COVID-19 was conducted, outlining the best available evidence for each pharmacologic treatment to date. Searches were performed in PubMed, EMBASE, and MEDLINE using key words COVID-19 and treatment, as well as related terms. Relevant research studies conducted in human populations and cases specific to patients with COVID-19 were included, as were relevant hand-searched papers and reviews. Only articles in English and Chinese were included. MAIN MESSAGE While current management of patients with COVID-19 largely involves supportive care, without a widely available vaccine, practitioners have also resorted to repurposing medications used for other indications. This has caused considerable controversy, as many of these treatments have limited clinical evidence supporting their use and therefore pose implications for patient safety, drug access, and public health. For instance, medications such as hydroxychloroquine and chloroquine, lopinavir-ritonavir, nonsteroidal anti-inflammatory drugs, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers gained widespread media attention owing to hype, misinformation, or misinterpretation of research evidence. CONCLUSION Given the severity of the pandemic and the potential broad effects of implementing safe and effective treatment, this article provides a narrative review of the current evidence behind the most widely used medications to treat COVID-19 in order to enable health care practitioners to make informed decisions in the care of patients with this life-threatening disease.
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Affiliation(s)
- T S Brandon Ng
- Medical student in the Faculty of Medicine at the University of British Columbia in Vancouver
| | - Kori Leblanc
- Assistant Professor in the Leslie Dan Faculty of Pharmacy at the University of Toronto in Ontario
| | - Darwin F Yeung
- Clinical Assistant Professor in the Faculty of Medicine at the University of British Columbia
| | - Teresa S M Tsang
- Director of Echocardiography at Vancouver General Hospital and the UBC Hospital, and Professor of Medicine in the Division of Cardiology and Associate Head of Research for the Department of Medicine at the University of British Columbia.
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269
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Mennuni MG, Renda G, Grisafi L, Rognoni A, Colombo C, Lio V, Foglietta M, Petrilli I, Pirisi M, Spinoni E, Azzolina D, Hayden E, Aimaretti G, Avanzi GC, Bellan M, Cantaluppi V, Capponi A, Castello LM, D'Ardes D, Corte FD, Gallina S, Krengli M, Malerba M, Pierdomenico SD, Savoia P, Zeppegno P, Sainaghi PP, Cipollone F, Patti G. Clinical outcome with different doses of low-molecular-weight heparin in patients hospitalized for COVID-19. J Thromb Thrombolysis 2021; 52:782-790. [PMID: 33649979 PMCID: PMC7919624 DOI: 10.1007/s11239-021-02401-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/11/2021] [Indexed: 12/19/2022]
Abstract
A pro-thrombotic milieu and a higher risk of thrombotic events were observed in patients with CoronaVirus disease-19 (COVID-19). Accordingly, recent data suggested a beneficial role of low molecular weight heparin (LMWH), but the optimal dosage of this treatment is unknown. We evaluated the association between prophylactic vs. intermediate-to-fully anticoagulant doses of enoxaparin and in-hospital adverse events in patients with COVID-19. We retrospectively included 436 consecutive patients admitted in three Italian hospitals. Outcome according to the use of prophylactic (4000 IU) vs. higher (> 4000 IU) daily dosage of enoxaparin was evaluated. The primary end-point was in-hospital death. Secondary outcome measures were in-hospital cardiovascular death, venous thromboembolism, new-onset acute respiratory distress syndrome (ARDS) and mechanical ventilation. A total of 287 patients (65.8%) were treated with the prophylactic enoxaparin regimen and 149 (34.2%) with a higher dosing regimen. The use of prophylactic enoxaparin dose was associated with a similar incidence of all-cause mortality (25.4% vs. 26.9% with the higher dose; OR at multivariable analysis, including the propensity score: 0.847, 95% CI 0.400–0.1.792; p = 0.664). In the prophylactic dose group, a significantly lower incidence of cardiovascular death (OR 0.165), venous thromboembolism (OR 0.067), new-onset ARDS (OR 0.454) and mechanical intubation (OR 0.150) was observed. In patients hospitalized for COVID-19, the use of a prophylactic dosage of enoxaparin appears to be associated with similar in-hospital overall mortality compared to higher doses. These findings require confirmation in a randomized, controlled study.
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Affiliation(s)
- Marco G Mennuni
- Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy
| | - Giulia Renda
- G. d'Annunzio University, Chieti-Pescara, Italy.,Ospedale Santissima Annunziata of Chieti, Chieti, Italy
| | - Leonardo Grisafi
- Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy.,Dipartimento di Medicina Traslazionale, Università del Piemonte Orientale, UPO, Azienda Ospedaliero-Universitaria Maggiore della Carità, Via Solaroli 17, 28100, Novara, Italy
| | - Andrea Rognoni
- Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy
| | - Crizia Colombo
- Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy.,Dipartimento di Medicina Traslazionale, Università del Piemonte Orientale, UPO, Azienda Ospedaliero-Universitaria Maggiore della Carità, Via Solaroli 17, 28100, Novara, Italy
| | - Veronica Lio
- Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy.,Dipartimento di Medicina Traslazionale, Università del Piemonte Orientale, UPO, Azienda Ospedaliero-Universitaria Maggiore della Carità, Via Solaroli 17, 28100, Novara, Italy
| | - Melissa Foglietta
- G. d'Annunzio University, Chieti-Pescara, Italy.,Ospedale Santissima Annunziata of Chieti, Chieti, Italy
| | - Ivan Petrilli
- G. d'Annunzio University, Chieti-Pescara, Italy.,Ospedale Santissima Annunziata of Chieti, Chieti, Italy
| | - Mario Pirisi
- Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy.,Dipartimento di Medicina Traslazionale, Università del Piemonte Orientale, UPO, Azienda Ospedaliero-Universitaria Maggiore della Carità, Via Solaroli 17, 28100, Novara, Italy
| | - Enrico Spinoni
- Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy.,Dipartimento di Medicina Traslazionale, Università del Piemonte Orientale, UPO, Azienda Ospedaliero-Universitaria Maggiore della Carità, Via Solaroli 17, 28100, Novara, Italy
| | - Danila Azzolina
- Dipartimento di Medicina Traslazionale, Università del Piemonte Orientale, UPO, Azienda Ospedaliero-Universitaria Maggiore della Carità, Via Solaroli 17, 28100, Novara, Italy
| | - Eyal Hayden
- Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy.,Dipartimento di Medicina Traslazionale, Università del Piemonte Orientale, UPO, Azienda Ospedaliero-Universitaria Maggiore della Carità, Via Solaroli 17, 28100, Novara, Italy
| | - Gianluca Aimaretti
- Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy.,Dipartimento di Medicina Traslazionale, Università del Piemonte Orientale, UPO, Azienda Ospedaliero-Universitaria Maggiore della Carità, Via Solaroli 17, 28100, Novara, Italy
| | - Gian Carlo Avanzi
- Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy.,Dipartimento di Medicina Traslazionale, Università del Piemonte Orientale, UPO, Azienda Ospedaliero-Universitaria Maggiore della Carità, Via Solaroli 17, 28100, Novara, Italy
| | - Mattia Bellan
- Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy.,Dipartimento di Medicina Traslazionale, Università del Piemonte Orientale, UPO, Azienda Ospedaliero-Universitaria Maggiore della Carità, Via Solaroli 17, 28100, Novara, Italy
| | - Vincenzo Cantaluppi
- Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy.,Dipartimento di Medicina Traslazionale, Università del Piemonte Orientale, UPO, Azienda Ospedaliero-Universitaria Maggiore della Carità, Via Solaroli 17, 28100, Novara, Italy
| | - Andrea Capponi
- Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy
| | - Luigi M Castello
- Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy.,Dipartimento di Medicina Traslazionale, Università del Piemonte Orientale, UPO, Azienda Ospedaliero-Universitaria Maggiore della Carità, Via Solaroli 17, 28100, Novara, Italy
| | - Damiano D'Ardes
- G. d'Annunzio University, Chieti-Pescara, Italy.,Ospedale Santissima Annunziata of Chieti, Chieti, Italy
| | - Francesco Della Corte
- Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy.,Dipartimento di Medicina Traslazionale, Università del Piemonte Orientale, UPO, Azienda Ospedaliero-Universitaria Maggiore della Carità, Via Solaroli 17, 28100, Novara, Italy
| | - Sabina Gallina
- G. d'Annunzio University, Chieti-Pescara, Italy.,Ospedale Santissima Annunziata of Chieti, Chieti, Italy
| | - Marco Krengli
- Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy.,Dipartimento di Medicina Traslazionale, Università del Piemonte Orientale, UPO, Azienda Ospedaliero-Universitaria Maggiore della Carità, Via Solaroli 17, 28100, Novara, Italy
| | - Mario Malerba
- Dipartimento di Medicina Traslazionale, Università del Piemonte Orientale, UPO, Azienda Ospedaliero-Universitaria Maggiore della Carità, Via Solaroli 17, 28100, Novara, Italy.,Sant'Andrea Hospital, Vercelli, Italy
| | - Sante D Pierdomenico
- G. d'Annunzio University, Chieti-Pescara, Italy.,Ospedale Santissima Annunziata of Chieti, Chieti, Italy
| | - Paola Savoia
- Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy.,Dipartimento di Medicina Traslazionale, Università del Piemonte Orientale, UPO, Azienda Ospedaliero-Universitaria Maggiore della Carità, Via Solaroli 17, 28100, Novara, Italy
| | - Patrizia Zeppegno
- Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy.,Dipartimento di Medicina Traslazionale, Università del Piemonte Orientale, UPO, Azienda Ospedaliero-Universitaria Maggiore della Carità, Via Solaroli 17, 28100, Novara, Italy
| | - Pier P Sainaghi
- Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy.,Dipartimento di Medicina Traslazionale, Università del Piemonte Orientale, UPO, Azienda Ospedaliero-Universitaria Maggiore della Carità, Via Solaroli 17, 28100, Novara, Italy
| | - Francesco Cipollone
- G. d'Annunzio University, Chieti-Pescara, Italy.,Ospedale Santissima Annunziata of Chieti, Chieti, Italy
| | - Giuseppe Patti
- Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy. .,Dipartimento di Medicina Traslazionale, Università del Piemonte Orientale, UPO, Azienda Ospedaliero-Universitaria Maggiore della Carità, Via Solaroli 17, 28100, Novara, Italy.
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270
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González-García JG, Pascual-Guardia S, Aguilar Colindres RJ, Ausín Herrero P, Alvarado Miranda M, Arita Guevara M, Badenes Bonet D, Bellido Calduch S, Caguana Vélez OA, Cumpli Gargallo C, Dominguez-Alvarez M, Gea J, Grau N, Khilzi K, Martínez-Llorens J, Sánchez Ortiz M, Sánchez-Font A, Sancho-Muñoz A, Parrilla-Gómez FJ, Marín Corral J, Pérez Terán P, Rodríguez-Sevilla JJ, Chalela R, Rodríguez-Chiaradia D. Incidence of pulmonary embolism in patients with non-invasive respiratory support during COVID-19 outbreak. Respir Med 2021; 178:106325. [PMID: 33581510 PMCID: PMC7857998 DOI: 10.1016/j.rmed.2021.106325] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 01/25/2021] [Accepted: 01/27/2021] [Indexed: 01/08/2023]
Abstract
While the incidence of thrombotic complications in critically ill patients is very high, in patients under non-invasive respiratory support (NIS) is still unknown. The specific incidence of thrombotic events in each of the clinical scenarios within the broad spectrum of severity of COVID-19, is not clearly established, and this has not allowed the implementation of thromboprophylaxis or anticoagulation for routine care in COVID-19. Patients admitted in a semi-critical unit treated initially with NIS, especially Continuous-Positive Airway Pressure (CPAP), were included in the study. The cumulative incidence of pulmonary embolism was analyzed and compared between patients with good response to NIS and patients with clinical deterioration that required orotracheal intubation. 93 patients were included and 16% required mechanical ventilation (MV) after the NIS. The crude cumulative incidence of the PE was 14% (95%, CI 8-22) for all group. In patients that required orotracheal intubation and MV, the cumulative incidence was significantly higher [33% (95%, CI 16-58)] compared to patients that continued with non-invasive support [11% (CI 5-18)] (Log-Rank, p = 0.013). Patients that required mechanical ventilation were at higher risk of PE for a HR of 4.3 (95%CI 1.2-16). In conclusion, cumulative incidence of PE is remarkably higher in critically patients with a potential impact in COVID-19 evolution. In this context, patients under NIS are a very high-risk group for developing PE without a clear strategy regarding thromboprophylaxis.
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Affiliation(s)
- Jose Gregorio González-García
- Respiratory Medicine Department, Hospital del Mar (PSMAR) - IMIM. Barcelona, Spain; School of Health & Life Sciences, Universitat Pompeu Fabra, Barcelona, Spain
| | - Sergi Pascual-Guardia
- Respiratory Medicine Department, Hospital del Mar (PSMAR) - IMIM. Barcelona, Spain; School of Health & Life Sciences, Universitat Pompeu Fabra, Barcelona, Spain; CIBER, Área de Enfermedades Respiratorias (CIBERES), ISCIII, Spain
| | | | - Pilar Ausín Herrero
- Respiratory Medicine Department, Hospital del Mar (PSMAR) - IMIM. Barcelona, Spain; School of Health & Life Sciences, Universitat Pompeu Fabra, Barcelona, Spain
| | | | | | - Diana Badenes Bonet
- Respiratory Medicine Department, Hospital del Mar (PSMAR) - IMIM. Barcelona, Spain; School of Health & Life Sciences, Universitat Pompeu Fabra, Barcelona, Spain
| | | | - Oswaldo A Caguana Vélez
- Respiratory Medicine Department, Hospital del Mar (PSMAR) - IMIM. Barcelona, Spain; School of Health & Life Sciences, Universitat Pompeu Fabra, Barcelona, Spain
| | | | - Marisol Dominguez-Alvarez
- Respiratory Medicine Department, Hospital del Mar (PSMAR) - IMIM. Barcelona, Spain; CIBER, Área de Enfermedades Respiratorias (CIBERES), ISCIII, Spain
| | - Joaquim Gea
- Respiratory Medicine Department, Hospital del Mar (PSMAR) - IMIM. Barcelona, Spain; School of Health & Life Sciences, Universitat Pompeu Fabra, Barcelona, Spain; CIBER, Área de Enfermedades Respiratorias (CIBERES), ISCIII, Spain
| | - Nuria Grau
- Respiratory Medicine Department, Hospital del Mar (PSMAR) - IMIM. Barcelona, Spain; School of Health & Life Sciences, Universitat Pompeu Fabra, Barcelona, Spain; CIBER, Área de Enfermedades Respiratorias (CIBERES), ISCIII, Spain
| | - Karys Khilzi
- Respiratory Medicine Department, Hospital del Mar (PSMAR) - IMIM. Barcelona, Spain
| | - Juana Martínez-Llorens
- Respiratory Medicine Department, Hospital del Mar (PSMAR) - IMIM. Barcelona, Spain; CIBER, Área de Enfermedades Respiratorias (CIBERES), ISCIII, Spain
| | - Mónica Sánchez Ortiz
- Respiratory Medicine Department, Hospital del Mar (PSMAR) - IMIM. Barcelona, Spain
| | - Albert Sánchez-Font
- Respiratory Medicine Department, Hospital del Mar (PSMAR) - IMIM. Barcelona, Spain; CIBER, Área de Enfermedades Respiratorias (CIBERES), ISCIII, Spain; Departamento de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Antonio Sancho-Muñoz
- Respiratory Medicine Department, Hospital del Mar (PSMAR) - IMIM. Barcelona, Spain; CIBER, Área de Enfermedades Respiratorias (CIBERES), ISCIII, Spain
| | | | | | | | | | - Roberto Chalela
- Respiratory Medicine Department, Hospital del Mar (PSMAR) - IMIM. Barcelona, Spain; School of Health & Life Sciences, Universitat Pompeu Fabra, Barcelona, Spain; CIBER, Área de Enfermedades Respiratorias (CIBERES), ISCIII, Spain.
| | - Diego Rodríguez-Chiaradia
- Respiratory Medicine Department, Hospital del Mar (PSMAR) - IMIM. Barcelona, Spain; CIBER, Área de Enfermedades Respiratorias (CIBERES), ISCIII, Spain; Departamento de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
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271
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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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272
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Ng TSB, Leblanc K, Yeung DF, Tsang TSM. Médicaments utilisés durant la COVID-19. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2021; 67:e69-e78. [PMID: 33727386 PMCID: PMC7963008 DOI: 10.46747/cfp.6703e69] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Objectif En réponse à la pandémie actuelle de maladie à coronavirus 2019 (COVID-19), garder les médecins au fait des médicaments qui ont été proposés pour combattre la maladie, et des données probantes à l’appui de leur utilisation. Sources d’information Une revue narrative des médicaments les plus fréquemment utilisés pour combattre la COVID-19 a été réalisée, afin de souligner les meilleures données probantes disponibles concernant chaque traitement pharmacologique jusqu’ici. Des recherches ont été effectuées sur PubMed, EMBASE et MEDLINE à l’aide des mots-clés anglais COVID-19 et treatment , ainsi que d’autres mots-clés connexes. Ont été inclus les études pertinentes menées auprès de populations humaines et des cas de patients atteints de la COVID-19, ainsi que les articles et revues relevés à la main. Seuls les articles rédigés en anglais et en chinois ont été retenus. Message principal Alors que la prise en charge actuelle des patients atteints de la COVID-19 consiste principalement en soins de soutien, sans accès aux vaccins, les praticiens se sont tournés vers des médicaments utilisés dans d’autres indications. Cela a causé une grande controverse, puisque des données cliniques limitées étayaient l’utilisation de beaucoup de ces traitements, et cela pouvait se répercuter sur la sécurité du patient, l’accès aux médicaments et la santé publique. Par exemple, les médicaments tels que l’hydroxychloroquine et la chloroquine, le lopinavir-ritonavir, les anti-inflammatoires non stéroïdiens, les inhibiteurs de l’enzyme de conversion de l’angiotensine et les antagonistes des récepteurs de l’angiotensine ont capté l’attention des médias en raison de la médiatisation, de la mésinformation ou de la mauvaise interprétation des données de recherche. Conclusion Vu la gravité de la pandémie et les vastes effets éventuels de l’adoption de traitements sûrs et efficaces, cet article se veut être une revue narrative des données probantes actuelles étayant les médicaments les plus utilisés pour le traitement de la COVID-19 afin de permettre aux professionnels de la santé de prendre des décisions éclairées en matière de soins pour les patients qui sont atteints de cette maladie potentiellement mortelle.
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Affiliation(s)
- T S Brandon Ng
- Étudiant en médecine à la faculté de médecine de l'Université de la Colombie-Britannique à Vancouver
| | - Kori Leblanc
- Professeure adjointe à la faculté de pharmacie Leslie Dan de l'Université de Toronto en Ontario
| | - Darwin F Yeung
- Professeur clinique adjoint à la faculté de médecine de l'Université de la Colombie-Britannique
| | - Teresa S M Tsang
- Directrice de l'échocardiographie à l'Hôpital Vancouver General Hospital et UBC Hospital, et elle est professeure de médecine à la division de cardiologie et directrice associée de recherche au département de médecine de l'Université de la Colombie-Britannique.
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273
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Association of coagulation dysfunction with cardiac injury among hospitalized patients with COVID-19. Sci Rep 2021; 11:4432. [PMID: 33627696 PMCID: PMC7904824 DOI: 10.1038/s41598-021-83822-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 01/18/2021] [Indexed: 01/08/2023] Open
Abstract
Cardiac injury is a common complication of the coronavirus disease 2019 (COVID-19), and is associated with adverse clinical outcomes. In this study, we aimed to reveal the association of cardiac injury with coagulation dysfunction. We enrolled 181 consecutive patients who were hospitalized with COVID-19, and studied the clinical characteristics and outcome of these patients. Cardiac biomarkers high-sensitivity troponin I (hs-cTnI), myohemoglobin and creatine kinase-myocardial band (CK-MB) were assessed in all patients. The clinical outcomes were defined as hospital discharge or death. The median age of the study cohort was 55 (IQR, 46-65) years, and 102 (56.4%) were males. Forty-two of the 181 patients (23.2%) had cardiac injury. Old age, high leukocyte count, and high levels of aspartate transaminase (AST), D-dimer and serum ferritin were significantly associated with cardiac injury. Multivariate regression analysis revealed old age and elevated D-dimer levels as being strong risk predictors of in-hospital mortality. Interleukin 6 (IL6) levels were comparable in patients with or without cardiac injury. Serial observations of coagulation parameters demonstrated highly synchronous alterations of D-dimer along with progression to cardiac injury. Cardiac injury is a common complication of COVID-19 and is an independent risk factor for in-hospital mortality. Old age, high leukocyte count, and high levels of AST, D-dimer and serum ferritin are significantly associated with cardiac injury, whereas IL6 are not. Therefore, the pathogenesis of cardiac injury in COVID-19 may be primarily due to coagulation dysfunction along with microvascular injury.
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274
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Turecek PL, Peck RC, Rangarajan S, Reilly-Stitt C, Laffan MA, Kazmi R, James I, Dushianthan A, Schrenk G, Gritsch H, Ewenstein BM, Mellgard B, Erdlenbruch W, Jain N, Binder NB, Mumford AD. Recombinant ADAMTS13 reduces abnormally up-regulated von Willebrand factor in plasma from patients with severe COVID-19. Thromb Res 2021; 201:100-112. [PMID: 33662796 PMCID: PMC7890348 DOI: 10.1016/j.thromres.2021.02.012] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 01/14/2021] [Accepted: 02/08/2021] [Indexed: 12/14/2022]
Abstract
Thrombosis affecting the pulmonary and systemic vasculature is common during severe COVID-19 and causes adverse outcomes. Although thrombosis likely results from inflammatory activation of vascular cells, the mediators of thrombosis remain unconfirmed. In a cross-sectional cohort of 36 severe COVID-19 patients, we show that markedly increased plasma von Willebrand factor (VWF) levels were accompanied by a partial reduction in the VWF regulatory protease ADAMTS13. In all patients we find this VWF/ADAMTS13 imbalance to be associated with persistence of ultra-high-molecular-weight (UHMW) VWF multimers that are highly thrombogenic in some disease settings. Incubation of plasma samples from patients with severe COVID-19 with recombinant ADAMTS13 (rADAMTS13) substantially reduced the abnormally high VWF activity, reduced overall multimer size and depleted UHMW VWF multimers in a time and concentration dependent manner. Our data implicate disruption of normal VWF/ADAMTS13 homeostasis in the pathogenesis of severe COVID-19 and indicate that this can be reversed ex vivo by correction of low plasma ADAMTS13 levels. These findings suggest a potential therapeutic role for rADAMTS13 in helping restore haemostatic balance in COVID-19 patients.
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Affiliation(s)
| | - Rachel C Peck
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, United Kingdom
| | - Savita Rangarajan
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; K J Somaiya Superspecialty Hospital and Research Centre, Mumbai, India
| | | | - Michael A Laffan
- Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Rashid Kazmi
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Izabela James
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | | | - Gerald Schrenk
- Baxalta Innovations GmbH, a Takeda company, Vienna, Austria
| | | | | | | | | | - Nisha Jain
- Baxalta US Inc., a Takeda company, Cambridge, MA, USA
| | - Nikolaus B Binder
- Technoclone Herstellung von Diagnostika und Arzneimitteln GmbH, Vienna, Austria
| | - Andrew D Mumford
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, United Kingdom; University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom.
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275
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Pellegrini JAS, Rech TH, Schwarz P, de Oliveira ACT, Vieceli T, Moraes RB, Sekine L, Viana MV. Incidence of venous thromboembolism among patients with severe COVID-19 requiring mechanical ventilation compared to other causes of respiratory failure: a prospective cohort study. J Thromb Thrombolysis 2021; 52:482-492. [PMID: 33599858 PMCID: PMC7890785 DOI: 10.1007/s11239-021-02395-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/06/2021] [Indexed: 12/11/2022]
Abstract
Previous studies have suggested that COVID-19 pneumonia is associated with an increased risk of venous thromboembolism (VTE). This study aimed to investigate the incidence of VTE among mechanically ventilated adults with COVID-19 pneumonia, compared to patients with respiratory failure related to other causes. Prospective study that enrolled critically ill adults with suspected COVID-19 pneumonia between June 2, 2020 and August 11, 2020. Critically ill adults with suspected COVID-19 pneumonia who required mechanical ventilation within 24 h after hospital admission were followed until death or hospital discharge. Sequential ultrasonography screening of the lower extremities and catheter insertion sites, as well as testing for plasma biochemical markers, were performed at the intensive care unit admission, day 3, day 7, and day 14. The primary outcome was a composite of deep venous thrombosis, pulmonary embolism, and thrombosis at the central catheter insertion sites. We enrolled 70 patients, including 57 patients with COVID-19 and 13 patients without COVID-19, and all patients completed follow-up. The incidence of the primary outcome was higher among patients with COVID-19 than among patients with respiratory failure related to other etiologies (36.8% vs. 0%, p = 0.023). Multivariate regression analysis revealed that VTE was independently associated with a COVID-19 diagnosis (odds ratio: 6.28, 95% confidence interval: 1.19–68.07) and D-dimer concentration (1-ng/mL increase, odds ratio: 1.15, 95% confidence interval: 1.05–1.30). The incidence of VTE was higher among critically ill mechanically ventilated patients, relative to among patients with respiratory failure related to other causes.
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Affiliation(s)
| | - Tatiana Helena Rech
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Ramiro Barcelos 2400, Porto Alegre, RS, 90035-003, Brazil.,Post-Graduate Program in Medical Sciences: Endocrinology, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, RS, Brazil
| | - Patrícia Schwarz
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Ramiro Barcelos 2400, Porto Alegre, RS, 90035-003, Brazil
| | | | - Tarsila Vieceli
- Internal Medicine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Rafael Barberena Moraes
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Ramiro Barcelos 2400, Porto Alegre, RS, 90035-003, Brazil.,Post-Graduate Program in Medical Sciences: Pneumology, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, RS, Brazil
| | - Leo Sekine
- Transfusion Medicine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil.,Post-Graduate Program in Medical Sciences, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, RS, Brazil
| | - Marina Verçoza Viana
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Ramiro Barcelos 2400, Porto Alegre, RS, 90035-003, Brazil.
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276
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[Systemic consequences and clinical aspects of SARS-CoV-2 infection]. DER PATHOLOGE 2021; 42:155-163. [PMID: 33575886 PMCID: PMC7877545 DOI: 10.1007/s00292-021-00913-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 01/06/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND COVID-19 is considered a systemic disease. A severe course with fatal outcome is possible and unpredictable. OBJECTIVES Which organ systems are predominantly involved? Which diseases are predisposed for a fatal course? Which organ changes are found with lethal outcome? MATERIALS AND METHODS Data from published autopsy studies (28 cases by our group) with respect to organ changes and possible cause of death. RESULTS The most severe alterations are found in the lungs by diffuse alveolar damage as a symptom of an acute respiratory distress syndrome (ARDS), in part with fibrosis. Thrombosis of small- to mid-sized pulmonary arteries is associated with hemorrhagic lung infarction. Frequent complications are bacterial pneumonias and less frequently fungal pneumonias by aspergillus. Pulmonary thromboembolism is found in 20-30% of lethal courses, also in the absence of deep venous thrombosis. Intestinal involvement of COVID-19 can be associated with intestinal ischemia, caused by shock or local thrombosis. In most cases, the kidneys display acute tubular injury reflecting acute renal failure, depletion of lymphocytes in the lymph nodes and spleen, and hyperplastic adrenal glands. The liver frequently reveals steatosis, liver cell necrosis, portal inflammation, and proliferation of Kupffer cells. Important preexisting diseases in autopsy studies are arterial hypertension with hypertensive and ischemic cardiomyopathy and diabetes mellitus but large population-based studies reveal increased risk of mortality only for diabetes mellitus not for arterial hypertension. CONCLUSIONS Alterations of the pulmonary circulation with pulmonary arterial thrombosis, infarction, and bacterial pneumonia are important and often lethal complications of COVID-19-associated ARDS. Findings from autopsy studies have influenced therapy and prophylaxis.
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277
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Rentsch CT, Beckman JA, Tomlinson L, Gellad WF, Alcorn C, Kidwai-Khan F, Skanderson M, Brittain E, King JT, Ho YL, Eden S, Kundu S, Lann MF, Greevy RA, Ho PM, Heidenreich PA, Jacobson DA, Douglas IJ, Tate JP, Evans SJW, Atkins D, Justice AC, Freiberg MS. Early initiation of prophylactic anticoagulation for prevention of coronavirus disease 2019 mortality in patients admitted to hospital in the United States: cohort study. BMJ 2021; 372:n311. [PMID: 33574135 PMCID: PMC7876672 DOI: 10.1136/bmj.n311] [Citation(s) in RCA: 138] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/01/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To evaluate whether early initiation of prophylactic anticoagulation compared with no anticoagulation was associated with decreased risk of death among patients admitted to hospital with coronavirus disease 2019 (covid-19) in the United States. DESIGN Observational cohort study. SETTING Nationwide cohort of patients receiving care in the Department of Veterans Affairs, a large integrated national healthcare system. PARTICIPANTS All 4297 patients admitted to hospital from 1 March to 31 July 2020 with laboratory confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and without a history of anticoagulation. MAIN OUTCOME MEASURES The main outcome was 30 day mortality. Secondary outcomes were inpatient mortality, initiating therapeutic anticoagulation (a proxy for clinical deterioration, including thromboembolic events), and bleeding that required transfusion. RESULTS Of 4297 patients admitted to hospital with covid-19, 3627 (84.4%) received prophylactic anticoagulation within 24 hours of admission. More than 99% (n=3600) of treated patients received subcutaneous heparin or enoxaparin. 622 deaths occurred within 30 days of hospital admission, 513 among those who received prophylactic anticoagulation. Most deaths (510/622, 82%) occurred during hospital stay. Using inverse probability of treatment weighted analyses, the cumulative incidence of mortality at 30 days was 14.3% (95% confidence interval 13.1% to 15.5%) among those who received prophylactic anticoagulation and 18.7% (15.1% to 22.9%) among those who did not. Compared with patients who did not receive prophylactic anticoagulation, those who did had a 27% decreased risk for 30 day mortality (hazard ratio 0.73, 95% confidence interval 0.66 to 0.81). Similar associations were found for inpatient mortality and initiation of therapeutic anticoagulation. Receipt of prophylactic anticoagulation was not associated with increased risk of bleeding that required transfusion (hazard ratio 0.87, 0.71 to 1.05). Quantitative bias analysis showed that results were robust to unmeasured confounding (e-value lower 95% confidence interval 1.77 for 30 day mortality). Results persisted in several sensitivity analyses. CONCLUSIONS Early initiation of prophylactic anticoagulation compared with no anticoagulation among patients admitted to hospital with covid-19 was associated with a decreased risk of 30 day mortality and no increased risk of serious bleeding events. These findings provide strong real world evidence to support guidelines recommending the use of prophylactic anticoagulation as initial treatment for patients with covid-19 on hospital admission.
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Affiliation(s)
- Christopher T Rentsch
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, USA
| | - Joshua A Beckman
- Cardiovascular Division, Vanderbilt University Medical Center and Vanderbilt Translational and Clinical Cardiovascular Research Center, Nashville, TN, USA
| | - Laurie Tomlinson
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
| | - Walid F Gellad
- Center for Pharmaceutical Policy and Prescribing, Health Policy Institute, University of Pittsburgh, Pittsburgh, PA, USA
- Division of General Internal Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Veterans Affairs Pittsburgh Healthcare System, US Department of Veterans Affairs, Pittsburgh, PA, USA
| | - Charles Alcorn
- Center for Occupational Biostatistics and Epidemiology, Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Farah Kidwai-Khan
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Melissa Skanderson
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, USA
| | - Evan Brittain
- Department of Medicine, Vanderbilt University Medical Center and Vanderbilt Translational and Clinical Cardiovascular Research Center, Nashville, TN, USA
| | - Joseph T King
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, USA
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Yuk-Lam Ho
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, MA, USA
| | - Svetlana Eden
- Faculty of Biostatistics, Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Suman Kundu
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael F Lann
- Center for Occupational Biostatistics and Epidemiology, Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Robert A Greevy
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - P Michael Ho
- Rocky Mountain Regional VA Medical Center, US Department of Veterans Affairs, Aurora, CO, USA
| | - Paul A Heidenreich
- VA Palo Alto Healthcare System, US Department of Veterans Affairs, Palo Alto, CA, USA
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Daniel A Jacobson
- Oak Ridge National Laboratory, Biosciences Division, Oak Ridge, TN, USA
| | - Ian J Douglas
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
| | - Janet P Tate
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Stephen J W Evans
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
| | - David Atkins
- Health Services Research and Development, US Department of Veterans Affairs, Washington, DC, USA
| | - Amy C Justice
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, USA
| | - Matthew S Freiberg
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric Research Education and Clinical Center, Tennessee Valley Healthcare System, US Department of Veterans Affairs, Nashville, TN, USA
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278
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Cuker A, Tseng EK, Nieuwlaat R, Angchaisuksiri P, Blair C, Dane K, Davila J, DeSancho MT, Diuguid D, Griffin DO, Kahn SR, Klok FA, Lee AI, Neumann I, Pai A, Pai M, Righini M, Sanfilippo KM, Siegal D, Skara M, Touri K, Akl EA, Bou Akl I, Boulos M, Brignardello-Petersen R, Charide R, Chan M, Dearness K, Darzi AJ, Kolb P, Colunga-Lozano LE, Mansour R, Morgano GP, Morsi RZ, Noori A, Piggott T, Qiu Y, Roldan Y, Schünemann F, Stevens A, Solo K, Ventresca M, Wiercioch W, Mustafa RA, Schünemann HJ. American Society of Hematology 2021 guidelines on the use of anticoagulation for thromboprophylaxis in patients with COVID-19. Blood Adv 2021; 5:872-888. [PMID: 33560401 PMCID: PMC7869684 DOI: 10.1182/bloodadvances.2020003763] [Citation(s) in RCA: 271] [Impact Index Per Article: 90.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 12/18/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19)-related critical illness and acute illness are associated with a risk of venous thromboembolism (VTE). OBJECTIVE These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in decisions about the use of anticoagulation for thromboprophylaxis for patients with COVID-19-related critical illness and acute illness who do not have confirmed or suspected VTE. METHODS ASH formed a multidisciplinary guideline panel and applied strict management strategies to minimize potential bias from conflicts of interest. The panel included 3 patient representatives. The McMaster University GRADE Centre supported the guideline-development process, including performing systematic evidence reviews (up to 19 August 2020). The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, including GRADE Evidence-to-Decision frameworks, to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel agreed on 2 recommendations. The panel issued conditional recommendations in favor of prophylactic-intensity anticoagulation over intermediate-intensity or therapeutic-intensity anticoagulation for patients with COVID-19-related critical illness or acute illness who do not have confirmed or suspected VTE. CONCLUSIONS These recommendations were based on very low certainty in the evidence, underscoring the need for high-quality, randomized controlled trials comparing different intensities of anticoagulation. They will be updated using a living recommendation approach as new evidence becomes available.
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Affiliation(s)
- Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Eric K Tseng
- St. Michael's Hospital, Division of Hematology/Oncology, University of Toronto, Toronto, ON, Canada
| | - Robby Nieuwlaat
- Michael G. DeGroote Cochrane Canada Centre
- McGRADE Centre, and
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Pantep Angchaisuksiri
- Division of Hematology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Kathryn Dane
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD
| | - Jennifer Davila
- Children's Hospital at Montefiore, Division of Pediatric Hematology, Oncology, and Cellular Therapies, Albert Einstein College of Medicine, Bronx, NY
| | - Maria T DeSancho
- Division of Hematology-Oncology, Department of Medicine, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, NY
| | - David Diuguid
- Department of Medicine, College of Physicians and Surgeons and
| | - Daniel O Griffin
- Division of Infectious Diseases, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY
- Research and Development at United Health Group, Minnetonka, MN
- Prohealth NY, Lake Success, NY
| | - Susan R Kahn
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Frederikus A Klok
- Thrombosis and Hemostasis, Department of Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Alfred Ian Lee
- Section of Hematology, School of Medicine, Yale University, New Haven, CT
| | - Ignacio Neumann
- Department of Internal Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Ashok Pai
- Division of Hematology and Oncology, Kaiser Permanente, Oakland/Richmond, CA
| | - Menaka Pai
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Marc Righini
- Division of Angiology and Hemostasis, Faculty of Medicine, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Kristen M Sanfilippo
- Department of Medicine, Washington University School of Medicine St. Louis, St. Louis, MO
| | - Deborah Siegal
- Department of Medicine and
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | | | | | - Elie A Akl
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Imad Bou Akl
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Mary Boulos
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Rana Charide
- Clinical Research Institute, American University of Beirut, Beirut, Lebanon
| | - Matthew Chan
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Karin Dearness
- Library Services, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada
| | - Andrea J Darzi
- Michael G. DeGroote Cochrane Canada Centre
- McGRADE Centre, and
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Philipp Kolb
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Luis E Colunga-Lozano
- Department of Clinical Medicine, Health Science Center, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - Razan Mansour
- Office of Scientific Affairs and Research, King Hussein Cancer Center, Amman, Jordan
| | - Gian Paolo Morgano
- Michael G. DeGroote Cochrane Canada Centre
- McGRADE Centre, and
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Rami Z Morsi
- Department of Neurology, University of Chicago, Chicago, IL
| | - Atefeh Noori
- Michael G. DeGroote Cochrane Canada Centre
- McGRADE Centre, and
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- The Michael G. DeGroote National Pain Center, McMaster University, Hamilton, ON, Canada
| | - Thomas Piggott
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Yuan Qiu
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Yetiani Roldan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Finn Schünemann
- Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Germany
| | - Adrienne Stevens
- Michael G. DeGroote Cochrane Canada Centre
- McGRADE Centre, and
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Karla Solo
- Michael G. DeGroote Cochrane Canada Centre
- McGRADE Centre, and
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Matthew Ventresca
- Michael G. DeGroote Cochrane Canada Centre
- McGRADE Centre, and
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Wojtek Wiercioch
- Michael G. DeGroote Cochrane Canada Centre
- McGRADE Centre, and
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Reem A Mustafa
- Michael G. DeGroote Cochrane Canada Centre
- McGRADE Centre, and
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Internal Medicine, Division of Nephrology, University of Kansas Medical Center, Kansas City, KS; and
| | - Holger J Schünemann
- Michael G. DeGroote Cochrane Canada Centre
- McGRADE Centre, and
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Institute for Evidence in Medicine, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany
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279
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Cuker A, Tseng EK, Nieuwlaat R, Angchaisuksiri P, Blair C, Dane K, Davila J, DeSancho MT, Diuguid D, Griffin DO, Kahn SR, Klok FA, Lee AI, Neumann I, Pai A, Pai M, Righini M, Sanfilippo KM, Siegal D, Skara M, Touri K, Akl EA, Bou Akl I, Boulos M, Brignardello-Petersen R, Charide R, Chan M, Dearness K, Darzi AJ, Kolb P, Colunga-Lozano LE, Mansour R, Morgano GP, Morsi RZ, Noori A, Piggott T, Qiu Y, Roldan Y, Schünemann F, Stevens A, Solo K, Ventresca M, Wiercioch W, Mustafa RA, Schünemann HJ. American Society of Hematology 2021 guidelines on the use of anticoagulation for thromboprophylaxis in patients with COVID-19. Blood Adv 2021. [PMID: 33560401 DOI: 10.1182/blood-advances.2020003763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19)-related critical illness and acute illness are associated with a risk of venous thromboembolism (VTE). OBJECTIVE These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in decisions about the use of anticoagulation for thromboprophylaxis for patients with COVID-19-related critical illness and acute illness who do not have confirmed or suspected VTE. METHODS ASH formed a multidisciplinary guideline panel and applied strict management strategies to minimize potential bias from conflicts of interest. The panel included 3 patient representatives. The McMaster University GRADE Centre supported the guideline-development process, including performing systematic evidence reviews (up to 19 August 2020). The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, including GRADE Evidence-to-Decision frameworks, to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel agreed on 2 recommendations. The panel issued conditional recommendations in favor of prophylactic-intensity anticoagulation over intermediate-intensity or therapeutic-intensity anticoagulation for patients with COVID-19-related critical illness or acute illness who do not have confirmed or suspected VTE. CONCLUSIONS These recommendations were based on very low certainty in the evidence, underscoring the need for high-quality, randomized controlled trials comparing different intensities of anticoagulation. They will be updated using a living recommendation approach as new evidence becomes available.
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Affiliation(s)
- Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Eric K Tseng
- St. Michael's Hospital, Division of Hematology/Oncology, University of Toronto, Toronto, ON, Canada
| | - Robby Nieuwlaat
- Michael G. DeGroote Cochrane Canada Centre
- McGRADE Centre, and
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Pantep Angchaisuksiri
- Division of Hematology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Kathryn Dane
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD
| | - Jennifer Davila
- Children's Hospital at Montefiore, Division of Pediatric Hematology, Oncology, and Cellular Therapies, Albert Einstein College of Medicine, Bronx, NY
| | - Maria T DeSancho
- Division of Hematology-Oncology, Department of Medicine, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, NY
| | - David Diuguid
- Department of Medicine, College of Physicians and Surgeons and
| | - Daniel O Griffin
- Division of Infectious Diseases, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY
- Research and Development at United Health Group, Minnetonka, MN
- Prohealth NY, Lake Success, NY
| | - Susan R Kahn
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Frederikus A Klok
- Thrombosis and Hemostasis, Department of Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Alfred Ian Lee
- Section of Hematology, School of Medicine, Yale University, New Haven, CT
| | - Ignacio Neumann
- Department of Internal Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Ashok Pai
- Division of Hematology and Oncology, Kaiser Permanente, Oakland/Richmond, CA
| | - Menaka Pai
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Marc Righini
- Division of Angiology and Hemostasis, Faculty of Medicine, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Kristen M Sanfilippo
- Department of Medicine, Washington University School of Medicine St. Louis, St. Louis, MO
| | - Deborah Siegal
- Department of Medicine and
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | | | | | - Elie A Akl
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Imad Bou Akl
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Mary Boulos
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Rana Charide
- Clinical Research Institute, American University of Beirut, Beirut, Lebanon
| | - Matthew Chan
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Karin Dearness
- Library Services, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada
| | - Andrea J Darzi
- Michael G. DeGroote Cochrane Canada Centre
- McGRADE Centre, and
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Philipp Kolb
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Luis E Colunga-Lozano
- Department of Clinical Medicine, Health Science Center, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - Razan Mansour
- Office of Scientific Affairs and Research, King Hussein Cancer Center, Amman, Jordan
| | - Gian Paolo Morgano
- Michael G. DeGroote Cochrane Canada Centre
- McGRADE Centre, and
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Rami Z Morsi
- Department of Neurology, University of Chicago, Chicago, IL
| | - Atefeh Noori
- Michael G. DeGroote Cochrane Canada Centre
- McGRADE Centre, and
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- The Michael G. DeGroote National Pain Center, McMaster University, Hamilton, ON, Canada
| | - Thomas Piggott
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Yuan Qiu
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Yetiani Roldan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Finn Schünemann
- Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Germany
| | - Adrienne Stevens
- Michael G. DeGroote Cochrane Canada Centre
- McGRADE Centre, and
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Karla Solo
- Michael G. DeGroote Cochrane Canada Centre
- McGRADE Centre, and
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Matthew Ventresca
- Michael G. DeGroote Cochrane Canada Centre
- McGRADE Centre, and
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Wojtek Wiercioch
- Michael G. DeGroote Cochrane Canada Centre
- McGRADE Centre, and
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Reem A Mustafa
- Michael G. DeGroote Cochrane Canada Centre
- McGRADE Centre, and
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Internal Medicine, Division of Nephrology, University of Kansas Medical Center, Kansas City, KS; and
| | - Holger J Schünemann
- Michael G. DeGroote Cochrane Canada Centre
- McGRADE Centre, and
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Institute for Evidence in Medicine, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Giordo R, Zinellu A, Eid AH, Pintus G. Therapeutic Potential of Resveratrol in COVID-19-Associated Hemostatic Disorders. Molecules 2021; 26:856. [PMID: 33562030 PMCID: PMC7915700 DOI: 10.3390/molecules26040856] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 01/30/2021] [Accepted: 02/03/2021] [Indexed: 12/14/2022] Open
Abstract
Coagulation disorders, endotheliopathy and inflammation are the most common hallmarks in SARS-CoV-2 infection, largely determining COVID-19's outcome and severity. Dysfunctions of endothelial cells and platelets are tightly linked in contributing to the systemic inflammatory response that appears to be both a cause and a consequence of COVID-19-associated coagulation disorders and thrombotic events. Indeed, elevated levels of circulating inflammatory cytokines are often associated with abnormal coagulation parameters in COVID-19 patients. Although treatments with low molecular weight heparin (LMWH) have shown beneficial effects in decreasing patient mortality with severe COVID-19, additional therapeutic strategies are urgently needed. Utilizing the anti-inflammatory and anti-thrombotic properties of natural compounds may provide alternative therapeutic approaches to prevent or reduce the risk factors associated with pre-existing conditions and comorbidities that can worsen COVID-19 patients' outcomes. In this regard, resveratrol, a natural compound found in several plants and fruits such as grapes, blueberries and cranberries, may represent a promising coadjuvant for the prevention and treatment of COVID-19. By virtue of its anti-thrombotic and anti-inflammatory properties, resveratrol would be expected to lower COVID-19-associated mortality, which is well known to be increased by thrombosis and inflammation. This review analyzes and discusses resveratrol's ability to modulate vascular hemostasis at different levels targeting both primary hemostasis (interfering with platelet activation and aggregation) and secondary hemostasis (modulating factors involved in coagulation cascade).
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Affiliation(s)
- Roberta Giordo
- Department of Medical Laboratory Sciences, College of Health Sciences, and Sharjah Institute for Medical Research, University of Sharjah, University City Rd, Sharjah 27272, United Arab Emirates;
| | - Angelo Zinellu
- Department of Biomedical Sciences, University of Sassari, 07100 Sassari, Italy;
| | - Ali Hussein Eid
- Department of Basic Medical Sciences, College of Medicine, QU Health, Qatar University, P.O. Box 2713 Doha, Qatar
- Biomedical and Pharmaceutical Research Unit, QU Health, Qatar University, P.O. Box 2713 Doha, Qatar
| | - Gianfranco Pintus
- Department of Medical Laboratory Sciences, College of Health Sciences, and Sharjah Institute for Medical Research, University of Sharjah, University City Rd, Sharjah 27272, United Arab Emirates;
- Department of Biomedical Sciences, University of Sassari, 07100 Sassari, Italy;
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281
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Bauer W, Galtung N, Neuwinger N, Kaufner L, Langer E, Somasundaram R, Tauber R, Kappert K. A Matter of Caution: Coagulation Parameters in COVID-19 Do Not Differ from Patients with Ruled-Out SARS-CoV-2 Infection in the Emergency Department. TH OPEN 2021; 5:e43-e55. [PMID: 33564744 PMCID: PMC7867413 DOI: 10.1055/s-0040-1722612] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 11/30/2020] [Indexed: 01/08/2023] Open
Abstract
COVID-19 (coronavirus disease 2019) patients often show excessive activation of coagulation, associated with increased risk of thrombosis. However, the diagnostic value of coagulation at initial clinical evaluation is not clear. We present an in-depth analysis of coagulation in patients presenting to the emergency department (ED) with suspected COVID-19. N = 58 patients with clinically suspected COVID-19 in the ED were enrolled. N = 17 subsequently tested positive using SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) polymerase chain reaction (PCR) swabs, while in n = 41 COVID-19 was ruled-out. We analyzed both standard and extended coagulation parameters, including thromboplastin time (INR), activated partial thromboplastin time (aPTT), antithrombin, plasminogen, plasminogen activator inhibitor-1 (PAI-1), D-dimers, and fibrinogen at admission, as well as α2-antiplasmin, activated protein C -resistance, factor V, lupus anticoagulant, protein C, protein S, and von Willebrand diagnostics. These data, as well as mortality and further laboratory parameters, were compared across groups based on COVID-19 diagnosis and severity of disease. In patients with COVID-19, we detected frequent clotting abnormalities, including D-dimers. The comparison cohort in the ED, however, showed similarly altered coagulation. Furthermore, parameters previously shown to distinguish between severe and moderate COVID-19 courses, such as platelets, plasminogen, fibrinogen, aPTT, INR, and antithrombin, as well as multiple nonroutine coagulation analytes showed no significant differences between patients with and without COVID-19 when presenting to the ED. At admission to the ED the prevalence of coagulopathy in patients with COVID-19 is high, yet comparable to the non-COVID-19 cohort presenting with respiratory symptoms. Nevertheless, coagulopathy might worsen during disease progression with the need of subsequent risk stratification.
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Affiliation(s)
- Wolfgang Bauer
- Department of Emergency Medicine, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Noa Galtung
- Department of Emergency Medicine, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Nick Neuwinger
- Institute of Laboratory Medicine, Clinical Chemistry and Pathobiochemistry, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Labor Berlin-Charité Vivantes GmbH, Berlin, Germany
| | - Lutz Kaufner
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Elisabeth Langer
- Institute of Laboratory Medicine, Clinical Chemistry and Pathobiochemistry, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Labor Berlin-Charité Vivantes GmbH, Berlin, Germany
| | - Rajan Somasundaram
- Department of Emergency Medicine, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Rudolf Tauber
- Institute of Laboratory Medicine, Clinical Chemistry and Pathobiochemistry, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Labor Berlin-Charité Vivantes GmbH, Berlin, Germany
| | - Kai Kappert
- Institute of Laboratory Medicine, Clinical Chemistry and Pathobiochemistry, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Labor Berlin-Charité Vivantes GmbH, Berlin, Germany
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282
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Tassiopoulos AK, Mofakham S, Rubano JA, Labropoulos N, Bannazadeh M, Drakos P, Volteas P, Cleri NA, Alkadaa LN, Asencio AA, Oganov A, Hou W, Rutigliano DN, Singer AJ, Vosswinkel J, Talamini M, Mikell CB, Kaushansky K. D-Dimer-Driven Anticoagulation Reduces Mortality in Intubated COVID-19 Patients: A Cohort Study With a Propensity-Matched Analysis. Front Med (Lausanne) 2021; 8:631335. [PMID: 33634153 PMCID: PMC7902033 DOI: 10.3389/fmed.2021.631335] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 01/11/2021] [Indexed: 12/12/2022] Open
Abstract
Objective: Examine the possible beneficial effects of early, D-dimer driven anticoagulation in preventing thrombotic complications and improving the overall outcomes of COVID-19 intubated patients. Methods: To address COVID-19 hypercoagulability, we developed a clinical protocol to escalate anticoagulation based on serum D-dimer levels. We retrospectively reviewed all our first 240 intubated patients with COVID-19. Of the 240, 195 were stratified into patients treated based on this protocol (ON-protocol, n = 91) and the control group, patients who received standard thromboprophylaxis (OFF-protocol, n = 104). All patients were admitted to the Stony Brook University Hospital intensive care units (ICUs) between February 7th, 2020 and May 17, 2020 and were otherwise treated in the same manner for all aspects of COVID-19 disease. Results: We found that the overall mortality was significantly lower ON-protocol compared to OFF-protocol (27.47 vs. 58.66%, P < 0.001). Average maximum D-dimer levels were significantly lower in the ON-protocol group (7,553 vs. 12,343 ng/mL), as was serum creatinine (2.2 vs. 2.8 mg/dL). Patients with poorly controlled D-dimer levels had higher rates of kidney dysfunction and mortality. Transfusion requirements and serious bleeding events were similar between groups. To address any possible between-group differences, we performed a propensity-matched analysis of 124 of the subjects (62 matched pairs, ON-protocol and OFF-protocol), which showed similar findings (31 vs. 57% overall mortality in the ON-protocol and OFF-protocol group, respectively). Conclusions: D-dimer-driven anticoagulation appears to be safe in patients with COVID-19 infection and is associated with improved survival. What This Paper Adds: It has been shown that hypercoagulability in patients with severe COVID-19 infection leads to thromboembolic complications and organ dysfunction. Anticoagulation has been variably administered to these patients, but it is unknown whether routine or escalated thromboprophylaxis provides a survival benefit. Our data shows that escalated D-dimer driven anticoagulation is associated with improved organ function and overall survival in intubated COVID-19 ICU patients at our institution. Importantly, we found that timely escalation of this anticoagulation is critical in preventing organ dysfunction and mortality in patients with severe COVID-19 infection.
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Affiliation(s)
- Apostolos K Tassiopoulos
- Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, United States.,Division of Vascular Surgery, Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, United States
| | - Sima Mofakham
- Department of Neurosurgery, Renaissance School of Medicine, Stony Brook, NY, United States
| | - Jerry A Rubano
- Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, United States
| | - Nicos Labropoulos
- Division of Vascular Surgery, Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, United States
| | - Mohsen Bannazadeh
- Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, United States.,Division of Vascular Surgery, Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, United States
| | - Panagiotis Drakos
- Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, United States
| | - Panagiotis Volteas
- Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, United States
| | - Nathaniel A Cleri
- Department of Neurosurgery, Renaissance School of Medicine, Stony Brook, NY, United States
| | - Leor N Alkadaa
- Department of Neurosurgery, Renaissance School of Medicine, Stony Brook, NY, United States
| | - Anthony A Asencio
- Department of Neurosurgery, Renaissance School of Medicine, Stony Brook, NY, United States
| | - Anthony Oganov
- Department of Neurosurgery, Renaissance School of Medicine, Stony Brook, NY, United States
| | - Wei Hou
- Department of Family, Population and Preventive Medicine, Renaissance School of Medicine, Stony Brook, NY, United States
| | - Daniel N Rutigliano
- Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, United States
| | - Adam J Singer
- Department of Emergency Medicine, Renaissance School of Medicine, Stony Brook, NY, United States
| | - James Vosswinkel
- Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, United States
| | - Mark Talamini
- Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, United States
| | - Charles B Mikell
- Department of Neurosurgery, Renaissance School of Medicine, Stony Brook, NY, United States
| | - Kenneth Kaushansky
- Department of Medicine, Renaissance School of Medicine, Stony Brook, NY, United States
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283
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Nalugo M, Schulte LJ, Masood MF, Zayed MA. Microvascular Angiopathic Consequences of COVID-19. Front Cardiovasc Med 2021; 8:636843. [PMID: 33604359 PMCID: PMC7884319 DOI: 10.3389/fcvm.2021.636843] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 01/11/2021] [Indexed: 02/06/2023] Open
Abstract
The coronavirus disease-2019 (COVID-19) pandemic has rapidly spread across the world. The disease is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which first appeared in Wuhan, China in December, 2019. Ever increasing data is continuing to emerge about the impact of COVID-19 on cardiovascular tissue and other organ system. Clinical features associated with COVID-19 suggest that endothelial cell dysfunction and microvascular thrombosis are to a large extent contributing to resultant multi-organ complications. This review is aimed at highlighting the critical aspects associated with COVID-19 and its presumed microvascular angiopathic consequences on the cardiovascular system leading to multi-organ dysfunction.
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Affiliation(s)
- Margaret Nalugo
- Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Linda J. Schulte
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Muhammad F. Masood
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Mohamed A. Zayed
- Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
- Division of Molecular Cell Biology, Washington University School of Medicine, St. Louis, MO, United States
- Department of Biomedical Engineering, McKelvey School of Engineering, Washington University, St. Louis, MO, United States
- Veterans Affairs St. Louis Health Care System, St. Louis, MO, United States
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284
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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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285
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Gao Y, Ding M, Dong X, Zhang J, Kursat Azkur A, Azkur D, Gan H, Sun Y, Fu W, Li W, Liang H, Cao Y, Yan Q, Cao C, Gao H, Brüggen M, Veen W, Sokolowska M, Akdis M, Akdis CA. Risk factors for severe and critically ill COVID-19 patients: A review. Allergy 2021; 76:428-455. [PMID: 33185910 DOI: 10.1111/all.14657] [Citation(s) in RCA: 760] [Impact Index Per Article: 253.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 10/28/2020] [Accepted: 11/09/2020] [Indexed: 02/06/2023]
Abstract
The pandemic of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has caused an unprecedented global social and economic impact, and high numbers of deaths. Many risk factors have been identified in the progression of COVID-19 into a severe and critical stage, including old age, male gender, underlying comorbidities such as hypertension, diabetes, obesity, chronic lung diseases, heart, liver and kidney diseases, tumors, clinically apparent immunodeficiencies, local immunodeficiencies, such as early type I interferon secretion capacity, and pregnancy. Possible complications include acute kidney injury, coagulation disorders, thoromboembolism. The development of lymphopenia and eosinopenia are laboratory indicators of COVID-19. Laboratory parameters to monitor disease progression include lactate dehydrogenase, procalcitonin, high-sensitivity C-reactive protein, proinflammatory cytokines such as interleukin (IL)-6, IL-1β, Krebs von den Lungen-6 (KL-6), and ferritin. The development of a cytokine storm and extensive chest computed tomography imaging patterns are indicators of a severe disease. In addition, socioeconomic status, diet, lifestyle, geographical differences, ethnicity, exposed viral load, day of initiation of treatment, and quality of health care have been reported to influence individual outcomes. In this review, we highlight the scientific evidence on the risk factors of severity of COVID-19.
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Affiliation(s)
- Ya‐dong Gao
- Department of Allergology Zhongnan Hospital of Wuhan University Wuhan China
| | - Mei Ding
- Department of Allergology Zhongnan Hospital of Wuhan University Wuhan China
- Swiss Institute of Allergy and Asthma Research (SIAF) University of Zurich Zurich Switzerland
| | - Xiang Dong
- Department of Allergology Zhongnan Hospital of Wuhan University Wuhan China
| | - Jin‐jin Zhang
- Department of Allergology Zhongnan Hospital of Wuhan University Wuhan China
| | - Ahmet Kursat Azkur
- Department of Virology Faculty of Veterinary Medicine University of Kirikkale Kirikkale Turkey
| | - Dilek Azkur
- Division of Pediatric Allergy and Immunology Department of Pediatrics Faculty of Medicine University of Kirikkale Kirikkale Turkey
| | - Hui Gan
- Department of Allergology Zhongnan Hospital of Wuhan University Wuhan China
| | - Yuan‐li Sun
- Department of Allergology Zhongnan Hospital of Wuhan University Wuhan China
| | - Wei Fu
- Department of Allergology Zhongnan Hospital of Wuhan University Wuhan China
| | - Wei Li
- Department of Allergology Zhongnan Hospital of Wuhan University Wuhan China
| | - Hui‐ling Liang
- Department of Allergology Zhongnan Hospital of Wuhan University Wuhan China
| | - Yi‐yuan Cao
- Department of Radiology Zhongnan Hospital of Wuhan University Wuhan China
| | - Qi Yan
- Department of Geriatrics Tongji Hospital Tongji Medical College Huazhong University of Science and Technology Huazhong China
| | - Can Cao
- Department of Allergology Zhongnan Hospital of Wuhan University Wuhan China
| | - Hong‐yu Gao
- Department of Geriatrics Tongji Hospital Tongji Medical College Huazhong University of Science and Technology Huazhong China
| | - Marie‐Charlotte Brüggen
- Department of Dermatology University Hospital Zurich Zurich Switzerland
- Faculty of Medicine University of Zurich Zurich Switzerland
- Hochgebirgsklinik Davos Christine Kühne‐Center for Allergy Research and Education Davos Switzerland
| | - Willem Veen
- Swiss Institute of Allergy and Asthma Research (SIAF) University of Zurich Zurich Switzerland
| | - Milena Sokolowska
- Swiss Institute of Allergy and Asthma Research (SIAF) University of Zurich Zurich Switzerland
| | - Mübeccel Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF) University of Zurich Zurich Switzerland
| | - Cezmi A. Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF) University of Zurich Zurich Switzerland
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286
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COVID-19: Prognoseverbesserung unter Antikoagulanzien. AKTUELLE KARDIOLOGIE 2021. [DOI: 10.1055/a-1305-2562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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287
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El‐Shimy IA, Mohamed MMA, Hasan SS, Hadi MA. Targeting host cell proteases as a potential treatment strategy to limit the spread of SARS-CoV-2 in the respiratory tract. Pharmacol Res Perspect 2021; 9:e00698. [PMID: 33369210 PMCID: PMC7758277 DOI: 10.1002/prp2.698] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 09/24/2020] [Accepted: 11/13/2020] [Indexed: 12/15/2022] Open
Abstract
As the death toll of Coronavirus disease 19 (COVID-19) continues to rise worldwide, it is imperative to explore novel molecular mechanisms for targeting SARS-CoV-2. Rather than looking for drugs that directly interact with key viral proteins inhibiting its replication, an alternative and possibly add-on approach is to dismantle the host cell machinery that enables the virus to infect the host cell and spread from one cell to another. Excellent examples of such machinery are host cell proteases whose role in viral pathogenesis has been demonstrated in numerous coronaviruses. In this review, we propose two therapeutic modalities to tackle SARS-CoV-2 infections; the first is to transcriptionally modulate the expression of cellular proteases and their endogenous inhibitors and the second is to directly inhibit their enzymatic activity. We present a nonexhaustive collection of clinically investigated drugs that act by one of these mechanisms and thus represent promising candidates for preclinical in vitro testing and hopefully clinical testing in COVID-19 patients.
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Affiliation(s)
- Ismail A. El‐Shimy
- Integrative Research Institute (IRI) for Life SciencesHumboldt University BerlinBerlinGermany
- Institute of PathologyCharité ‐ Universitätsmedizin BerlinBerlinGermany
| | | | | | - Muhammad A. Hadi
- School of PharmacyCollege of Medical and Dental SciencesUniversity of BirminghamBirminghamUK
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288
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Roshdy A, Zaher S, Fayed H, Coghlan JG. COVID-19 and the Heart: A Systematic Review of Cardiac Autopsies. Front Cardiovasc Med 2021; 7:626975. [PMID: 33585586 PMCID: PMC7876291 DOI: 10.3389/fcvm.2020.626975] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 12/17/2020] [Indexed: 01/06/2023] Open
Abstract
Importance: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-associated cardiac injury has been postulated secondary to several mechanisms. While tissue diagnosis is limited during the acute illness, postmortem studies can help boost our understanding and guide management. Objective: To report the cardiac tissue autopsy findings in coronavirus disease 2019 (COVID-19) decedents. Evidence Review: Articles published in PubMed and Embase reporting postmortem cardiac pathology of COVID-19 decedents till September 2020. We included adult studies excluding preprints. The Joanna Briggs Institute Critical Appraisal Checklist for Case Reports was used to assess quality. We extracted gross and histology data as well as the incidence of myocarditis, cardiac ischemia, thrombosis, and dilatation. We also looked at the reported cause of death (PROSPERO registration CRD42020190898). Findings: Forty-one relevant studies identified including 316 cases. The deceased were mostly male (62%) and elderly (median age, 75; range, 22-97 years). The most common comorbidities were hypertension (48%) and coronary artery disease (33%). Cardiac pathologies contributed to the death of 15 cases. Besides chronic cardiac pathologies, postmortem examination demonstrated cardiac dilatation (20%), acute ischemia (8%), intracardiac thrombi (2.5%), pericardial effusion (2.5%), and myocarditis (1.5%). SARS-CoV-2 was detected within the myocardium of 47% of studied hearts. Conclusions and Relevance: SARS-CoV-2 can invade the heart, but a minority of cases were found to have myocarditis. Cardiac dilatation, ischemia, mural, and microthrombi were the most frequent findings. The systematic review was limited by the small number of cases and the quality of the studies, and there is a need to standardize the cardiac postmortem protocols.
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Affiliation(s)
- Ashraf Roshdy
- Critical Care Unit, Whipps Cross University Hospital, Barts Health NHS Trust, London, United Kingdom.,Critical Care Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Shroque Zaher
- Department of Pathology, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
| | - Hossam Fayed
- National Pulmonary Hypertension Unit-Cardiology Department, Royal Free Hospital, London, United Kingdom.,Institute of Cardiovascular Science, UCL, London, United Kingdom
| | - John Gerry Coghlan
- National Pulmonary Hypertension Unit-Cardiology Department, Royal Free Hospital, London, United Kingdom
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289
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Does anticoagulation reduce mortality in patients with atrial fibrillation who later developed a COVID-19 infection? Int J Cardiol 2021; 331:340-341. [PMID: 33515615 PMCID: PMC7839803 DOI: 10.1016/j.ijcard.2021.01.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 01/04/2021] [Indexed: 11/20/2022]
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290
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Cohen SL, Gianos E, Barish MA, Chatterjee S, Kohn N, Lesser M, Giannis D, Coppa K, Hirsch JS, McGinn TG, Goldin ME, Spyropoulos AC. Prevalence and Predictors of Venous Thromboembolism or Mortality in Hospitalized COVID-19 Patients. Thromb Haemost 2021; 121:1043-1053. [PMID: 33472255 DOI: 10.1055/a-1366-9656] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND We aimed to identify the prevalence and predictors of venous thromboembolism (VTE) or mortality in hospitalized coronavirus disease 2019 (COVID-19) patients. METHODS A retrospective cohort study of hospitalized adult patients admitted to an integrated health care network in the New York metropolitan region between March 1, 2020 and April 27, 2020. The final analysis included 9,407 patients with an overall VTE rate of 2.9% (2.4% in the medical ward and 4.9% in the intensive care unit [ICU]) and a VTE or mortality rate of 26.1%. Most patients received prophylactic-dose thromboprophylaxis. Multivariable analysis showed significantly reduced VTE or mortality with Black race, history of hypertension, angiotensin converting enzyme/angiotensin receptor blocker use, and initial prophylactic anticoagulation. It also showed significantly increased VTE or mortality with age 60 years or greater, Charlson Comorbidity Index (CCI) of 3 or greater, patients on Medicare, history of heart failure, history of cerebrovascular disease, body mass index greater than 35, steroid use, antirheumatologic medication use, hydroxychloroquine use, maximum D-dimer four times or greater than the upper limit of normal (ULN), ICU level of care, increasing creatinine, and decreasing platelet counts. CONCLUSION In our large cohort of hospitalized COVID-19 patients, the overall in-hospital VTE rate was 2.9% (4.9% in the ICU) and a VTE or mortality rate of 26.1%. Key predictors of VTE or mortality included advanced age, increasing CCI, history of cardiovascular disease, ICU level of care, and elevated maximum D-dimer with a cutoff at least four times the ULN. Use of prophylactic-dose anticoagulation but not treatment-dose anticoagulation was associated with reduced VTE or mortality.
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Affiliation(s)
- Stuart L Cohen
- Department of Radiology, Northwell Health, Manhasset, New York, United States.,Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States
| | - Eugenia Gianos
- Department of Cardiology, Northwell Health, Manhasset, New York, United States
| | - Mathew A Barish
- Department of Radiology, Northwell Health, Manhasset, New York, United States
| | - Saurav Chatterjee
- Department of Cardiology, Northwell Health, Manhasset, New York, United States.,Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, United States
| | - Nina Kohn
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States
| | - Martin Lesser
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States.,Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, United States
| | - Dimitrios Giannis
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States.,Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, United States
| | - Kevin Coppa
- Department of Information Services, Northwell Health, New Hyde Park, New York, United States
| | - Jamie S Hirsch
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States.,Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, United States.,Department of Information Services, Northwell Health, New Hyde Park, New York, United States
| | - Thomas G McGinn
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States.,Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, United States
| | - Mark E Goldin
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States.,Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, United States
| | - Alex C Spyropoulos
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States.,Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, United States
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291
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Vuorio A, Kovanen PT. Statins as Adjuvant Therapy for COVID-19 to Calm the Stormy Immunothrombosis and Beyond. Front Pharmacol 2021; 11:579548. [PMID: 33542685 PMCID: PMC7851087 DOI: 10.3389/fphar.2020.579548] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 12/04/2020] [Indexed: 12/15/2022] Open
Affiliation(s)
- Alpo Vuorio
- Mehiläinen Airport Health Centre, Vantaa, Finland.,Department of Forensic Medicine, University of Helsinki, Helsinki, Finland
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292
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Iqbal P, Laswi B, Jamshaid MB, Shahzad A, Chaudhry HS, Khan D, Qamar MS, Yousaf Z. The Role of Anticoagulation in Post-COVID-19 Concomitant Stroke, Myocardial Infarction, and Left Ventricular Thrombus: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e928852. [PMID: 33446625 PMCID: PMC7816663 DOI: 10.12659/ajcr.928852] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Patient: Male, 65-year-old Final Diagnosis: Heart failure • myocardial infarction • stroke Symptoms: Right sided weakness Medication:— Clinical Procedure: CT scan • echocardiography Specialty: Cardiology • Infectious Diseases • Medicine, General and Internal • Neurology
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Affiliation(s)
- Phool Iqbal
- Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Bushra Laswi
- Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar
| | | | - Aamir Shahzad
- Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar
| | | | - Dawlat Khan
- Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar
| | | | - Zohaib Yousaf
- Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar
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293
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Meizlish ML, Goshua G, Liu Y, Fine R, Amin K, Chang E, DeFilippo N, Keating C, Liu Y, Mankbadi M, McManus D, Wang S, Price C, Bona RD, Chaar CIO, Chun HJ, Pine AB, Rinder HM, Siner J, Neuberg DS, Owusu KA, Lee AI. Intermediate-dose anticoagulation, aspirin, and in-hospital mortality in COVID-19: a propensity score-matched analysis. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2021:2021.01.12.21249577. [PMID: 33469595 PMCID: PMC7814841 DOI: 10.1101/2021.01.12.21249577] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background Thrombotic complications occur at high rates in hospitalized patients with COVID-19, yet the impact of intensive antithrombotic therapy on mortality is uncertain. Research Question How does in-hospital mortality compare with intermediate- versus prophylactic-dose anticoagulation, and separately with in-hospital aspirin versus no antiplatelet therapy, in treatment of COVID-19? Study Design and Methods Using data from 2785 hospitalized adult COVID-19 patients, we established two separate, nested cohorts of patients (1) who received intermediate- or prophylactic-dose anticoagulation ("anticoagulation cohort", N = 1624), or (2) who were not on home antiplatelet therapy and received either in-hospital aspirin or no antiplatelet therapy ("aspirin cohort", N = 1956). Propensity score matching utilizing various markers of illness severity and other patient-specific covariates yielded treatment groups with well-balanced covariates in each cohort. The primary outcome was cumulative incidence of in-hospital death. Results Among propensity score-matched patients in the anticoagulation cohort (N = 382), in a multivariable regression model, intermediate- compared to prophylactic-dose anticoagulation was associated with a significantly lower cumulative incidence of in-hospital death (hazard ratio 0.518 [0.308-0.872]). Among propensity-score matched patients in the aspirin cohort (N = 638), in a multivariable regression model, in-hospital aspirin compared to no antiplatelet therapy was associated with a significantly lower cumulative incidence of in-hospital death (hazard ratio 0.522 [0.336-0.812]). Interpretation In this propensity score-matched, observational study of COVID-19, intermediate-dose anticoagulation and aspirin were each associated with a lower cumulative incidence of in-hospital death.
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Affiliation(s)
| | - George Goshua
- Section of Hematology, Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Yiwen Liu
- Dana-Farber Cancer Institute, Boston, MA
| | - Rebecca Fine
- Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Kejal Amin
- Department of Pharmacy, Yale-New Haven Hospital, New Haven, CT
| | - Eric Chang
- Section of Hematology, Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Nicholas DeFilippo
- Department of Pharmacy, Yale-New Haven Hospital, New Haven, CT
- School of Pharmacy, University of Connecticut, Storrs, CT
| | - Craig Keating
- Joint Data Analytics Team, Yale New Haven Hospital, New Haven, CT
| | - Yuxin Liu
- Section of Hematology, Department of Medicine, Yale School of Medicine, New Haven, CT
| | | | - Dayna McManus
- Department of Pharmacy, Yale-New Haven Hospital, New Haven, CT
| | - Stephen Wang
- Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Christina Price
- Section of Allergy and Immunology, Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Robert D. Bona
- Section of Hematology, Department of Medicine, Yale School of Medicine, New Haven, CT
| | | | - Hyung J. Chun
- Section of Cardiology, Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Alexander B. Pine
- Section of Hematology, Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Henry M. Rinder
- Section of Hematology, Department of Medicine, Yale School of Medicine, New Haven, CT
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT
| | - Jonathan Siner
- Section of Pulmonary and Sleep Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT
| | | | - Kent A. Owusu
- Department of Pharmacy, Yale-New Haven Hospital, New Haven, CT
- Clinical Redesign, Yale New Haven Health, New Haven, CT
| | - Alfred Ian Lee
- Section of Hematology, Department of Medicine, Yale School of Medicine, New Haven, CT
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294
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Kluge S, Janssens U, Welte T, Weber-Carstens S, Schälte G, Spinner CD, Malin JJ, Gastmeier P, Langer F, Wepler M, Westhoff M, Pfeifer M, Rabe KF, Hoffmann F, Böttiger BW, Weinmann-Menke J, Kersten A, Berlit P, Haase R, Marx G, Karagiannidis C. [S2k Guideline - Recommendations for Inpatient Therapy of Patients with COVID-19]. Pneumologie 2021; 75:88-112. [PMID: 33450783 DOI: 10.1055/a-1334-1925] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Since December 2019, the novel coronavirus SARS-CoV-2 (Severe Acute Respiratory Syndrome - Corona Virus-2) has been spreading rapidly in the sense of a global pandemic. This poses significant challenges for clinicians and hospitals and is placing unprecedented strain on the healthcare systems of many countries. The majority of patients with Coronavirus Disease 2019 (COVID-19) present with only mild symptoms such as cough and fever. However, about 6 % require hospitalization. Early clarification of whether inpatient and, if necessary, intensive care treatment is medically appropriate and desired by the patient is of particular importance in the pandemic. Acute hypoxemic respiratory insufficiency with dyspnea and high respiratory rate (> 30/min) usually leads to admission to the intensive care unit. Often, bilateral pulmonary infiltrates/consolidations or even pulmonary emboli are already found on imaging. As the disease progresses, some of these patients develop acute respiratory distress syndrome (ARDS). Mortality reduction of available drug therapy in severe COVID-19 disease has only been demonstrated for dexamethasone in randomized controlled trials. The main goal of supportive therapy is to ensure adequate oxygenation. In this regard, invasive ventilation and repeated prone positioning are important elements in the treatment of severely hypoxemic COVID-19 patients. Strict adherence to basic hygiene, including hand hygiene, and the correct wearing of adequate personal protective equipment are essential when handling patients. Medically necessary actions on patients that could result in aerosol formation should be performed with extreme care and preparation.
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Affiliation(s)
- S Kluge
- Deutsche Gesellschaft für Internistische Intensivmedizin und Notfallmedizin (DGIIN); Berlin.,Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), Berlin.,Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin (DGP), Berlin.,ARDS Netzwerk Deutschland, Berlin
| | - U Janssens
- Deutsche Gesellschaft für Internistische Intensivmedizin und Notfallmedizin (DGIIN); Berlin.,Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), Berlin.,ARDS Netzwerk Deutschland, Berlin
| | - T Welte
- Deutsche Gesellschaft für Internistische Intensivmedizin und Notfallmedizin (DGIIN); Berlin.,Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin (DGP), Berlin.,ARDS Netzwerk Deutschland, Berlin
| | - S Weber-Carstens
- Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), Berlin.,Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI), Nürnberg.,ARDS Netzwerk Deutschland, Berlin
| | - G Schälte
- Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI), Nürnberg
| | - C D Spinner
- Deutsche Gesellschaft für Infektiologie (DGI), Berlin
| | - J J Malin
- Deutsche Gesellschaft für Infektiologie (DGI), Berlin
| | - P Gastmeier
- Deutsche Gesellschaft für Hygiene und Mikrobiologie (DGHM), Münster
| | - F Langer
- Gesellschaft für Thrombose und Hämostaseforschung (GTH), Köln
| | - M Wepler
- Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI), Nürnberg
| | - M Westhoff
- Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin (DGP), Berlin
| | - M Pfeifer
- Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin (DGP), Berlin
| | - K F Rabe
- Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin (DGP), Berlin
| | - F Hoffmann
- Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), Berlin.,Deutsche Gesellschaft für Kinder- und Jugendmedizin (DGKJ), Berlin
| | - B W Böttiger
- Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), Berlin.,Deutscher Rat für Wiederbelebung (German Resuscitation Council; GRC), Ulm
| | | | - A Kersten
- Deutsche Gesellschaft für Kardiologie (DGK)
| | - P Berlit
- Deutsche Gesellschaft für Neurologie (DGN)
| | - R Haase
- Patientenvertretung (individueller Betroffener)
| | - G Marx
- Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), Berlin.,Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI), Nürnberg.,ARDS Netzwerk Deutschland, Berlin
| | - C Karagiannidis
- Deutsche Gesellschaft für Internistische Intensivmedizin und Notfallmedizin (DGIIN); Berlin.,Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), Berlin.,Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin (DGP), Berlin.,ARDS Netzwerk Deutschland, Berlin
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295
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Nakamura H, Ouchi G, Miyagi K, Higure Y, Otsuki M, Nishiyama N, Kinjo T, Nakamatsu M, Tateyama M, Kukita I, Fujita J. Case Report: Iliopsoas Hematoma during the Clinical Course of Severe COVID-19 in Two Male Patients. Am J Trop Med Hyg 2021; 104:1018-1021. [PMID: 33534775 PMCID: PMC7941852 DOI: 10.4269/ajtmh.20-1507] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 12/29/2020] [Indexed: 12/19/2022] Open
Abstract
Anticoagulation plays a major role in reducing the risk of systematic thrombosis in patients with severe COVID-19. Serious hemorrhagic complications, such as intracranial hemorrhage, have also been recognized. However, intra-abdominal hemorrhage is under-recognized because of its rare occurrence, despite high mortality. Here, we discuss two cases of spontaneous iliopsoas hematoma (IPH) likely caused by anticoagulants during the clinical course of COVID-19. We also explored published case reports to identify clinical characteristics of IPH in COVID-19 patients. The use of anticoagulants may increase the risk of lethal IPH among COVID-19 patients becsuse of scarce data on optimal dosage and adequate monitoring of anticoagulant effects. Rapid diagnosis and timely intervention are crucial to ensure good patient outcomes.
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Affiliation(s)
- Hideta Nakamura
- 1Department of Infectious, Respiratory and Digestive Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Gen Ouchi
- 2Department of Emergency and Critical Care Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Kazuya Miyagi
- 1Department of Infectious, Respiratory and Digestive Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Yuuri Higure
- 1Department of Infectious, Respiratory and Digestive Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Mariko Otsuki
- 1Department of Infectious, Respiratory and Digestive Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Naoya Nishiyama
- 1Department of Infectious, Respiratory and Digestive Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Takeshi Kinjo
- 1Department of Infectious, Respiratory and Digestive Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Masashi Nakamatsu
- 1Department of Infectious, Respiratory and Digestive Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Masao Tateyama
- 1Department of Infectious, Respiratory and Digestive Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Ichiro Kukita
- 2Department of Emergency and Critical Care Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Jiro Fujita
- 1Department of Infectious, Respiratory and Digestive Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
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296
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Ahmed HY, Papali A, Haile T, Shrestha GS, Schultz MJ, Lundeg G, Akrami KM, For The Covid-Lmic Task Force. Pragmatic Recommendations for the Management of Anticoagulation and Venous Thrombotic Disease for Hospitalized Patients with COVID-19 in Low- and Middle-Income Countries. Am J Trop Med Hyg 2021; 104:99-109. [PMID: 33432908 PMCID: PMC7957232 DOI: 10.4269/ajtmh.20-1305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 12/23/2020] [Indexed: 12/19/2022] Open
Abstract
New studies of COVID–19 are constantly updating best practices in clinical care. Often, it is impractical to apply recommendations based on high-income country investigations to resource limited settings in low- and middle-income countries (LMICs). We present a set of pragmatic recommendations for the management of anticoagulation and thrombotic disease for hospitalized patients with COVID-19 in LMICs. In the absence of contraindications, we recommend prophylactic anticoagulation with either low molecular weight heparin (LMWH) or unfractionated heparin (UFH) for all hospitalized COVID-19 patients in LMICs. If available, we recommend LMWH over UFH for venous thromboembolism (VTE) prophylaxis to minimize risk to healthcare workers. We recommend against the use of aspirin for VTE prophylaxis in hospitalized COVID-19 and non–COVID-19 patients in LMICs. Because of limited evidence, we suggest against the use of “enhanced” or “intermediate” prophylaxis in COVID-19 patients in LMICs. Based on current available evidence, we recommend against the initiation of empiric therapeutic anticoagulation without clinical suspicion for VTE. If contraindications exist to chemical prophylaxis, we recommend mechanical prophylaxis with intermittent pneumatic compression (IPC) devices or graduated compression stockings (GCS) for hospitalized COVID-19 patients in LMICs. In LMICs, we recommend initiating therapeutic anticoagulation for hospitalized COVID-19 patients, in accordance with local clinical practice guidelines, if there is high clinical suspicion for VTE, even in the absence of testing. If available, we recommend LMWH over UFH or Direct oral anticoagulants for treatment of VTE in LMICs to minimize risk to healthcare workers. In LMIC settings where continuous intravenous UFH or LMWH are unavailable or not feasible to use, we recommend fixed dose heparin, adjusted to body weight, in hospitalized COVID-19 patients with high clinical suspicion of VTE. We suggest D-dimer measurement, if available and affordable, at the time of admission for risk stratification, or when clinical suspicion for VTE is high. For hospitalized COVID-19 patients in LMICs, based on current available evidence, we make no recommendation on the use of serial D-dimer monitoring for the initiation of therapeutic anticoagulation. For hospitalized COVID-19 patients in LMICs receiving intravenous therapeutic UFH, we recommend serial monitoring of partial thromboplastin time or anti-factor Xa level, based on local laboratory capabilities. For hospitalized COVID-19 patients in LMICs receiving LMWH, we suggest against serial monitoring of anti-factor Xa level. We suggest serial monitoring of platelet counts in patients receiving therapeutic anticoagulation for VTE, to assess risk of bleeding or development of heparin induced thrombocytopenia.
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Affiliation(s)
- Hanan Y Ahmed
- Division of Pulmonary and Critical Care Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Alfred Papali
- Division of Pulmonary and Critical Care Medicine, Atrium Health, Charlotte, North Carolina
| | - Tewodros Haile
- Division of Pulmonary and Critical Care Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Gentle S Shrestha
- Department of Anaesthesiology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Marcus J Schultz
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Department of Clinical Tropical Medicine, Mahidol University, Bangkok, Thailand.,Department of Intensive Care, Amsterdam University Medical Centers, Location 'Academic Medical Center', Amsterdam, The Netherlands
| | - Ganbold Lundeg
- Critical Care and Anaesthesia Department, Mongolian National University of Medical Sciences, Ulan Bator, Mongolia
| | - Kevan M Akrami
- Divisions of Infectious Disease and Critical Care Medicine, University of California San Diego, San Diego, California.,Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil
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297
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Di Castelnuovo A, Costanzo S, Antinori A, Berselli N, Blandi L, Bonaccio M, Cauda R, Guaraldi G, Menicanti L, Mennuni M, Parruti G, Patti G, Santilli F, Signorelli C, Vergori A, Abete P, Ageno W, Agodi A, Agostoni P, Aiello L, Al Moghazi S, Arboretti R, Astuto M, Aucella F, Barbieri G, Bartoloni A, Bonfanti P, Cacciatore F, Caiano L, Carrozzi L, Cascio A, Ciccullo A, Cingolani A, Cipollone F, Colomba C, Colombo C, Crosta F, Danzi GB, D'Ardes D, de Gaetano Donati K, Di Gennaro F, Di Tano G, D'Offizi G, Fantoni M, Fusco FM, Gentile I, Gianfagna F, Grandone E, Graziani E, Grisafi L, Guarnieri G, Larizza G, Leone A, Maccagni G, Madaro F, Maitan S, Mancarella S, Mapelli M, Maragna R, Marcucci R, Maresca G, Marongiu S, Marotta C, Marra L, Mastroianni F, Mazzitelli M, Mengozzi A, Menichetti F, Meschiari M, Milic J, Minutolo F, Molena B, Montineri A, Mussini C, Musso M, Niola D, Odone A, Olivieri M, Palimodde A, Parisi R, Pasi E, Pesavento R, Petri F, Pinchera B, Poletti V, Ravaglia C, Rognoni A, Rossato M, Rossi M, Sangiovanni V, Sanrocco C, Scorzolini L, Sgariglia R, Simeone PG, Taddei E, Torti C, Vettor R, Vianello A, Vinceti M, Virano A, Vocciante L, De Caterina R, Iacoviello L. Heparin in COVID-19 Patients Is Associated with Reduced In-Hospital Mortality: The Multicenter Italian CORIST Study. Thromb Haemost 2021; 121:1054-1065. [PMID: 33412596 DOI: 10.1055/a-1347-6070] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION A hypercoagulable condition was described in patients with coronavirus disease 2019 (COVID-19) and proposed as a possible pathogenic mechanism contributing to disease progression and lethality. AIM We evaluated if in-hospital administration of heparin improved survival in a large cohort of Italian COVID-19 patients. METHODS In a retrospective observational study, 2,574 unselected patients hospitalized in 30 clinical centers in Italy from February 19, 2020 to June 5, 2020 with laboratory-confirmed severe acute respiratory syndrome coronavirus-2 infection were analyzed. The primary endpoint in a time-to event analysis was in-hospital death, comparing patients who received heparin (low-molecular-weight heparin [LMWH] or unfractionated heparin [UFH]) with patients who did not. We used multivariable Cox proportional-hazards regression models with inverse probability for treatment weighting by propensity scores. RESULTS Out of 2,574 COVID-19 patients, 70.1% received heparin. LMWH was largely the most used formulation (99.5%). Death rates for patients receiving heparin or not were 7.4 and 14.0 per 1,000 person-days, respectively. After adjustment for propensity scores, we found a 40% lower risk of death in patients receiving heparin (hazard ratio = 0.60; 95% confidence interval: 0.49-0.74; E-value = 2.04). This association was particularly evident in patients with a higher severity of disease or strong coagulation activation. CONCLUSION In-hospital heparin treatment was associated with a lower mortality, particularly in severely ill COVID-19 patients and in those with strong coagulation activation. The results from randomized clinical trials are eagerly awaited to provide clear-cut recommendations.
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Affiliation(s)
| | - Simona Costanzo
- Department of Epidemiology and Prevention, IRCCS Neuromed, Pozzilli, Isernia, Italy
| | - Andrea Antinori
- UOC Immunodeficienze Virali, National Institute for Infectious Diseases "L. Spallanzani," IRCCS, Rome, Italy
| | - Nausicaa Berselli
- Section of Public Health, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | | | - Marialaura Bonaccio
- Department of Epidemiology and Prevention, IRCCS Neuromed, Pozzilli, Isernia, Italy
| | - Roberto Cauda
- Fondazione Policlinico Universitario A, Gemelli IRCCS, Rome, Italy.,Dipartimento di Sicurezza e Bioetica Sede di Roma, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Guaraldi
- Infectious Disease Unit, Department of Surgical, Medical, Dental and Morphological Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | | | - Marco Mennuni
- University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy
| | - Giustino Parruti
- Department of Infectious Disease, Azienda Sanitaria Locale (AUSL) di Pescara, Pescara, Italy
| | - Giuseppe Patti
- University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy
| | - Francesca Santilli
- Department of Medicine and Aging, Clinica Medica, "SS. Annunziata" Hospital and University of Chieti, Chieti, Italy
| | - Carlo Signorelli
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandra Vergori
- Department of HIV/AIDS, National Institute for Infectious Diseases "Lazzaro Spallanzani"-IRCCS, Rome, Italy
| | - Pasquale Abete
- Dipartimento di Scienze Mediche Traslazionali, Università degli studi di Napoli "Federico II," Napoli, Italy
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Antonella Agodi
- Department of Medical and Surgical Sciences and Advanced Technologies "G.F. Ingrassia," University of Catania; AOU Policlinico "G. Rodolico - San Marco," Catania, Italy
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino IRCCS, Milan, Italy.,Section of Cardiovascular, Department of Clinical Sciences and Community Health, University of Milano, Milan, Italy
| | - Luca Aiello
- UOC, Anestesia e Rianimazione, Dipartimento di Chirurgia Generale Ospedale Morgagni-Pierantoni, Forlì, Italy
| | - Samir Al Moghazi
- UOC Infezioni Sistemiche dell'Immunodepresso, National Institute for Infectious Diseases L. Spallanzani, IRCCS, Rome, Italy
| | - Rosa Arboretti
- Department of Civil Environmental and Architectural Engineering, University of Padova, Padova, Italy
| | - Marinella Astuto
- Department of General Surgery and Medical-Surgical Specialties, University of Catania, U.O. Anestesia, Rianimazione 1. P.O. "G. Rodolico," AOU Policlinico "G. Rodolico - San Marco," Catania, Italy
| | - Filippo Aucella
- Fondazione I.R.C.C.S "Casa Sollievo della Sofferenza," San Giovanni Rotondo, Foggia, Italy
| | - Greta Barbieri
- Department of Surgical, Medical and Molecular Medicine and Critical Care, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Alessandro Bartoloni
- Department of Experimental and Clinical Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
| | - Paolo Bonfanti
- UOC Malattie Infettive, Ospedale San Gerardo, ASST Monza, Monza, Italy.,School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Francesco Cacciatore
- Dipartimento di Scienze Mediche Traslazionali, Università degli studi di Napoli "Federico II," Napoli, Italy
| | - Lucia Caiano
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Laura Carrozzi
- Cardiovascular and Thoracic Department, Azienda Ospedaliero-Universitaria Pisana and University of Pisa, Pisa, Italy
| | - Antonio Cascio
- Infectious and Tropical Diseases Unit, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Arturo Ciccullo
- Fondazione Policlinico Universitario A, Gemelli IRCCS, Rome, Italy
| | - Antonella Cingolani
- Fondazione Policlinico Universitario A, Gemelli IRCCS, Rome, Italy.,Dipartimento di Sicurezza e Bioetica Sede di Roma, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Cipollone
- Department of Medicine and Aging, Clinica Medica, "SS. Annunziata" Hospital and University of Chieti, Chieti, Italy
| | - Claudia Colomba
- Infectious and Tropical Diseases Unit, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Crizia Colombo
- University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy
| | - Francesca Crosta
- Department of Infectious Disease, Azienda Sanitaria Locale (AUSL) di Pescara, Pescara, Italy
| | | | - Damiano D'Ardes
- Department of Medicine and Aging, Clinica Medica, "SS. Annunziata" Hospital and University of Chieti, Chieti, Italy
| | | | | | | | - Gianpiero D'Offizi
- UOC Malattie Infettive-Epatologia, National Institute for Infectious Diseases L, Spallanzani, IRCCS, Roma, Italy
| | - Massimo Fantoni
- Fondazione Policlinico Universitario A, Gemelli IRCCS, Rome, Italy.,Dipartimento di Sicurezza e Bioetica Sede di Roma, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Maria Fusco
- UOC Infezioni Sistemiche e dell'Immunodepresso, Azienda Ospedaliera dei Colli, Ospedale Cotugno, Napoli, Italy
| | - Ivan Gentile
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Napoli, Italy
| | - Francesco Gianfagna
- Mediterranea Cardiocentro, Napoli, Italy.,Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Elvira Grandone
- Fondazione I.R.C.C.S "Casa Sollievo della Sofferenza," San Giovanni Rotondo, Foggia, Italy
| | - Emauele Graziani
- Medicina Interna, Ospedale di Ravenna, AUSL della Romagna, Ravenna, Italy
| | - Leonardo Grisafi
- University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy
| | - Gabriella Guarnieri
- Division of Respiratory Pathophysiology, Department of Cardiologic, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Giovanni Larizza
- COVID-19 Unit, EE Ospedale Regionale F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - Armando Leone
- UOC di Pneumologia, P.O. San Giuseppe Moscati, Taranto, Italy
| | - Gloria Maccagni
- Department of Cardiology, Ospedale di Cremona, Cremona, Italy
| | - Ferruccio Madaro
- COVID-19 Unit, EE Ospedale Regionale F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - Stefano Maitan
- UOC, Anestesia e Rianimazione, Dipartimento di Chirurgia Generale Ospedale Morgagni-Pierantoni, Forlì, Italy
| | - Sandro Mancarella
- ASST Milano Nord, Ospedale Edoardo Bassini Cinisello Balsamo, Milan, Italy
| | - Massimo Mapelli
- Centro Cardiologico Monzino IRCCS, Milan, Italy.,Section of Cardiovascular, Department of Clinical Sciences and Community Health, University of Milano, Milan, Italy
| | - Riccardo Maragna
- Centro Cardiologico Monzino IRCCS, Milan, Italy.,Section of Cardiovascular, Department of Clinical Sciences and Community Health, University of Milano, Milan, Italy
| | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
| | - Giulio Maresca
- UOC di Medicina - Presidio Ospedaliero S. Maria di Loreto Nuovo. ASL Napoli 1 Centro. Napoli. Italy
| | | | | | - Lorenzo Marra
- UOC di Pneumologia, P.O. San Giuseppe Moscati, Taranto, Italy
| | - Franco Mastroianni
- COVID-19 Unit, EE Ospedale Regionale F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - Maria Mazzitelli
- Infectious and Tropical Diseases Unit, Department of Medical and Surgical Sciences "Magna Graecia" University, Catanzaro, Italy
| | - Alessandro Mengozzi
- Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Francesco Menichetti
- Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Marianna Meschiari
- Infectious Disease Unit, Department of Surgical, Medical, Dental and Morphological Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Jovana Milic
- Infectious Disease Unit, Department of Surgical, Medical, Dental and Morphological Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | | | - Beatrice Molena
- Division of Respiratory Pathophysiology, Department of Cardiologic, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Arturo Montineri
- U.O. C. Malattie Infettive e Tropicali, P.O. "San Marco." AOU Policlinico "G. Rodolico - San Marco," Catania, Italy
| | - Cristina Mussini
- Infectious Disease Unit, Department of Surgical, Medical, Dental and Morphological Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Maria Musso
- UOC Malattie Infettive-Apparato Respiratorio, National Institute for Infectious Diseases "L. Spallanzani," IRCCS, Rome, Italy
| | - Daniela Niola
- Department of Medicine and Aging, Clinica Medica, "SS. Annunziata" Hospital and University of Chieti, Chieti, Italy
| | | | - Marco Olivieri
- Computer Service, University of Molise, Campobasso, Italy
| | | | - Roberta Parisi
- Department of Epidemiology and Prevention, IRCCS Neuromed, Pozzilli, Isernia, Italy
| | - Emanuela Pasi
- Medicina Interna, Ospedale di Ravenna, AUSL della Romagna, Ravenna, Italy
| | - Raffaele Pesavento
- Clinica Medica 3, Department of Medicine - DIMED, University hospital of Padova, Padova, Italy
| | - Francesco Petri
- UOC Malattie Infettive, Ospedale San Gerardo, ASST Monza, Monza, Italy
| | - Biagio Pinchera
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Napoli, Italy
| | - Venerino Poletti
- UOC Pneumologia, Dipartimento di Malattie Apparato Respiratorio e Torace, Ospedale Morgagni-Pierantoni, Forlì, Italy.,Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
| | - Claudia Ravaglia
- UOC Pneumologia, Dipartimento di Malattie Apparato Respiratorio e Torace, Ospedale Morgagni-Pierantoni, Forlì, Italy
| | - Andrea Rognoni
- University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy
| | - Marco Rossato
- Clinica Medica 3, Department of Medicine - DIMED, University hospital of Padova, Padova, Italy
| | - Marianna Rossi
- UOC Malattie Infettive, Ospedale San Gerardo, ASST Monza, Monza, Italy
| | - Vincenzo Sangiovanni
- UOC Infezioni Sistemiche e dell'Immunodepresso, Azienda Ospedaliera dei Colli, Ospedale Cotugno, Napoli, Italy
| | - Carlo Sanrocco
- Department of Infectious Disease, Azienda Sanitaria Locale (AUSL) di Pescara, Pescara, Italy
| | - Laura Scorzolini
- UOC Malattie Infettive ad Alta Intensità di Cura, National Institute for Infectious Diseases "L. Spallanzani," IRCCS, Rome, Italy
| | | | - Paola Giustina Simeone
- Department of Infectious Disease, Azienda Sanitaria Locale (AUSL) di Pescara, Pescara, Italy
| | - Eleonora Taddei
- Fondazione Policlinico Universitario A, Gemelli IRCCS, Rome, Italy
| | - Carlo Torti
- Infectious and Tropical Diseases Unit, Department of Medical and Surgical Sciences "Magna Graecia" University, Catanzaro, Italy
| | - Roberto Vettor
- Clinica Medica 3, Department of Medicine - DIMED, University hospital of Padova, Padova, Italy
| | - Andrea Vianello
- Division of Respiratory Pathophysiology, Department of Cardiologic, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Marco Vinceti
- Section of Public Health, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy.,Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States
| | - Alexandra Virano
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Laura Vocciante
- UOC di Medicina - Presidio Ospedaliero S. Maria di Loreto Nuovo. ASL Napoli 1 Centro. Napoli. Italy
| | - Raffaele De Caterina
- Cardiovascular and Thoracic Department, Azienda Ospedaliero-Universitaria Pisana and University of Pisa, Pisa, Italy
| | - Licia Iacoviello
- Department of Epidemiology and Prevention, IRCCS Neuromed, Pozzilli, Isernia, Italy.,Department of Medicine and Surgery, University of Insubria, Varese, Italy
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298
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Patell R, Chiasakul T, Bauer E, Zwicker JI. Pharmacologic Thromboprophylaxis and Thrombosis in Hospitalized Patients with COVID-19: A Pooled Analysis. Thromb Haemost 2021; 121:76-85. [PMID: 33378787 PMCID: PMC7869062 DOI: 10.1055/s-0040-1721664] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 11/08/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) increases thrombosis in hospitalized patients prompting adoption of different thromboprophylaxis strategies. Safety and efficacy of escalated-dose pharmacologic thromboprophylaxis are not established. OBJECTIVES To determine the pooled incidence of thrombosis/bleeding in hospitalized patients with COVID-19 for standard-dose, intermediate-dose, therapeutic anticoagulation, and no pharmacologic thromboprophylaxis. METHODS MEDLINE, EMBASE, and Cochrane CENTRAL were searched up to August 29, 2020 for studies reporting pharmacologic thromboprophylaxis and thrombosis or bleeding. Pooled event rates were calculated using a random-effects model. RESULTS Thirty-five observational studies were included. The pooled incidence rates of total venous thromboembolism (N = 4,685) were: no prophylaxis 41.9% (95% confidence interval [CI]: 28.1-57.2, I 2 = 76%), standard-dose prophylaxis 19.8% (95% CI: 13.2-28.6, I 2 = 95%), intermediate-dose prophylaxis 11.9% (95% CI: 4.3-28.6, I 2 = 91%), and therapeutic-dose anticoagulants 10.5% (95% CI: 4.2-23.8, I 2 = 82%, p = 0.003). The pooled incidence rates of arterial thrombosis (N = 1,464) were: no prophylaxis 11.3% (95% CI: 5.2-23.0, I 2 = 0%), standard-dose prophylaxis 2.5% (95% CI: 1.4-4.3, I 2 = 45%), intermediate-dose prophylaxis 2.1% (95% CI: 0.5-7.7, I 2 = 45%), and therapeutic-dose anticoagulants 1.3% (95% CI: 0.2-8.8, I 2 = 0, p = 0.009). The pooled bleeding event rates (N = 6,393) were nonsignificantly higher in therapeutic-dose anticoagulants compared with standard-dose prophylaxis, (6.3 vs. 1.7%, p = 0.083). CONCLUSION Thrombosis rates were lower in hospitalized COVID-19 patients who received pharmacologic thromboprophylaxis. Thrombosis and bleeding rates for patients receiving intermediate-dose thromboprophylaxis or therapeutic anticoagulation were similar to those who received standard-dose pharmacologic thromboprophylaxis.
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Affiliation(s)
- Rushad Patell
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Thita Chiasakul
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
- Division of Hematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Ethan Bauer
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jeffrey I. Zwicker
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
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299
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Nadeem R, Thomas SJ, Fathima Z, Palathinkal AS, Alkilani YE, Dejan EA, Darwish IMI, Alsubousi AA, Backour AM, Kandeel H, Omar M, Kewan HFYT, Makhlof ME, Kotgire AB. Pattern of anticoagulation prescription for patients with Covid-19 acute respiratory distress syndrome admitted to ICU. Does it impact outcome? Heart Lung 2021; 50:1-5. [PMID: 33138975 PMCID: PMC7574696 DOI: 10.1016/j.hrtlng.2020.10.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 10/05/2020] [Accepted: 10/16/2020] [Indexed: 01/08/2023]
Abstract
Covid-19 has affected 16Millions people worldwide with 644 K death as of July 26th, 2020. It is associated with inflammation and microvascular thrombosis-anticoagulation in widely used in these patients especially in patients with elevated d-Dimers. The significance of anticoagulation in these patients is not yet established. We aim to define the anticoagulation pattern and its impact on outcomes (28-day survival, LOSICU, DVT, and PE and bleeding complications. We also observe if levels of d-Dimers affect the anticoagulation prescription. METHODS We analyzed data of all consecutive patients with Covid-19 ARDS admitted to ICU retrospectively. The primary variable of interest was anticoagulation. The daily dose of anticoagulant medication for each patient was recorded. Survival (28-day survival), Length of stay in ICU (LOSICU), the occurrence of DVT, PE, or bleeding were primary outcome variables. We also recorded confounding factors with potential impact on clinical outcomes. We assign Patients to one of the four groups based on anticoagulant dosing during the ICU (increasing dose, decreasing dose, increase followed by a decrease, multiple changes). We analyze the effect of different anticoagulation dosing strategies on 28-day survival, LOSICU, the occurrence of DVT, PE, and bleeding. We also observe if levels of d-Dimers affect the anticoagulation prescription. RESULTS The sample includes 149 patients. The most frequently used medication was subcutaneous Enoxaparin (85.2%). The Enoxaparin mean dose per day for the whole sample was 49.5 mg + 15.7 (mean + SD). There was no significant difference in doses of anticoagulants between survivors and nonsurvivors (62.8 mg + 21.7 mg vs. 61.2 mg + 25.7 mg, p 0.3). Multinomial regression showed no difference in 28-day survival among four-dose modification (increasing dose, decreasing dose, increase followed by a decrease, multiple changes). Logistic regression showed that BMI, d-Dimers, platelets, and the use of mechanical ventilation predict 28-day survival. Kaplan-Meier Survival plots for 4 anticoagulant groups showed no survival advantage for any anticoagulant strategy. Secondary outcome analysis showed that d-dimer levels significantly affect anticoagulants doses. CONCLUSION Prescription of anticoagulation is quite variable in patients admitted to ICU for Covid-19 associated ARDS. Anticoagulation dosing strategy has no significant effect on 28-day survival, LOSICU, the occurrence of DVT, PE, or bleeding.
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Affiliation(s)
- Rashid Nadeem
- Dubai Hospital, P. O. Box 7272, Al Baraha, Dubai, UAE.
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300
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Yamakawa K, Yamamoto R, Ishimaru G, Hashimoto H, Terayama T, Hara Y, Hasegawa D, Ishihara T, Imura H, Okano H, Narita C, Mayumi T, Yasuda H, Yamada K, Yamada H, Kawasaki T, Shime N, Doi K, Egi M, Ogura H, Aihara M, Tanaka H, Nishida O. Japanese rapid/living recommendations on drug management for COVID-19. Acute Med Surg 2021; 8:e664. [PMID: 34178358 PMCID: PMC8209876 DOI: 10.1002/ams2.664] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The coronavirus disease (COVID-19) has spread worldwide since early 2020, and there are still no signs of resolution. The Japanese Clinical Practice Guidelines for the Management of Sepsis and Septic Shock (J-SSCG) 2020 Special Committee created the Japanese rapid/living recommendations on drug management for COVID-19 using the experience of creating the J-SSCGs. The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach was used to determine the certainty of the evidence and strength of the recommendations. The first edition of this guideline was released on 9 September, 2020, and this document is the revised edition (version 3.1) (released 30 March, 2021). Clinical questions (CQs) were set for the following seven drugs: favipiravir (CQ1), remdesivir (CQ2), hydroxychloroquine (CQ3), corticosteroids (CQ4), tocilizumab (CQ5), ciclesonide (CQ6), and anticoagulants (CQ7). Favipiravir is recommended for patients with mild COVID-19 not requiring supplemental oxygen (GRADE 2C); remdesivir for moderate COVID-19 patients requiring supplemental oxygen/hospitalization (GRADE 2B). Hydroxychloroquine is not recommended for all COVID-19 patients (GRADE 1B). Corticosteroids are recommended for moderate COVID-19 patients requiring supplemental oxygen/hospitalization (GRADE 1B) and severe COVID-19 patients requiring ventilator management/intensive care (GRADE 1A); however, their use is not recommended for mild COVID-19 patients not requiring supplemental oxygen (GRADE 1B). Tocilizumab is recommended for moderate COVID-19 patients requiring supplemental oxygen/hospitalization (GRADE 2B). Anticoagulant therapy is recommended for moderate COVID-19 patients requiring supplemental oxygen/hospitalization and severe COVID-19 patients requiring ventilator management/intensive care (GRADE 2C). We hope that these clinical practice guidelines will aid medical professionals involved in the care of COVID-19 patients.
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Affiliation(s)
- Kazuma Yamakawa
- Department of Emergency MedicineOsaka Medical and Pharmaceutical UniversityTakatsukiJapan
| | - Ryo Yamamoto
- Department of Emergency and Critical Care MedicineKeio University School of MedicineTokyoJapan
| | - Go Ishimaru
- Department of General Internal MedicineSoka Municipal HospitalSokaJapan
| | - Hideki Hashimoto
- Department of Infectious DiseasesThe University of Tokyo HospitalTokyoJapan
| | - Takero Terayama
- Department of PsychiatrySchool of MedicineNational Defense Medical CollegeTokorozawaJapan
| | - Yoshitaka Hara
- Department of Anesthesiology and Critical Care MedicineFujita Health University School of MedicineToyoakeJapan
| | - Daisuke Hasegawa
- Department of Anesthesiology and Critical Care MedicineFujita Health University School of MedicineToyoakeJapan
| | - Tadashi Ishihara
- Department of Emergency and Critical Care MedicineJuntendo University Urayasu HospitalUrayasuJapan
| | - Haruki Imura
- Department of Infectious DiseasesRakuwakai Otowa Hospital/Department of Health InformaticsSchool of Public HealthKyoto UniversityKyotoJapan
| | - Hiromu Okano
- Department of Critical Care and Emergency MedicineNational Hospital Organization Yokohama Medical CenterKanagawaJapan
| | - Chihiro Narita
- Department of Emergency Medicine and Intensive Care MedicineShizuoka General HospitalShizuokaJapan
| | - Takuya Mayumi
- Department of Cardiovascular MedicineGraduate School of Medical ScienceKanazawa UniversityKanazawaJapan
| | - Hideto Yasuda
- Department of Emergency and Critical Care MedicineJichi Medical University Saitama Medical CenterSaitamaJapan
| | - Kohei Yamada
- Department of Traumatology and Critical Care MedicineNational Defense Medical CollegeTokorozawaJapan
| | - Hiroyuki Yamada
- Department of Primary Care and Emergency MedicineKyoto University HospitalKyotoJapan
| | - Tatsuya Kawasaki
- Department of Pediatric Critical CareShizuoka Children’s HospitalShizuokaJapan
| | - Nobuaki Shime
- Department of Emergency and Critical Care MedicineGraduate School of Biomedical and Health SciencesHiroshima UniversityHiroshimaJapan
| | - Kent Doi
- Department of Acute MedicineThe University of TokyoTokyoJapan
| | - Moritoki Egi
- Division of AnesthesiologyDepartment of Surgery RelatedKobe University Graduate School of MedicineKobeJapan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical MedicineOsaka University Medical SchoolSuitaJapan
| | - Morio Aihara
- Department of Gastroenterology and HematologyGraduate School of Medicine of Hirosaki UniversityHirosakiJapan
| | - Hiroshi Tanaka
- Department of Emergency and Critical Care MedicineJuntendo University Urayasu HospitalUrayasuJapan
| | - Osamu Nishida
- Department of Anesthesiology and Critical Care MedicineFujita Health University School of MedicineToyoakeJapan
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