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Reis S, Faske A, Monsef I, Langer F, Müller OJ, Kranke P, Meybohm P, Weibel S. Anticoagulation in COVID-19 patients - An updated systematic review and meta-analysis. Thromb Res 2024; 238:141-150. [PMID: 38718472 DOI: 10.1016/j.thromres.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 04/08/2024] [Accepted: 04/10/2024] [Indexed: 05/21/2024]
Abstract
BACKGROUND Thromboembolic events are common complications of COVID-19. Clinical study results on safety and efficacy of anticoagulation in COVID-19 are controversial. MATERIAL AND METHODS This report is the second update of our systematic review with meta-analysis on randomized controlled trials (RCTs) comparing standard thromboprophylaxis, intermediate or therapeutic dose anticoagulation or no anticoagulation in COVID-19 in- and outpatients. We searched eligible studies up to 5 October 2023. Certainty of evidence was assessed using GRADE. RESULTS For this update we included fourteen new RCTs and a total of 27 RCTs with 16,789 patients. Certainty of evidence ranged from very low to high depending on outcome and comparison. Standard thromboprophylaxis with low dose anticoagulation may have little or no effect for COVID-19 outpatients compared to no anticoagulation. In inpatients with moderate or severe COVID-19, intermediate dose anticoagulation may decrease any thrombotic events or death, but may increase major bleeding compared to standard thromboprophylaxis. Therapeutic dose anticoagulation decreases thrombotic events or deaths in inpatients with moderate COVID-19, but probably has little or no effect in patients with severe COVID-19 compared to standard thromboprophylaxis with low or intermediate dose anticoagulation. With therapeutic dose anticoagulation, the risk of major bleeding probably increases regardless of COVID-19 severity. We are uncertain on the effect of thromboprophylaxis with low dose anticoagulation compared to no anticoagulation in the post-discharge setting. CONCLUSIONS Hospitalized, moderately-ill COVID-19 patients may benefit from intermediate or therapeutic dose anticoagulation, while critically ill patients may not. Risk of major bleeding must be considered.
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Affiliation(s)
- Stefanie Reis
- University Hospital Würzburg, Department for Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Würzburg, Germany
| | - Amon Faske
- University Hospital Würzburg, Department for Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Würzburg, Germany
| | - Ina Monsef
- Cochrane Haematology, Institute of Population Health, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Florian Langer
- II. Medical Clinic and Polyclinic, University Medical Center Eppendorf, Hamburg, Germany
| | - Oliver J Müller
- Dept. of Internal Medicine V, University Hospital Schleswig-Holstein, German Centre for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Kiel, Germany
| | - Peter Kranke
- University Hospital Würzburg, Department for Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Würzburg, Germany
| | - Patrick Meybohm
- University Hospital Würzburg, Department for Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Würzburg, Germany
| | - Stephanie Weibel
- University Hospital Würzburg, Department for Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Würzburg, Germany.
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2
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Schulman S, Arnold DM, Bradbury CA, Broxmeyer L, Connors JM, Falanga A, Iba T, Kaatz S, Levy JH, Middeldorp S, Minichiello T, Nazy I, Ramacciotti E, Resnick HE, Samama CM, Sholzberg M, Thachil J, Zarychanski R, Spyropoulos AC. 2023 ISTH update of the 2022 ISTH guidelines for antithrombotic treatment in COVID-19. J Thromb Haemost 2024; 22:1779-1797. [PMID: 38503600 DOI: 10.1016/j.jtha.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 01/31/2024] [Accepted: 02/13/2024] [Indexed: 03/21/2024]
Abstract
Based on emerging evidence from the COVID-19 pandemic, the International Society on Thrombosis and Haemostasis (ISTH) guidelines for antithrombotic treatment in COVID-19 were published in 2022. Since then, at least 16 new randomized controlled trials have contributed additional evidence, which necessitated a modification of most of the previous recommendations. We used again the American College of Cardiology Foundation/American Heart Association methodology for assessment of level of evidence (LOE) and class of recommendation (COR). Five recommendations had the LOE upgraded to A and 2 new recommendations on antithrombotic treatment for patients with COVID-19 were added. Furthermore, a section was added to answer questions about COVID-19 vaccination and vaccine-induced immune thrombotic thrombocytopenia (VITT), for which studies have provided some evidence. We only included recommendations with LOE A or B. Panelists agreed on 19 recommendations, 4 for nonhospitalized, 5 for noncritically ill hospitalized, 3 for critically ill hospitalized, and 2 for postdischarge patients, as well as 5 for vaccination and VITT. A strong recommendation (COR 1) was given for (a) use of prophylactic dose of low-molecular-weight heparin or unfractionated heparin in noncritically ill patients hospitalized for COVID-19, (b) for select patients in this group, use of therapeutic-dose low-molecular-weight heparin/unfractionated heparin in preference to prophylactic dose, and (c) for use of antiplatelet factor 4 enzyme immunoassays for diagnosing VITT. A strong recommendation was given against (COR 3) the addition of an antiplatelet agent in hospitalized, noncritically ill patients. These international guidelines provide recommendations for countries with diverse healthcare resources and COVID-19 vaccine availability.
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Affiliation(s)
- Sam Schulman
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Obstetrics and Gynecology and Perinatal Medicine, I.M. Sechenov First Moscow State Medical University, Moscow, Russia.
| | - Donald M Arnold
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | | | - Lisa Broxmeyer
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Jean Marie Connors
- Division of Hematology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Anna Falanga
- Department of Transfusion Medicine and Hematology, Hospital Papa Giovanni XXIII, Bergamo, Italy; University of Milan Bicocca, Monza, Italy
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University, Tokyo, Japan
| | - Scott Kaatz
- Division of Hospital Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Jerrold H Levy
- Departments of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, North Carolina, USA
| | - Saskia Middeldorp
- Department of Internal Medicine and Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Tracy Minichiello
- Division of Hematology, San Francisco VA Medical Center, University of California, San Francisco, San Francisco, California, USA
| | - Ishac Nazy
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Eduardo Ramacciotti
- Science Valley Research Institute, São Paulo, Brazil; Hospital e Maternidade Christóvão da Gama, Grupo Leforte, Santo André, São Paulo, Brazil
| | | | - Charles Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, Groupe Hospitalo-Universitaire, Assistance Publique-Hôpitaux de Paris Centre -Université Paris Cité, Cochin Hospital, Paris, France
| | - Michelle Sholzberg
- Departments of Medicine and Laboratory Medicine and Pathobiology, St Michael's Hospital, Li Ka Shing Knowledge Institute, University of Toronto, Toronto, Ontario, Canada
| | - Jecko Thachil
- Department of Haematology, Manchester University Hospitals, Manchester, United Kingdom
| | - Ryan Zarychanski
- Sections of Hematology/Oncology and Critical Care, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alex C Spyropoulos
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA; Institute of Health System Science, Feinstein Institutes for Medical Research, Manhasset, New York, USA
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3
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Chen X, Zhang S, Liu H, Zhang Q, Chen J, Zheng Q, Guo N, Cai Y, Luo Q, Xu Q, Yang S, Chen X. Effect of anticoagulation on the incidence of venous thromboembolism, major bleeding, and mortality among hospitalized COVID-19 patients: an updated meta-analysis. Front Cardiovasc Med 2024; 11:1381408. [PMID: 38646150 PMCID: PMC11026614 DOI: 10.3389/fcvm.2024.1381408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 03/26/2024] [Indexed: 04/23/2024] Open
Abstract
Objective Anticoagulation is crucial for patients hospitalized with coronavirus disease 2019 (COVID-19) due to the high risk of venous thromboembolism (VTE). However, the optimal anticoagulation regimen needs further exploration. Therefore, we evaluated the efficacy and safety of diverse anticoagulation dosage dosages for COVID-19. Methods An updated meta-analysis was performed to assess the effect of thromboprophylaxis (standard, intermediate, and therapeutic dose) on the incidence of VTE, mortality and major bleeding among COVID-19 patients. Literature was searched via PubMed, EMBASE, Web of Science, and China National Knowledge Infrastructure (CNKI) database. The odds ratio (OR) and 95% confidence interval (CI) were calculated for effect estimates. Results Nineteen studies involving 25,289 participants without VTE history were included. The mean age of patients was 59.3 years old. About 50.96% were admitted to the intensive care unit. In the pooled analysis, both therapeutic-dose and intermediate-dose anticoagulation did not have a significant advantage in reducing VTE risk over standard dosage (OR = 1.09, 95% CI: 0.58-2.02, and OR = 0.89, 95% CI: 0.70-1.12, respectively). Similarly, all-cause mortality was not further decreased in either therapeutic-dose group (OR = 1.12, 95% CI: 0.75-1.67) or intermediate-dose group (OR = 1.34, 95% CI: 0.83-2.17). While the major bleeding risk was significantly elevated in the therapeutic-dose group (OR = 2.59, 95%CI: 1.87-3.57) as compared with the standard-dose regimen. Compared with intermediate dosage, therapeutic anticoagulation did not reduce consequent VTE risk (OR = 0.85, 95% CI: 0.52-1.38) and all-cause mortality (OR = 0.84, 95% CI: 0.60-1.17), but significantly increased major bleeding rate (OR = 2.42, 95% CI: 1.58-3.70). In subgroup analysis of patients older than 65 years, therapeutic anticoagulation significantly lowered the incidence of VTE in comparation comparison with standard thromboprophylaxis, however, at the cost of elevated risk of major bleeding. Conclusion Our results indicated that for most hospitalized patients with COVID-19, standard-dose prophylactic anticoagulation might be the optimal choice. For elderly patients at low risk of bleeding, therapeutic-dose anticoagulation could further reduce VTE risk and should be considered especially when there were other strong risk factors of VTE during hospital stay. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO, identifier, CRD42023388429.
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Affiliation(s)
- Xinwang Chen
- Department of Pulmonary and Critical Care Medicine, Fujian Medical University Union Hospital, Fuzhou, China
| | - Suyun Zhang
- Department of Internal Medicine, Fujian Medical University Union Hospital, Fuzhou, China
| | - Haiyu Liu
- Department of Pulmonary and Critical Care Medicine, Fujian Medical University Union Hospital, Fuzhou, China
| | - Qianyuan Zhang
- Department of General Medicine, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jinghan Chen
- Department of Oncology Medicine, Fujian Medical University Union Hospital, Fuzhou, China
| | - Qixian Zheng
- Department of Pulmonary and Critical Care Medicine, Fujian Medical University Union Hospital, Fuzhou, China
| | - Ningjing Guo
- Department of Oncology Medicine, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yuanyuan Cai
- Department of General Medicine, Fujian Medical University Union Hospital, Fuzhou, China
| | - Qiong Luo
- Department of Oncology Medicine, Fujian Medical University Union Hospital, Fuzhou, China
| | - Qian Xu
- Department of Oncology Medicine, Fujian Medical University Union Hospital, Fuzhou, China
| | - Sheng Yang
- Department of Oncology Medicine, Fujian Medical University Union Hospital, Fuzhou, China
- Fujian Key Laboratory of Translational Research in Cancer and Neurodegenerative Diseases, Fuzhou, China
| | - Xiangqi Chen
- Department of Pulmonary and Critical Care Medicine, Fujian Medical University Union Hospital, Fuzhou, China
- Fujian Key Laboratory of Translational Research in Cancer and Neurodegenerative Diseases, Fuzhou, China
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4
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Ortega-Paz L, Talasaz AH, Sadeghipour P, Potpara TS, Aronow HD, Jara-Palomares L, Sholzberg M, Angiolillo DJ, Lip GYH, Bikdeli B. COVID-19-Associated Pulmonary Embolism: Review of the Pathophysiology, Epidemiology, Prevention, Diagnosis, and Treatment. Semin Thromb Hemost 2023; 49:816-832. [PMID: 36223804 DOI: 10.1055/s-0042-1757634] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
COVID-19 is associated with endothelial activation in the setting of a potent inflammatory reaction and a hypercoagulable state. The end result of this thromboinflammatory state is an excess in thrombotic events, in particular venous thromboembolism. Pulmonary embolism (PE) has been of special interest in patients with COVID-19 given its association with respiratory deterioration, increased risk of intensive care unit admission, and prolonged hospital stay. The pathophysiology and clinical characteristics of COVID-19-associated PE may differ from the conventional non-COVID-19-associated PE. In addition to embolic events from deep vein thrombi, in situ pulmonary thrombosis, particularly in smaller vascular beds, may be relevant in patients with COVID-19. Appropriate prevention of thrombotic events in COVID-19 has therefore become of critical interest. Several changes in viral biology, vaccination, and treatment management during the pandemic may have resulted in changes in incidence trends. This review provides an overview of the pathophysiology, epidemiology, clinical characteristics, and risk factors of COVID-19-associated PE. Furthermore, we briefly summarize the results from randomized controlled trials of preventive antithrombotic therapies in COVID-19, focusing on their findings related to PE. We discuss the acute treatment of COVID-19-associated PE, which is substantially similar to the management of conventional non-COVID-19 PE. Ultimately, we comment on the current knowledge gaps in the evidence and the future directions in the treatment and follow-up of COVID-19-associated PE, including long-term management, and its possible association with long-COVID.
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Affiliation(s)
- Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida
| | - Azita H Talasaz
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Parham Sadeghipour
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Clinical Trial Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Tatjana S Potpara
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Intensive Arrhythmia Care, Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia
| | - Herbert D Aronow
- Department of Cardiology, Warren Alpert Medical School of Brown University, Providence, Rhode Island
- Department of Cardiology, Henry Ford Health, Detroit, Michigan
| | - Luis Jara-Palomares
- Respiratory Unit, Hospital Universitario Virgen del Rocio, Sevilla, Spain
- Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias (CIBERES), Carlos III Health Institute, Madrid, Spain
| | - Michelle Sholzberg
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Behnood Bikdeli
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Yale/YNHH Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut
- Cardiovascular Research Foundation (CRF), New York, New York
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5
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Milano V, Hurt J, Nielsen ND. The standard of care is standard for a reason: Commentary on "Optimal dosing of heparin for prophylactic anticoagulation in critically ill COVID-19 patients: A systematic review and Meta-analysis of randomized clinical trials". J Crit Care 2023; 77:154345. [PMID: 37244208 PMCID: PMC10209671 DOI: 10.1016/j.jcrc.2023.154345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 05/17/2023] [Indexed: 05/29/2023]
Affiliation(s)
- Victoria Milano
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Jacob Hurt
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Nathan D Nielsen
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA; Section of Transfusion Medicine and Therapeutic Pathology, Department of Pathology, University of New Mexico School of Medicine, Albuquerque, NM, USA.
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6
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Batista DR, Floriano I, Silvinato A, Bacha HA, Barbosa AN, Tanni SE, Bernardo WM. Use of anticoagulants in patients with COVID-19: an update of a living systematic review and meta-analysis. J Bras Pneumol 2023; 49:e20230095. [PMID: 37283403 PMCID: PMC10578923 DOI: 10.36416/1806-3756/e20230095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023] Open
Affiliation(s)
- Diane R Batista
- . Disciplina de Pneumologia, Departamento de Clínica Médica, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista - UNESP - Botucatu (SP) Brasil
| | - Idevaldo Floriano
- . Medicina Baseada em Evidências, Associação Médica Brasileira, São Paulo (SP) Brasil
| | - Antonio Silvinato
- . Medicina Baseada em Evidências, Cooperativa Baixa Mogiana, Mogi-Guaçu (SP) Brasil
| | - Hélio A Bacha
- . Hospital Israelita Albert Einstein, São Paulo (SP) Brasil
| | | | - Suzana E Tanni
- . Disciplina de Pneumologia, Departamento de Clínica Médica, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista - UNESP - Botucatu (SP) Brasil
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7
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Bonfim LCMG, Guerini IS, Zambon MG, Pires GB, Silva ACF, Gobatto ALN, Lopes MA, Brosnahan SB. Optimal dosing of heparin for prophylactic anticoagulation in critically ill COVID-19 patients a systematic review and meta-analysis of randomized controlled trials. J Crit Care 2023; 77:154344. [PMID: 37244209 PMCID: PMC10211463 DOI: 10.1016/j.jcrc.2023.154344] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 04/10/2023] [Accepted: 04/11/2023] [Indexed: 05/29/2023]
Abstract
PURPOSE The optimal amount of anticoagulation for critically ill COVID-19 patients is controversial. Therefore, we aimed to evaluate the efficacy and safety of escalated doses of anticoagulation in critically ill patients with severe COVID-19. MATERIALS AND METHODS We conducted a systematic search of three major databases, including PubMed, Cochrane Library, and Embase, from inception to May 2022. Randomized controlled trials (RCTs) were included comparing therapeutic or intermediate doses to standard prophylactic doses of anticoagulants in critically ill COVID-19 patients, with heparins as the only anticoagulation therapy considered. RESULTS Out of the six RCTs, 2130 patients were administered escalated dose anticoagulation (50.2%) and standard thromboprophylaxis therapy (49.8%). The escalated dose showed no significant impact on mortality (RR, 1.01; 95% CI, 0.90-1.13). Although there was no significant difference in DVT (RR, 0.81; 95% CI, 0.61-1.08), the risk of PE was significantly reduced in patients receiving escalated dose anticoagulation (RR, 0.35; 95% CI, 0.21-0.60), with an increased risk of bleeding events (RR, 1.65; 95% CI, 1.08-2.53). CONCLUSION This systematic review and meta-analysis fail to support escalated anticoagulation doses to reduce mortality in critically ill COVID-19 patients. However, higher doses of anticoagulants appear to reduce thrombotic events while increasing the risk of bleeding effectively.
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Affiliation(s)
- Luana C M G Bonfim
- Department of Medicine, University of South Santa Catarina, Florianópolis, SC, Brazil.
| | - Isadora S Guerini
- Department of Medicine, State University of Western Paraná, Francisco Beltrão, PR, Brazil
| | - Marjorie G Zambon
- Department of Medicine, Mackenzie Evangelical University Hospital, Curitiba, PR, Brazil
| | - Gabriela B Pires
- Department of Medicine, School of Medicine Souza Marques, Rio de Janeiro, RJ, Brazil
| | - Amanda C F Silva
- Department of Medicine, Federal University of Santa Catarina, Florianópolis, SC, Brazil
| | - André L N Gobatto
- Department of Critical Care, São Rafael Hospital, Salvador, Bahia, Brazil; Department of Critical Care, Hospital da Cidade, Salvador, Bahia, Brazil
| | - Marcela A Lopes
- Department of Critical Care, Hospital da Cidade, Salvador, Bahia, Brazil
| | - Shari B Brosnahan
- Department of Pulmonary and Critical Care, New York University School of Medicine, New York, NY, USA
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8
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Koulas I, Goldin M, Schulman S, Spyropoulos AC. Antithrombotic therapy in the management of hospitalised patients with COVID-19. Br J Hosp Med (Lond) 2023; 84:1-11. [PMID: 37235671 DOI: 10.12968/hmed.2022.0519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Hospitalised patients with coronavirus disease 2019 (COVID-19) are at a significantly higher risk of having thromboembolic events while in hospital and in the immediate post-hospital discharge period. Based on early data from observational studies, multiple high quality randomised controlled trials have been conducted worldwide to evaluate optimal thromboprophylaxis regimens to reduce thromboembolism and other COVID-19-related adverse outcomes in hospitalised patients. The International Society on Thrombosis and Haemostasis has published evidence-based guideline recommendations using established methodology for the management of antithrombotic therapy of COVID-19 patients, both in-hospital and in the immediate post-hospital discharge period. A good clinical practice statement supplemented these guidelines based on topics for which there was no or limited high-quality evidence. This review summarises the main recommendations of these documents to serve as a quick access tool for hospital doctors to use in their everyday practice when treating COVID-19 patients.
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Affiliation(s)
- Ioannis Koulas
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Mark Goldin
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Sam Schulman
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
| | - Alex C Spyropoulos
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, NY, USA
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9
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Abdulaziz-Opiela G, Sobieraj A, Sibrecht G, Bajdor J, Mroziński B, Kozłowska Z, Iciek R, Wróblewska-Seniuk K, Wender-Ożegowska E, Szczapa T. Prenatal and Neonatal Pulmonary Thrombosis as a Potential Complication of SARS-CoV-2 Infection in Late Pregnancy. Int J Mol Sci 2023; 24:ijms24087629. [PMID: 37108791 PMCID: PMC10146603 DOI: 10.3390/ijms24087629] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 04/18/2023] [Accepted: 04/19/2023] [Indexed: 04/29/2023] Open
Abstract
Neonatal venous thrombosis is a rare condition that can be iatrogenic or occur due to viral infections or genetic mutations. Thromboembolic complications are also commonly observed as a result of SARS-CoV-2 infections. They can affect pediatric patients, especially the ones suffering from multisystem inflammatory syndrome in children (MIS-C) or multisystem inflammatory syndrome in neonates (MIS-N). The question remains whether the maternal SARS-CoV-2 infection during pregnancy can lead to thromboembolic complications in fetuses and neonates. We report on a patient born with an embolism in the arterial duct, left pulmonary artery, and pulmonary trunk, who presented several characteristic features of MIS-N, suspecting that the cause might have been the maternal SARS-CoV2 infection in late pregnancy. Multiple genetic and laboratory tests were performed. The neonate presented only with a positive result of IgG antibodies against SARS-CoV-2. He was treated with low molecular weight heparin. Subsequent echocardiographic tests showed that the embolism dissolved. More research is necessary to evaluate the possible neonatal complications of maternal SARS-CoV-2 infection.
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Affiliation(s)
| | - Anna Sobieraj
- Faculty of Medicine, Poznan University of Medical Sciences, 61-701 Poznan, Poland
| | - Greta Sibrecht
- II Department of Neonatology, Poznan University of Medical Sciences, 61-701 Poznan, Poland
| | - Julia Bajdor
- Department of Radiology, Nicolaus Copernicus Hospital, 80-803 Gdansk, Poland
| | - Bartłomiej Mroziński
- Department of Pediatric Cardiology, Poznan University of Medical Sciences, 61-701 Poznan, Poland
| | - Zuzanna Kozłowska
- II Department of Neonatology, Poznan University of Medical Sciences, 61-701 Poznan, Poland
| | - Rafał Iciek
- Department of Reproduction, Poznan University of Medical Sciences, 61-701 Poznan, Poland
| | | | - Ewa Wender-Ożegowska
- Department of Reproduction, Poznan University of Medical Sciences, 61-701 Poznan, Poland
| | - Tomasz Szczapa
- II Department of Neonatology, Poznan University of Medical Sciences, 61-701 Poznan, Poland
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10
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Pantet O, Combescure C, Ltaief Z, Mazzolai L, Jeanneret S, Manzocchi-Besson S, Stricker H, Cereghetti S, Pugin J, Calmy A, Marti C, Robert-Ebadi H, Fontana P, Righini M, Casini A, Blondon M. Effect of therapeutic anticoagulation on gas exchange in mechanically ventilated COVID-19 patients: A secondary analysis of the COVID-HEP trial. Thromb Res 2023; 224:13-16. [PMID: 36801649 PMCID: PMC9911973 DOI: 10.1016/j.thromres.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/18/2023] [Accepted: 02/03/2023] [Indexed: 02/12/2023]
Affiliation(s)
- Olivier Pantet
- Division of Intensive Care, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | | | - Zied Ltaief
- Division of Intensive Care, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Lucia Mazzolai
- Division of Angiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | | | | | - Hans Stricker
- Division of Angiology, Locarno Regional Hospital, Locarno, Switzerland
| | - Sara Cereghetti
- Division of Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Jérôme Pugin
- Division of Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Alexandra Calmy
- HIV/AIDS Unit, Division of Infectious Disease, Geneva University Hospitals, Geneva, Switzerland
| | - Christophe Marti
- Division of General Internal Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Geneva University Hospitals, Geneva, Switzerland
| | - Pierre Fontana
- Division of Angiology and Hemostasis, Geneva University Hospitals, Geneva, Switzerland
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals, Geneva, Switzerland
| | - Alessandro Casini
- Division of Angiology and Hemostasis, Geneva University Hospitals, Geneva, Switzerland
| | - Marc Blondon
- Division of Angiology and Hemostasis, Geneva University Hospitals, Geneva, Switzerland.
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Labbé V, Contou D, Heming N, Megarbane B, Razazi K, Boissier F, Ait-Oufella H, Turpin M, Carreira S, Robert A, Monchi M, Souweine B, Preau S, Doyen D, Vivier E, Zucman N, Dres M, Fejjal M, Noel-Savina E, Bachir M, Jaffal K, Timsit JF, Picos SA, Mariotte E, Martis N, Juguet W, Melica G, Rondeau P, Audureau E, Mekontso Dessap A. Effects of Standard-Dose Prophylactic, High-Dose Prophylactic, and Therapeutic Anticoagulation in Patients With Hypoxemic COVID-19 Pneumonia: The ANTICOVID Randomized Clinical Trial. JAMA Intern Med 2023:2802821. [PMID: 36946232 PMCID: PMC10034664 DOI: 10.1001/jamainternmed.2023.0456] [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: 03/23/2023]
Abstract
Importance Given the high risk of thrombosis and anticoagulation-related bleeding in patients with hypoxemic COVID-19 pneumonia, identifying the lowest effective dose of anticoagulation therapy for these patients is imperative. Objectives To determine whether therapeutic anticoagulation (TA) or high-dose prophylactic anticoagulation (HD-PA) decreases mortality and/or disease duration compared with standard-dose prophylactic anticoagulation (SD-PA), and whether TA outperforms HD-PA; and to compare the net clinical outcomes among the 3 strategies. Design, Settings, and Participants The ANTICOVID randomized clinical open-label trial included patients with hypoxemic COVID-19 pneumonia requiring supplemental oxygen and having no initial thrombosis on chest computer tomography with pulmonary angiogram at 23 health centers in France from April 14 to December 13, 2021. Of 339 patients randomized, 334 were included in the primary analysis-114 patients in the SD-PA group, 110 in the HD-PA, and 110 in the TA. At randomization, 90% of the patients were in the intensive care unit. Data analyses were performed from April 13, 2022, to January 3, 2023. Interventions Patients were randomly assigned (1:1:1) to receive either SD-PA, HD-PA, or TA with low-molecular-weight or unfractionated heparin for 14 days. Main Outcomes and Measures A hierarchical criterion of all-cause mortality followed by time to clinical improvement at day 28. Main secondary outcome was net clinical outcome at day 28 (composite of thrombosis, major bleeding, and all-cause death). Results Among the study population of 334 individuals (mean [SD] age, 58.3 [13.0] years; 226 [67.7%] men and 108 [32.3%] women), use of HD-PA and SD-PA had similar probabilities of favorable outcome (47.3% [95% CI, 39.9% to 54.8%] vs 52.7% [95% CI, 45.2% to 60.1%]; P = .48), as did TA compared with SD-PA (50.9% [95% CI, 43.4% to 58.3%] vs 49.1% [95% CI, 41.7% to 56.6%]; P = .82) and TA compared with HD-PA (53.5% [95% CI 45.8% to 60.9%] vs 46.5% [95% CI, 39.1% to 54.2%]; P = .37). Net clinical outcome was met in 29.8% of patients receiving SD-PA (20.2% thrombosis, 2.6% bleeding, 14.0% death), 16.4% receiving HD-PA (5.5% thrombosis, 3.6% bleeding, 11.8% death), and 20.0% receiving TA (5.5% thrombosis, 3.6% bleeding, 12.7% death). Moreover, HD-PA and TA use significantly reduced thrombosis compared with SD-PA (absolute difference, -14.7 [95% CI -6.2 to -23.2] and -14.7 [95% CI -6.2 to -23.2], respectively). Use of HD-PA significantly reduced net clinical outcome compared with SD-PA (absolute difference, -13.5; 95% CI -2.6 to -24.3). Conclusions and Relevance This randomized clinical trial found that compared with SD-PA, neither HD-PA nor TA use improved the primary hierarchical outcome of all-cause mortality or time to clinical improvement in patients with hypoxemic COVID-19 pneumonia; however, HD-PA resulted in significantly better net clinical outcome by decreasing the risk of de novo thrombosis. Trial Registration ClinicalTrials.gov Identifier: NCT04808882.
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Affiliation(s)
- Vincent Labbé
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire Tenon, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
- Service des Soins Intensifs, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Bruxelles, Belgium
- Université Paris Est Créteil, Institut Mondor de Recherche Biomédicale, Groupe de Recherche Clinique CARMAS (Cardiovascular and Respiratory Manifestations of Acute lung injury and Sepsis), Créteil, France
| | - Damien Contou
- Service de Réanimation Polyvalente, Centre Hospitalier Victor Dupouy, Argenteuil, France
| | - Nicholas Heming
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire Raymond Poincaré, Assistance Publique-Hôpitaux de Paris, Université Versailles Saint Quentin-Université Paris Saclay, Garches, France
- Laboratoire d'infection et inflammation, Unité 1173, Faculté de Médecine Simone Veil, Institut national de la santé et de la recherche médicale, Université Versailles Saint Quentin - Université Paris Saclay, Garches, France
| | - Bruno Megarbane
- Service de Réanimation Médicale et Toxicologique, Centre Hospitalier Universitaire Lariboisière, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
- Unité Mixte de Recherche en Santé 1144, Institut national de la santé et de la recherche médicale, Université Paris Cité, Paris, France
| | - Keyvan Razazi
- Université Paris Est Créteil, Institut Mondor de Recherche Biomédicale, Groupe de Recherche Clinique CARMAS (Cardiovascular and Respiratory Manifestations of Acute lung injury and Sepsis), Créteil, France
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris Est Créteil, Créteil, France
| | - Florence Boissier
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Poitiers, Université de Poitiers, Poitiers, France
- Centre d'Investigation Clinique 1402 (Investigations of Sleep, Acute Lung Injury, & Ventilation group), Institut national de la santé et de la recherche médicale, Université de Poitiers, Poitiers, France
| | - Hafid Ait-Oufella
- Service de Médecine Intensive Réanimation, Hôpital Saint Antoine, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Matthieu Turpin
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire Tenon, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Serge Carreira
- Service d'Anesthésie-Réanimation polyvalente, Hôpital Saint Camille, Bry-sur-Marne, France
| | - Alexandre Robert
- Service de Médecine Intensive Réanimation, Hôpital Simone Veil, Centre Hospitalier de Cannes, Cannes, France
- Centre Méditerranéen de Médecine Moléculaire, Institut national de la santé et de la recherche médicale, Université Côte d'Azur, Nice, France
| | - Mehran Monchi
- Service de Médecine Intensive Réanimation, Groupe Hospitalier Sud Ile de France, Melun, France
| | - Bertrand Souweine
- Service de Médecine Intensive Réanimation, Hôpital Universitaire Gabriel-Montpied, Clermont-Ferrand, France
| | - Sebastien Preau
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire Lille, Université de Lille, Lille, France
- Unité 1167, Institut Pasteur de Lille, Institut national de la santé et de la recherche médicale, Université de Lille, Lille, France
| | - Denis Doyen
- Service de Médecine Intensive Réanimation, Hôpital l'Archet 1, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, Nice, France
- Unité de Recherche Clinique Côte d'Azur, Université Côte d'Azur, Nice, France
| | - Emmanuel Vivier
- Service de Réanimation Polyvalente, Centre Hospitalier Saint Joseph-Saint Luc, Lyon, France
| | - Noémie Zucman
- Service de Médecine Intensive Réanimation, Departement Médico-Universitaire ESPRIT, Centre Hospitalier Universitaire Louis Mourier, Assistance Publique-Hôpitaux de Paris, Colombes, France
- Unité de Formation et de Recherche de Médecine, Université Paris Cité, Paris, France
| | - Martin Dres
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Mohamed Fejjal
- Service de Médecine Intensive Réanimation, Centre Hospitalier Léon Binet, Provins, France
| | - Elise Noel-Savina
- Service de Pneumologie et de Soins Intensifs Respiratoires, Hôpital Larrey, Toulouse, France
| | - Marwa Bachir
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier Universitaire Tenon, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Karim Jaffal
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier Universitaire Raymond Poincaré, Assistance Publique-Hôpitaux de Paris, Garches, France
| | - Jean-François Timsit
- Service de Médecine Intensive et Réanimation Infectieuse, Centre Hospitalier Universitaire Bichat, Assistance Publique-Hôpitaux de Paris, Université de Paris-Cité, Paris, France
- Infection, Anti-microbien, Modélisation, Evolution, Institut National de la Santé et de la Recherche Médicale, Unité 1137, Université de Paris-Cité, Paris, France
| | - Santiago Alberto Picos
- Service de Médecine Intensive Réanimation, Centre Hospitalier La Dracénie De Draguignan, Draguignan, France
| | - Eric Mariotte
- Service de Médecine Intensive-Réanimation, Centre Hospitalier Universitaire Saint-Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Nihal Martis
- Service de Médecine Interne, Hôpital l'Archet 1, Centre Hospitalier Universitaire de Nice, Nice, France
| | - William Juguet
- Service de Réanimation Médico-Chirurgicale, Centre Hospitalier Universitaire Avicenne, Assistance Publique-Hôpitaux de Paris, Université Sorbonne Paris Nord, Bobigny, France
| | - Giovanna Melica
- Service des Maladies Infectieuses et Tropicales, Hôpitaux Universitaires Henri-Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris Est Créteil, Créteil, France
| | - Paul Rondeau
- Service de Médecine Interne, Hôpital Saint Camille, Bry-sur-Marne, France
| | - Etienne Audureau
- Unité de Recherche Clinique Henri Mondor, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris Est Créteil, Créteil, France
- Institut Mondor de Recherche Biomédicale, Unité 955, Institut National de la Santé et de la Recherche Médicale, Université Paris Est Créteil, Créteil, France
| | - Armand Mekontso Dessap
- Université Paris Est Créteil, Institut Mondor de Recherche Biomédicale, Groupe de Recherche Clinique CARMAS (Cardiovascular and Respiratory Manifestations of Acute lung injury and Sepsis), Créteil, France
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris Est Créteil, Créteil, France
- Université Paris Est Créteil, Institut Mondor de recherche biomédicale, Institut national de la santé et de la recherche médicale, Créteil, France
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McCarthy MW. Montelukast as a potential treatment for COVID-19. Expert Opin Pharmacother 2023; 24:551-555. [PMID: 36927284 DOI: 10.1080/14656566.2023.2192866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
INTRODUCTION Montelukast is a leukotriene inhibitor that is widely used to treat chronic asthma and allergic rhinitis. The drug interferes with molecular signaling pathways produced by leukotrienes in a variety of cells and tissues throughout the human body that lead to tightening of airway muscles, production of aberrant pulmonary fluid (airway edema), and in some cases, pulmonary inflammation. AREAS COVERED Montelukast has also been noted to have anti-inflammatory properties, suggesting it may have a role in the treatment of coronavirus disease 2019 (COVID-19), the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which has been noted to induce misfiring of the immune system in some patients. A literature search of PubMed was performed to identify all relevant studies of montelukast and SARS-CoV-2 through 27 January 2023. EXPERT OPINION Montelukast has been the subject of small studies of SARS-CoV-2 and will be included in a large, randomized, double-blind, placebo-controlled study of outpatients with COVID-19 sponsored by the United States National Institutes of Health known as Accelerating COVID-19 Therapeutic Interventions and Vaccines-6. This paper reviews what is known about montelukast, an inexpensive, well-tolerated, and widely available medication, and examines the rationale for using this drug to potentially treat patients with COVID-19.
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Pilia E, Belletti A, Fresilli S, Lee TC, Zangrillo A, Finco G, Landoni G. The Effect of Heparin Full-Dose Anticoagulation on Survival of Hospitalized, Non-critically Ill COVID-19 Patients: A Meta-analysis of High Quality Studies. Lung 2023; 201:135-147. [PMID: 36738324 PMCID: PMC9899107 DOI: 10.1007/s00408-023-00599-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 01/16/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND International COVID-19 guidelines recommend thromboprophylaxis for non-critically ill inpatients to prevent thrombotic complications. It is still debated whether full-dose thromboprophylaxis reduces all-cause mortality. The main aim of this updated systematic review and meta-analysis is to evaluate the effect of full-dose heparin-based thromboprophylaxis on survival in hospitalized non-critically ill COVID-19 patients. METHODS A systematic review was performed across Pubmed/Medline, EMBASE, Cochrane Central Register of clinical trials, Clinicaltrials.gov, and medRxiv.org from inception to November 2022. We conducted a meta-analysis of randomized clinical trials (RCTs) comparing full-dose heparin-based anticoagulation to prophylactic or intermediate dose anticoagulation or standard treatment in hospitalized non-critically ill COVID-19 patients. The risk of bias was assessed using the Cochrane risk-of-bias tool for randomized trials and Grading of Recommendations Assessment, Development and Evaluation was applied. The primary outcome was all-cause mortality at the longest follow-up available. RESULTS We identified 6 multicenter RCTs involving 3297 patients from 13 countries across 4 continents. The rate of all-cause mortality was 6.2% (103/1662) in the full-dose group vs 7.7% (126/1635) in the prophylactic or intermediate dose group (Risk Ratio [RR] = 0.76; 95% confidence interval [CI] = 0.59-0.98; P = 0.037). The probabilities of any mortality difference and of NNT ≤ 100 were estimated at 98.2% and 84.5%, respectively. The risk of bias was low for all included RCTs and the strength of the evidence was "moderate." CONCLUSION Our meta-analysis of high-quality multicenter RCTs suggests that full-dose anticoagulation with heparin or low molecular weight heparin reduces all-cause mortality in hospitalized non-critically ill COVID-19 patients. STUDY REGISTRATION PROSPERO, review no. CRD42022348993.
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Affiliation(s)
- Eros Pilia
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy ,Department of Anesthesia, Resuscitation and Pain Therapy, University of Cagliari, Cagliari, Italy
| | - Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Stefano Fresilli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Todd C. Lee
- Division of Infectious Diseases, Department of Medicine, McGill University, Montreal, QC Canada
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy ,School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Gabriele Finco
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy ,Department of Anesthesia, Resuscitation and Pain Therapy, University of Cagliari, Cagliari, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy ,School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
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Vedovati MC, Graziani M, Agnelli G, Becattini C. Efficacy and safety of two heparin regimens for prevention of venous thromboembolism in hospitalized patients with COVID-19: a meta-analysis. Intern Emerg Med 2022; 18:863-877. [PMID: 36580269 PMCID: PMC9798367 DOI: 10.1007/s11739-022-03159-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 11/20/2022] [Indexed: 12/30/2022]
Abstract
Venous thromboembolism (VTE) is common in patients with coronavirus disease-2019 (COVID-19). The optimal heparin regimen remains unknown and should balance thromboembolic and bleeding risks. The aim of this study was to evaluate the efficacy and safety of standard or higher heparin regimens for the prevention of VTE in patients hospitalized due to COVID-19. We performed a systematic literature search; studies reporting on hospitalized patients with COVID-19 who received standard heparin prophylaxis vs. high (intermediate or therapeutic) heparin regimens were included if outcome events were reported by treatment group and more than 10 patients were included. Primary study outcome was in-hospital VTE. Secondary study outcomes were major bleeding (MB), all-cause death, fatal bleeding and fatal pulmonary embolism. Overall, 33 studies (11,387 patients) were included. Venous thromboembolic events occurred in 5.2% and in 8.2% of patients who received heparin prophylaxis with at high-dose or standard-dose, respectively (RR 0.71, 95% CI 0.55-0.90, I2 48.8%). MB was significantly higher in patients who received high- compared to the standard-dose (4.2% vs 2.2%, RR 1.94, 95% CI 1.47-2.56, I2 18.1%). Sub-analyses showed a slight benefit associated with high-dose heparin in patients admitted to non-intensive care unit (ICU) but not in those to ICU. No significant differences were observed for mortality outcomes. Heparin prophylaxis at high-dose reduces the risk of VTE, but increased the risk of MB compared to the standard-dose. No clinical benefit for heparin high-dose was observed for ICU setting, but its role in the non-ICU deserves further evaluation. PROSPERO registration number: CRD42021252550.
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Affiliation(s)
- Maria Cristina Vedovati
- grid.9027.c0000 0004 1757 3630Internal, Vascular and Emergency Medicine–Stroke Unit, University of Perugia, Via G. Dottori, Perugia, Italy
| | - Mara Graziani
- grid.9027.c0000 0004 1757 3630Internal, Vascular and Emergency Medicine–Stroke Unit, University of Perugia, Via G. Dottori, Perugia, Italy
| | - Giancarlo Agnelli
- grid.9027.c0000 0004 1757 3630Internal, Vascular and Emergency Medicine–Stroke Unit, University of Perugia, Via G. Dottori, Perugia, Italy
| | - Cecilia Becattini
- grid.9027.c0000 0004 1757 3630Internal, Vascular and Emergency Medicine–Stroke Unit, University of Perugia, Via G. Dottori, Perugia, Italy
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Practical Recommendations for Optimal Thromboprophylaxis in Patients with COVID-19: A Consensus Statement Based on Available Clinical Trials. J Clin Med 2022; 11:jcm11205997. [PMID: 36294316 PMCID: PMC9604499 DOI: 10.3390/jcm11205997] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 09/22/2022] [Accepted: 10/07/2022] [Indexed: 11/23/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) has been shown to be strongly associated with increased risk for venous thromboembolism events (VTE) mainly in the inpatient but also in the outpatient setting. Pharmacologic thromboprophylaxis has been shown to offer significant benefits in terms of reducing not only VTE events but also mortality, especially in acutely ill patients with COVID-19. Although the main source of evidence is derived from observational studies with several limitations, thromboprophylaxis is currently recommended for all hospitalized patients with acceptable bleeding risk by all national and international guidelines. Recently, high quality data from randomized controlled trials (RCTs) further support the role of thromboprophylaxis and provide insights into the optimal thromboprophylaxis strategy. The aim of this statement is to systematically review all the available evidence derived from RCTs regarding thromboprophylaxis strategies in patients with COVID-19 in different settings (either inpatient or outpatient) and provide evidence-based guidance to practical questions in everyday clinical practice. Clinical questions accompanied by practical recommendations are provided based on data derived from 20 RCTs that were identified and included in the present study. Overall, the main conclusions are: (i) thromboprophylaxis should be administered in all hospitalized patients with COVID-19, (ii) an optimal dose of inpatient thromboprophylaxis is dependent upon the severity of COVID-19, (iii) thromboprophylaxis should be administered on an individualized basis in post-discharge patients with COVID-19 with high thrombotic risk, and (iv) thromboprophylaxis should not be routinely administered in outpatients. Changes regarding the dominant SARS-CoV-2 variants, the wide immunization status (increasing rates of vaccination and reinfections), and the availability of antiviral therapies and monoclonal antibodies might affect the characteristics of patients with COVID-19; thus, future studies will inform us about the thrombotic risk and the optimal therapeutic strategies for these patients.
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Kovács EH, Tánczos K, Szabó L, Turan C, Dembrovszky F, Ocskay K, Lee BY, Hegyi P, Molnár Z. Higher Dose Anticoagulation Cannot Prevent Disease Progression in COVID-19 Patients: A Systematic Review and Meta-Analysis. Biomedicines 2022; 10:2194. [PMID: 36140295 PMCID: PMC9496532 DOI: 10.3390/biomedicines10092194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 08/30/2022] [Accepted: 08/31/2022] [Indexed: 11/29/2022] Open
Abstract
Implementation of higher dose (HD) thromboprophylaxis has been considered in patients infected with coronavirus disease 2019 (COVID-19). Our aim was to compare HD to standard dose (SD) thromboprophylaxis in COVID-19 patients. The protocol is registered on PROSPERO (CRD42021284808). We searched for randomised controlled studies (CENTRAL, Embase, Medline and medRxviv) that compared HD to SD anticoagulation in COVID-19 and analysed outcomes such as mortality, thrombotic events, bleedings, and disease progression. The statistical analyses were made using the random effects model. Fourteen articles were included (6253 patients). HD compared with SD showed no difference in mortality (OR 0.83 [95% CI 0.54−1.28]). The use of HD was associated with a decreased risk of thrombosis (OR 0.58 [95% CI 0.44−0.76]), although with an increased risk of major bleeding (OR 1.64 [95% CI 1.25−2.16]). The cohort with D-dimer < 1 mg/mL showed no effect (OR 1.19 [95% CI 0.67−2.11]), but in the case of D-dimer > 1 mg/mL, a tendency of lower risk in the HD group was observed (OR 0.56 [95% CI 0.31−1.00]). The need for intubation in moderately ill patients showed a nonsignificant lower likelihood in the HD group (OR 0.82 [95% CI 0.63−1.08]). We cannot advocate for HD in all COVID-19 patients, although it shows some nonsignificant benefits on disease progression in those with elevated D-dimer who do not need ICU admission.
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Affiliation(s)
- Emőke Henrietta Kovács
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1085 Budapest, Hungary
- Selye János Doctoral College for Advanced Studies, Semmelweis University, 1085 Budapest, Hungary
| | - Krisztián Tánczos
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1085 Budapest, Hungary
| | - László Szabó
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary
| | - Caner Turan
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1085 Budapest, Hungary
| | - Fanni Dembrovszky
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary
| | - Klementina Ocskay
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary
| | - Bo-Young Lee
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary
- Division of Pancreatic Diseases, Heart and Vascular Center, Semmelweis University, 1085 Budapest, Hungary
| | - Zsolt Molnár
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1085 Budapest, Hungary
- Department of Anaesthesiology and Intensive Therapy, Faculty of Medicine, Poznan University of Medical Sciences, 61-701 Poznan, Poland
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Dalager-Pedersen M. Thromboprophylaxis and anticoagulation for inpatients with COVID-19 in 2022 and beyond. Clin Microbiol Infect 2022; 28:1184-1186. [PMID: 35640843 PMCID: PMC9148432 DOI: 10.1016/j.cmi.2022.05.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/19/2022] [Accepted: 05/21/2022] [Indexed: 11/23/2022]
Affiliation(s)
- Michael Dalager-Pedersen
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg 9000, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg 9000, Denmark.
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Bikdeli B. To escalate thromboprophylacic heparin intensity in COVID‐19 or not? That is still the question. Res Pract Thromb Haemost 2022; 6:e12738. [PMID: 35664534 PMCID: PMC9148841 DOI: 10.1002/rth2.12738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 05/03/2022] [Accepted: 05/05/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Behnood Bikdeli
- Cardiovascular Medicine Division Brigham and Women’s Hospital Harvard Medical School Boston Massachusetts USA
- Thrombosis Research Group Brigham and Women’s Hospital Harvard Medical School Boston Massachusetts USA
- YNHH/Yale Center for Outcomes Research and Evaluation (CORE) New Haven Connecticut USA
- Cardiovascular Research Foundation (CRF) New York New York USA
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