1
|
Goldin M, Tsaftaridis N, Koulas I, Solomon J, Qiu M, Leung T, Smith K, Ochani K, McGinn T, Spyropoulos AC. Universal clinical decision support tool for thromboprophylaxis in hospitalized COVID-19 patients: post hoc analysis of the IMPROVE-DD cluster randomized trial. J Thromb Haemost 2024:S1538-7836(24)00446-X. [PMID: 39128654 DOI: 10.1016/j.jtha.2024.07.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 07/15/2024] [Accepted: 07/18/2024] [Indexed: 08/13/2024]
Abstract
BACKGROUND Inpatient and extended postdischarge thromboprophylaxis of COVID-19 patients remains suboptimal despite antithrombotic guidelines. OBJECTIVES To determine whether a novel electronic health record-agnostic clinical decision support (CDS) tool incorporating the International Medical Prevention Registry on Venous Thromboembolism plus D-dimer (IMPROVE-DD) venous thromboembolism (VTE) scores increases appropriate inpatient and extended postdischarge thromboprophylaxis and improves outcomes in COVID-19 inpatients. METHODS This post hoc analysis of the IMPROVE-DD cluster randomized trial evaluated thromboprophylaxis CDS among COVID-19 inpatients at 4 New York hospitals between December 21, 2020, and January 21, 2022. Hospitals were randomized 1:1 to CDS (intervention, n = 2) vs no CDS (usual care, n = 2). The primary outcome was rate of appropriate thromboprophylaxis. Secondary outcomes included rates of major thromboembolism, all-cause and VTE-related readmissions and death, major bleeding (MB), and all-cause mortality 30 days after discharge. RESULTS Two thousand four hundred fifty-two COVID-19 inpatients were analyzed (CDS, 1355; no CDS, 1097). Mean age was 73.7 ± 9.37 years; 50.1% of participants were male. CDS adoption was 96.8% (intervention group). CDS was associated with increased appropriate at-discharge extended thromboprophylaxis (42.6% vs 28.8%; odds ratio [OR], 1.83; 95% CI, 1.39-2.41; P < .001). CDS was associated with reduced VTE (OR, 0.54; 95% CI, 0.39-0.75; P < .001), arterial thromboembolism (OR, 0.10; 95% CI, 0.01-0.81; P = .01), total thromboembolism (OR, 0.50; 95% CI, 0.36-0.69; P < .001), and 30-day all-cause readmission/death (OR, 0.78; 95% CI, 0.62-0.99; P = .04). There were no differences in MB, VTE-related readmissions/death, or all-cause mortality. CONCLUSION Electronic health record-agnostic CDS incorporating IMPROVE-DD VTE scores had high adoption, was associated with increased appropriate at-discharge extended thromboprophylaxis, and reduced thromboembolism and all-cause readmission/death without increasing MB in COVID-19 inpatients.
Collapse
Affiliation(s)
- Mark Goldin
- Northwell, New Hyde Park, New York, USA; Institute of Health System Science, Feinstein Institutes for Medical Research, Manhasset, New York, USA; Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA.
| | - Nikolaos Tsaftaridis
- Northwell, New Hyde Park, New York, USA; Institute of Health System Science, Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Ioannis Koulas
- Northwell, New Hyde Park, New York, USA; Institute of Health System Science, Feinstein Institutes for Medical Research, Manhasset, New York, USA; Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Jeffrey Solomon
- Northwell, New Hyde Park, New York, USA; Institute of Health System Science, Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Michael Qiu
- Northwell, New Hyde Park, New York, USA; Institute of Health System Science, Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Tungming Leung
- Northwell, New Hyde Park, New York, USA; Biostatistics Unit, Office of Academic Affairs, Northwell, Hempstead, New York, USA
| | - Kolton Smith
- Northwell, New Hyde Park, New York, USA; Department of Internal Medicine, Lenox Hill Hospital at Northwell Health, New York, New York, USA
| | - Kanta Ochani
- Northwell, New Hyde Park, New York, USA; Institute of Health System Science, Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Thomas McGinn
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA; CommonSpirit Health, Chicago, Illinois, USA
| | - Alex C Spyropoulos
- Northwell, New Hyde Park, New York, USA; Institute of Health System Science, Feinstein Institutes for Medical Research, Manhasset, New York, USA; Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA. https://twitter.com/AlexSpyropoul
| |
Collapse
|
2
|
Spyropoulos AC, Ramacciotti E. Venous thromboembolism risk models in hospitalized medical patients: the time for implementation, not never-ending development. Res Pract Thromb Haemost 2024; 8:102473. [PMID: 39040519 PMCID: PMC11262158 DOI: 10.1016/j.rpth.2024.102473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 06/05/2024] [Accepted: 06/05/2024] [Indexed: 07/24/2024] Open
Affiliation(s)
- Alex C. Spyropoulos
- Department of Medicine, Anticoagulation and Clinical Thrombosis Service, Northwell Health at Lenox Hill Hospital, New York, New York, USA
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
- Institute of Health Systems Science, The Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Eduardo Ramacciotti
- Science Valley Research Institute, Santo André, São Paulo, Brazil
- Hospital e Maternidade Christóvão da Gama, Grupo DASA, Santo André, São Paulo, Brazil
- Hemostasis and Thrombosis Research Laboratories, Loyola University Medical Center, Maywood, Illinois, USA
| |
Collapse
|
3
|
Tufano A, Brenner B. Prevention of Venous Thromboembolism in Medical Patients with Thrombocytopenia or with Platelet Dysfunction: The Last 10 Years. Semin Thromb Hemost 2024; 50:96-103. [PMID: 37201536 DOI: 10.1055/s-0043-1769013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Current guideline recommendations for primary prophylaxis of venous thromboembolism (VTE) are based on randomized clinical trials that usually exclude subjects at a potentially high risk of bleeding complications. For this reason, no specific guideline is available for thromboprophylaxis in hospitalized patients with thrombocytopenia and/or platelet dysfunction. However, except in patients with absolute contraindications to anticoagulant drugs, antithrombotic prophylaxis should always be considered, for example, in hospitalized cancer patients with thrombocytopenia, especially in those with multiple VTE risk factors. Low platelet number, platelet dysfunction, and clotting abnormalities are also very common in patients with liver cirrhosis, but these patients have a high incidence of portal venous thrombosis, implying that cirrhotic coagulopathy does not fully protect against thrombosis. These patients may benefit from antithrombotic prophylaxis during hospitalization. Patients hospitalized for COVID-19 need prophylaxis, but frequently experience thrombocytopenia or coagulopathy. In patients with antiphospholipid antibodies, a high thrombotic risk is usually present, even in the presence of thrombocytopenia. VTE prophylaxis in high-risk conditions is thus suggested in these patients. At variance with severe thrombocytopenia (< 50,000/mm3), mild/moderate thrombocytopenia (≥ 50,000/mm3) should not interfere with VTE prevention decisions. In patients with severe thrombocytopenia, pharmacological prophylaxis should be considered on an individual basis. Aspirin is not as effective as heparins in lowering the risk of VTE. Studies in patients with ischemic stroke demonstrated that thromboprophylaxis with heparins is safe in these patients also during antiplatelet treatment. The use of direct oral anticoagulants in the prophylaxis of VTE in internal medicine patients has been recently evaluated, but no specific recommendation exists for patients with thrombocytopenia. The need for VTE prophylaxis in patients on chronic treatment with antiplatelet agents should be evaluated after assessing the individual risk of bleeding complications. Finally, the selection of patients who require post-discharge pharmacological prophylaxis remains debated. New molecules currently under development (such as the inhibitors of factor XI) may contribute to improve the risk/benefit ratio of VTE primary prevention in this setting of patients.
Collapse
Affiliation(s)
- Antonella Tufano
- Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Via Sergio Pansini, Naples, Italy
| | - Benjamin Brenner
- Department of Hematology and Bone Marrow Transplantation, Haifa, Israel
| |
Collapse
|
4
|
Xiong W, Cheng Y, Zhao Y. Risk Scores in Venous Thromboembolism Guidelines of ESC, ACCP, and ASH: An Updated Review. Clin Appl Thromb Hemost 2024; 30:10760296241263856. [PMID: 38887044 PMCID: PMC11185021 DOI: 10.1177/10760296241263856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 05/24/2024] [Accepted: 06/07/2024] [Indexed: 06/20/2024] Open
Abstract
Venous thromboembolism (VTE) is associated with high morbidity and mortality. Risk scores associated with VTE have been widely used in clinical practice. Among numerous scores published, those included in guidelines are usually typical risk scores which have been extensively validated and globally recognized. This review provides an updated overview of the risk scores associated with VTE endorsed by 3 guidelines which are highly recognized in the field of VTE including the European Society of Cardiology, American College of Chest Physicians, and American Society of Hematology, focusing on the development, modification, validation, and comparison of these scores, to provide a comprehensive and updated understanding of all the classic risk scores associated with VTE to medical readers including but not limited to cardiologists, pulmonologists, hematologists, intensivists, physicians, surgeons, and researchers. Although each score recommended by these guidelines was more or less validated, there may still be room for further improvement. It may still be necessary to seek simpler, more practical, and more universally applicable VTE-related risk scores in the future.
Collapse
Affiliation(s)
- Wei Xiong
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Department of Pulmonary and Critical Care Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yi Cheng
- Department of Pulmonary and Critical Care Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yunfeng Zhao
- Department of Pulmonary and Critical Care Medicine, Punan Hospital, Pudong New District, Shanghai, China
| |
Collapse
|
5
|
Petramala L, Sarlo F, Servello A, Baroni S, Suppa M, Circosta F, Galardo G, Gandini O, Marino L, Cavallaro G, Iannucci G, Concistrè A, Letizia C. Pulmonary embolism post-Covid-19 infection: physiopathological mechanisms and vascular damage biomarkers. Clin Exp Med 2023; 23:4871-4880. [PMID: 37537404 PMCID: PMC10725340 DOI: 10.1007/s10238-023-01150-w] [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: 05/06/2023] [Accepted: 07/22/2023] [Indexed: 08/05/2023]
Abstract
Covid-19 infection is characterized by several acute complications, as well long-term sequelae, mostly sustained by endothelial dysfunction; several studies show that complications as pulmonary embolism (PE) are described both in the acute phase and after negativization. Aim of research was to evaluate anthropometric, bio-humoral, instrumental parameters in a group of patients affected by PE after recent Covid-19 infection compared to PE patients without previous Covid-19 infection. We enrolled 72 consecutive patients (35M, 37F) with acute PE, distinguished in relation to previous acute Covid-19 infection: 54 pts without previous acute Covid-19 infection and 18 pts with previous Covid-19 infection within negativity at least 2 months before PE diagnosis; 44 healthy subjects (21M, 23F) were recruited as control group. Patients who had previously developed Covid-19 needed hospitalization in high percentage (84%); this group showed significantly higher prevalence of diabetes mellitus than Covid-19-free PE patients, reduced serum levels of C-reactive protein, sST2 and PESI score. In post-Covid-19 PE group, we observed higher mean IMPROVE risk score, whereas in Covid-19-free group lower P/F ratio, higher radiological severity, and worse PESI score and severity index. Covid-19 infection affects not just the lung parenchyma but also other organs; endothelial damage plays pivotal role in long-term alterations; in high thrombotic risk group (recent hospitalization due to acute Covid-19 infection), we have described thrombotic complications characterized by persistent prothrombotic state after recovery, highlighted by well-known markers as PCR and D-Dimer as well as novel vascular marker (sST2).
Collapse
Affiliation(s)
- Luigi Petramala
- Department of Translational and Precision Medicine, "Sapienza" University of Rome, Rome, Italy
| | - Francesca Sarlo
- UOC Chimica, Biochimica e Biologia Molecolare Clinica, Fondazione Policlinico Universitario A. Gemelli I.R.C.C.S., Rome, Italy
| | - Adriana Servello
- Emergency Medicine Unit, Department of Emergency-Acceptance, Critical Areas and Trauma, Policlinico "Umberto I", Rome, Italy
| | - Silvia Baroni
- Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marianna Suppa
- UOC Chimica, Biochimica e Biologia Molecolare Clinica, Fondazione Policlinico Universitario A. Gemelli I.R.C.C.S., Rome, Italy
| | - Francesco Circosta
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Gioacchino Galardo
- UOC Chimica, Biochimica e Biologia Molecolare Clinica, Fondazione Policlinico Universitario A. Gemelli I.R.C.C.S., Rome, Italy
| | - Orietta Gandini
- Department of Molecular Medicine, "Sapienza" University of Rome, Rome, Italy
| | - Luca Marino
- UOC Chimica, Biochimica e Biologia Molecolare Clinica, Fondazione Policlinico Universitario A. Gemelli I.R.C.C.S., Rome, Italy.
- Department of Mechanical and Aerospace Engineering, "Sapienza" University of Rome, Rome, Italy.
| | - Giuseppe Cavallaro
- Department of Surgery Pietro Valdoni, Sapienza" University of Rome, Rome, Italy
| | - Gino Iannucci
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Antonio Concistrè
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Claudio Letizia
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, "Sapienza" University of Rome, Rome, Italy
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
Spyropoulos AC, Goldin M, Koulas I, Solomon J, Qiu M, Ngu S, Smith K, Leung T, Ochani K, Malik F, Cohen SL, Giannis D, Khan S, McGinn T. Universal EHRs Clinical Decision Support for Thromboprophylaxis in Medical Inpatients: A Cluster Randomized Trial. JACC. ADVANCES 2023; 2:100597. [PMID: 38938337 PMCID: PMC11198051 DOI: 10.1016/j.jacadv.2023.100597] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 05/18/2023] [Accepted: 06/23/2023] [Indexed: 06/29/2024]
Abstract
Background Thromboprophylaxis for medically ill patients during hospitalization and postdischarge remains underutilized. Clinical decision support (CDS) may address this need if embedded within workflow, interchangeable among electronic health records (EHRs), and anchored on a validated model. Objectives The purpose of this study was to assess the clinical impact of a universal EHR-integrated CDS tool based on the International Medical Prevention Registry on Venous Thromboembolism plus D-Dimer venous thromboembolism model. Methods This was a cluster randomized trial of 4 tertiary academic hospitals from December 21, 2020 to January 21, 2022. Inpatients over age 60 with key medical illnesses were eligible. We embedded CDS at admission and discharge. Hospitals were randomized to intervention (CDS; n = 2) vs usual care (n = 2) groups. The primary outcome was rate of appropriate thromboprophylaxis. Secondary outcomes included venous, arterial, and total thromboembolism, major bleeding, and all-cause mortality through 30 days postdischarge. Results After exclusions, 10,699 of 19,823 patients were analyzed. Intervention group tool adoption was 77.8%. Appropriate thromboprophylaxis was increased at intervention hospitals, both inpatient (80.1% vs 72.5%, OR: 1.52, 95% CI: 1.39-1.67) and at discharge (13.6% vs 7.5%, OR: 1.93, 95% CI: 1.60-2.33). There were fewer venous (2.7% vs 3.3%, OR: 0.80, 95% CI: 0.64-1.00), arterial (0.25% vs 0.70%, OR: 0.35, 95% CI: 0.19-0.67), and total thromboembolisms (2.9% vs 4.0%, OR: 0.71, 95% CI: 0.58-0.88) at intervention hospitals. Major bleeding was rare and did not differ between groups. Mortality was higher at intervention hospitals (9.1% vs 7.0%, OR: 1.32, 95% CI: 1.15-1.53). Conclusions EHR-embedded CDS increased appropriate thromboprophylaxis and reduced thromboembolism without increasing major bleeding in medically ill inpatients. Mortality was higher at intervention hospitals.
Collapse
Affiliation(s)
- Alex C. Spyropoulos
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Mark Goldin
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Ioannis Koulas
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Jeffrey Solomon
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Michael Qiu
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Sam Ngu
- Department of Hematology/Oncology, Lenox Hill Hospital at Northwell Health, New York, New York, USA
| | - Kolton Smith
- Department of Internal Medicine, Lenox Hill Hospital at Northwell Health, New York, New York, USA
| | - Tungming Leung
- Biostatistics Unit, Office of Academic Affairs, Northwell Health, Hempstead, New York, USA
| | - Kanta Ochani
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Fatima Malik
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Stuart L. Cohen
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
- Department of Radiology, North Shore University Hospital at Northwell Health, Manhasset, New York, USA
| | - Dimitrios Giannis
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Sundas Khan
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas, USA
| | - Thomas McGinn
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- CommonSpirit Health, Chicago, Illinois, USA
| |
Collapse
|
8
|
Amani-Beni R, Kermani-Alghoraishi M, Darouei B, Reid CM. A systematic review on post-discharge venous thromboembolism prophylaxis in patients with COVID-19. Egypt Heart J 2023; 75:72. [PMID: 37596465 PMCID: PMC10439090 DOI: 10.1186/s43044-023-00400-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 08/12/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND Coronavirus disease of 2019 (COVID-19) is associated with venous thromboembolism (VTE), not only during hospitalization but also after discharge, raising concerns about anticoagulant (AC) use for post-discharge COVID-19 patients. We aimed to systematically review the current literature on the possible benefits or risks regarding extended thromboprophylaxis. MAIN BODY We searched related databases from December 1, 2019, to October 6, 2022, including studies on the necessity, duration, and selection of the ideal AC regarding extended thromboprophylaxis for post-discharge COVID-19 patients. The screening of the selected databases led to 18 studies and 19 reviews and guidelines. Studies included 52,927 hospitalized COVID-19 patients, with 19.25% receiving extended thromboprophylaxis. VTE events ranging from 0 to 8.19% (median of 0.7%) occurred in a median follow-up of 49.5 days. All included studies and guidelines, except four studies, recommended post-discharge prophylaxis after an individual risk assessment indicating high thrombotic and low bleeding risk. Studies used risk assessment models (RAMs), clinical evaluation, and laboratory data to identify COVID-19 patients with a high risk of VTE. IMPROVE-DD was the most recommended RAM. Direct oral anticoagulants (DOACs) and low molecular weight heparins (LMWHs) were the most used AC classes. CONCLUSIONS Post-discharge prophylaxis for COVID-19 patients is recommended after an individual assessment. The IMPROVE-DD model can help predict VTE risk. After distinguishing patients who need post-discharge AC therapy, DOACs for 30-35 days and LMWHs for 40-45 days can be the drug of choice. Further studies, particularly the results of the ongoing randomized controlled trials (RCTs), are required. Also, to properly handle such patients, every physician should consider lifestyle modification in addition to pharmacological treatment for post-discharge VTE prophylaxis.
Collapse
Affiliation(s)
- Reza Amani-Beni
- Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Kermani-Alghoraishi
- Interventional Cardiology Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Bahar Darouei
- Hypertension Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Christopher M Reid
- Centre of Clinical Research and Education, Curtin University, Perth, WA, Australia
| |
Collapse
|
9
|
Carvalho de Oliveira CC, Agati LB, Ribeiro CM, Resende Aguiar VC, Caffaro RA, da Silva Santos M, Alves Fernandes RR, Alberto da Silva Magliano C, Tafur A, Spyropoulos AC, Lopes RD, Fareed J, Ramacciotti E. Cost-effectiveness analysis of extended thromboprophylaxis with rivaroxaban versus no prophylaxis in high-risk patients after hospitalisation for COVID-19: an economic modelling study. LANCET REGIONAL HEALTH. AMERICAS 2023; 24:100543. [PMID: 37366432 PMCID: PMC10288203 DOI: 10.1016/j.lana.2023.100543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 06/08/2023] [Accepted: 06/12/2023] [Indexed: 06/28/2023]
Abstract
Background In patients at high risk of thromboembolism who were discharged after hospitalisation due to COVID-19, thromboprophylaxis with rivaroxaban 10 mg/day for 35 days significantly improved clinical outcomes, reducing thrombotic events compared with no post-discharge anticoagulation. The present study aimed to estimate the cost-effectiveness of this anticoagulation strategy. Methods Using the database of the MICHELLE trial, we developed a decision tree to estimate the cost-effectiveness of thromboprophylaxis with rivaroxaban 10 mg/day for 35 days versus no thromboprophylaxis in high-risk post-discharge patients for COVID-19 through an incremental cost-effectiveness analysis. Findings 318 patients in 14 centres in Brazil were enrolled in the primary MICHELLE trial. The mean age was 57.1 years (SD 15.2), 127 (40%) were women, 191 (60%) were men, and the mean body-mass index was 29.7 kg/m2 (SD 5.6). Rivaroxaban 10 mg per day orally for 35 days after discharge decreased the risk of events defined by the primary efficacy outcome by 67% (relative risk 0.33, 95% CI 0.12-0.90; p = 0.03). The mean cost for thromboprophylaxis with rivaroxaban was $53.37/patient, and no prophylaxis was $34.22/patient, with an incremental cost difference of $19.15. The effectiveness means obtained in the intervention group was 0.1457, while in the control group was 0.1421, determining an incremental QALY difference of 0.0036. The estimated incremental cost-effectiveness ratio (ICER) was $5385.52/QALY. Interpretation Extended treatment with Rivaroxaban as thromboprophylaxis after hospital discharge for high-risk patients with COVID-19 is a cost-effective treatment option. Funding Modest funding was provided by Science Valley Research Institute, São Paulo, Brazil.
Collapse
Affiliation(s)
- Caroline Cândida Carvalho de Oliveira
- Science Valley Research Institute, Santo André, São Paulo, Brazil
- Hospital e Maternidade Christóvão da Gama, Grupo DASA, Santo André, São Paulo, Brazil
- Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
| | | | | | - Valéria Cristina Resende Aguiar
- Science Valley Research Institute, Santo André, São Paulo, Brazil
- Hospital e Maternidade Christóvão da Gama, Grupo DASA, Santo André, São Paulo, Brazil
| | | | | | | | | | - Alfonso Tafur
- Northshore University Health System, Evanston, IL, USA
| | - Alex C Spyropoulos
- Zucker School of Medicine at Hofstra/Northwell and the Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - Renato Delascio Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Jawed Fareed
- Hemostasis & Thrombosis Research Laboratories at Loyola University Medical Center, Maywood, IL, USA
| | - Eduardo Ramacciotti
- Science Valley Research Institute, Santo André, São Paulo, Brazil
- Hospital e Maternidade Christóvão da Gama, Grupo DASA, Santo André, São Paulo, Brazil
- Hemostasis & Thrombosis Research Laboratories at Loyola University Medical Center, Maywood, IL, USA
| |
Collapse
|
10
|
Risk of posthospital venous thromboembolism in patients with COVID-19 varies by SARS-CoV-2 period and vaccination status. Blood Adv 2022; 7:141-144. [PMID: 36260734 PMCID: PMC9585885 DOI: 10.1182/bloodadvances.2022008984] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 09/20/2022] [Accepted: 09/20/2022] [Indexed: 01/07/2023] Open
|
11
|
Spyropoulos AC, Connors JM, Douketis JD, Goldin M, Hunt BJ, Kotila TR, Lopes RD, Schulman S. Good practice statements for antithrombotic therapy in the management of COVID-19: Guidance from the SSC of the ISTH. J Thromb Haemost 2022; 20:2226-2236. [PMID: 35906715 PMCID: PMC9349985 DOI: 10.1111/jth.15809] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/14/2022] [Accepted: 07/05/2022] [Indexed: 12/30/2022]
Abstract
Despite the emergence of high quality randomized trial data with the use of antithrombotic agents to reduce the risk of thromboembolism, end-organ failure, and possibly mortality in patients with coronavirus disease 2019 (COVID-19), questions still remain as to optimal patient selection for these strategies, the use of antithrombotics in outpatient settings and in-hospital settings (including critical care units), thromboprophylaxis in special patient populations, and the management of acute thrombosis in hospitalized COVID-19 patients. In October 2021, the International Society on Thrombosis and Haemostasis (ISTH) formed a multidisciplinary and international panel of content experts, two patient representatives, and a methodologist to develop recommendations on treatment with anticoagulants and antiplatelet agents for COVID-19 patients. The ISTH Guideline panel discussed additional topics to be well suited to a non-Grading of Recommendations Assessment, Development, and Evaluation (GRADE) for Good Practice Statements (GPS) to support good clinical care in the antithrombotic management of COVID-19 patients in various clinical settings. The GPS panel agreed on 17 GPS: 3 in the outpatient (pre-hospital) setting, 12 in the hospital setting both in non-critical care (ward) as well as intensive care unit settings, and 2 in the immediate post-hospital discharge setting based on limited evidence or expert opinion that supports net clinical benefit in enacting the statements provided. The antithrombotic therapies discussed in these GPS should be available in low- and middle-income countries.
Collapse
Affiliation(s)
- Alex C Spyropoulos
- Institute of Health Systems Science-Feinstein Institutes for Medical Research, Manhasset, New York, USA
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hemptead, New York, USA
- Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, New York, USA
| | - Jean M Connors
- Hematology Division Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - James D Douketis
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Mark Goldin
- Institute of Health Systems Science-Feinstein Institutes for Medical Research, Manhasset, New York, USA
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hemptead, New York, USA
| | - Beverley J Hunt
- Thrombosis & Haemophilia Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Taiwo R Kotila
- Department of Haematology, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Renato D Lopes
- Duke University Medical Center, Duke Clinical Research Institute, Department of Medicine, Division of Cardiology, Durham, North Carolina, USA
- Brazilian Clinical Research Institute, Sao Paulo, Brazil
| | - Sam Schulman
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| |
Collapse
|
12
|
Chi G, Lee JJ, Memar Montazerin S, Marszalek J. Association of D-dimer with short-term risk of venous thromboembolism in acutely ill medical patients: A systematic review and meta-analysis. Vasc Med 2022; 27:478-486. [PMID: 35913041 DOI: 10.1177/1358863x221109855] [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: 01/09/2023]
Abstract
BACKGROUND D-dimer, a marker of ongoing procoagulant activity, has been widely used for the diagnosis of venous thromboembolism (VTE). The prognostic significance of D-dimer in stratifying VTE risk for acutely ill medical patients has not been well-established. METHODS A literature search was performed to collect studies that compared the incidence of short-term VTE between acutely ill medical patients with elevated or nonelevated D-dimer levels. The cutoff of D-dimer was 0.5 μg/mL or otherwise defined by included studies. The study endpoint was any occurrence of VTE (inclusive of deep vein thrombosis [DVT], pulmonary embolism, or VTE-related death) within 90 days of hospital presentation. A meta-analytic approach was employed to estimate the odds ratio (OR) with 95% CI by fitting random-effects models using the generic inverse variance weighted approach. RESULTS A total of 10 studies representing 31,119 acutely ill medical patients were included. Compared to those with nonelevated D-dimer levels, patients with elevated D-dimer had approximately threefold greater odds for short-term VTE within 90 days (OR, 3.28; 95% CI, 2.44 to 4.40; p < 0.0001). The association of elevated D-dimer with VTE composite (OR, 3.33; 95% CI, 2.20 to 5.02) and with DVT (OR, 3.26; 95% CI, 2.32 to 4.58) was comparable. The association was significant among patients who presented various acute medical illness (OR, 2.68; 95% CI, 2.01 to 3.58) and those who presented with acute stroke (OR, 3.25; 95% CI, 2.31 to 4.58). CONCLUSION Elevation of D-dimer was predictive of the occurrence of VTE within 90 days among acutely ill medical patients. PROSPERO Registration ID: CRD42021264555.
Collapse
Affiliation(s)
- Gerald Chi
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Jane J Lee
- Baim Institute for Clinical Research, Boston, MA, USA
| | | | - Jolanta Marszalek
- David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA, USA
| |
Collapse
|
13
|
Galli E, Maggio E, Pomero F. Venous Thromboembolism in Sepsis: From Bench to Bedside. Biomedicines 2022; 10:biomedicines10071651. [PMID: 35884956 PMCID: PMC9313423 DOI: 10.3390/biomedicines10071651] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 07/04/2022] [Accepted: 07/04/2022] [Indexed: 12/22/2022] Open
Abstract
Septic patients were commonly affected by coagulation disorders; thus, they are at high risk of thrombotic complications. In the last decades, novel knowledge has emerged about the interconnected and reciprocal influence of immune and coagulation systems. This phenomenon is called immunothrombosis, and it indicates an effective response whereby immune cells and the coagulation cascade cooperate to limit pathogen invasion and endothelial damage. When this network becomes dysregulated due to a systemic inflammatory activation, as occurs during sepsis, it can result in pathological thrombosis. Endothelium, platelets and neutrophils are the main characters involved in this process, together with the TF and coagulation cascade, playing a critical role in both the host defense and in thrombogenesis. A deeper understanding of this relationship may allow us to answer the growing need for clinical instruments to establish the thrombotic risk and treatments that consider more the connection between coagulation and inflammation. Heparin remains the principal therapeutical response to this phenomenon, although not sufficiently effective. To date, no other significant alternatives have been found yet. In this review, we discuss the role of sepsis-related inflammation in the development and resolution of venous thromboembolism and its clinical implications, from bench to bedside.
Collapse
Affiliation(s)
- Eleonora Galli
- Internal Medicine Residency Program, University of Turin, 10100 Turin, TO, Italy;
- Department of Internal Medicine, M. and P. Ferrero Hospital, 12060 Verduno, CN, Italy;
| | - Elena Maggio
- Department of Internal Medicine, M. and P. Ferrero Hospital, 12060 Verduno, CN, Italy;
| | - Fulvio Pomero
- Department of Internal Medicine, M. and P. Ferrero Hospital, 12060 Verduno, CN, Italy;
- Correspondence: ; Tel.: +39-01721408100
| |
Collapse
|
14
|
Lee Y, Jehangir Q, Lin CH, Li P, Sule AA, Poisson L, Balijepally V, Halabi AR, Patel K, Krishnamoorthy G, Nair GB. 3D-PAST: Risk Assessment Model for Predicting Venous Thromboembolism in COVID-19. J Clin Med 2022; 11:jcm11143949. [PMID: 35887713 PMCID: PMC9325096 DOI: 10.3390/jcm11143949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 06/25/2022] [Accepted: 07/04/2022] [Indexed: 12/22/2022] Open
Abstract
Hypercoagulability is a recognized feature in SARS-CoV-2 infection. There exists a need for a dedicated risk assessment model (RAM) that can risk-stratify hospitalized COVID-19 patients for venous thromboembolism (VTE) and guide anticoagulation. We aimed to build a simple clinical model to predict VTE in COVID-19 patients. This large-cohort, retrospective study included adult patients admitted to four hospitals with PCR-confirmed SARS-CoV-2 infection. Model training was performed on 3531 patients hospitalized between March and December 2020 and validated on 2508 patients hospitalized between January and September 2021. Diagnosis of VTE was defined as acute deep vein thrombosis (DVT) or pulmonary embolism (PE). The novel RAM was based on commonly available parameters at hospital admission. LASSO regression and logistic regression were performed, risk scores were assigned to the significant variables, and cutoffs were derived. Seven variables with assigned scores were delineated as: DVT History = 2; High D-Dimer (>500−2000 ng/mL) = 2; Very High D-Dimer (>2000 ng/mL) = 5; PE History = 2; Low Albumin (<3.5 g/dL) = 1; Systolic Blood Pressure <120 mmHg = 1, Tachycardia (heart rate >100 bpm) = 1. The model had a sensitivity of 83% and specificity of 53%. This simple, robust clinical tool can help individualize thromboprophylaxis for COVID-19 patients based on their VTE risk category.
Collapse
Affiliation(s)
- Yi Lee
- Department of Medicine, St. Joseph Mercy Oakland Hospital, Pontiac, MI 48341, USA; (Q.J.); (A.A.S.); (G.K.)
- Correspondence: or ; Tel.: +1-(248) 858-3000
| | - Qasim Jehangir
- Department of Medicine, St. Joseph Mercy Oakland Hospital, Pontiac, MI 48341, USA; (Q.J.); (A.A.S.); (G.K.)
| | - Chun-Hui Lin
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI 48202, USA; (C.-H.L.); (P.L.); (L.P.)
| | - Pin Li
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI 48202, USA; (C.-H.L.); (P.L.); (L.P.)
| | - Anupam A. Sule
- Department of Medicine, St. Joseph Mercy Oakland Hospital, Pontiac, MI 48341, USA; (Q.J.); (A.A.S.); (G.K.)
- Department of Informatics, St. Joseph Mercy Oakland Hospital, Pontiac, MI 48341, USA
| | - Laila Poisson
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI 48202, USA; (C.-H.L.); (P.L.); (L.P.)
| | | | - Abdul R. Halabi
- Division of Cardiology, St. Joseph Mercy Oakland Hospital, Pontiac, MI 48341, USA; (A.R.H.); (K.P.)
- William Beaumont School of Medicine, Oakland University, Auburn Hills, MI 48307, USA;
| | - Kiritkumar Patel
- Division of Cardiology, St. Joseph Mercy Oakland Hospital, Pontiac, MI 48341, USA; (A.R.H.); (K.P.)
| | - Geetha Krishnamoorthy
- Department of Medicine, St. Joseph Mercy Oakland Hospital, Pontiac, MI 48341, USA; (Q.J.); (A.A.S.); (G.K.)
| | - Girish B. Nair
- William Beaumont School of Medicine, Oakland University, Auburn Hills, MI 48307, USA;
- Division of Pulmonary and Critical Care Medicine, Beaumont Health System, Royal Oak, MI 48183, USA
| |
Collapse
|
15
|
Spyropoulos AC. Extended post-discharge thromboprophylaxis in hospitalized COVID-19 patients. Expert Rev Hematol 2022; 15:597-605. [PMID: 35786377 DOI: 10.1080/17474086.2022.2098104] [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: 11/04/2022]
Abstract
INTRODUCTION Hospitalized COVID-19 patients, particularly those with high risk features, are at risk for venous and arterial thromboembolic events for approximately 30 days or more after hospital discharge. Extended post-hospital discharge thromboprophylaxis has potential to reduce this risk. AREAS COVERED Recent cohort, registry, and randomized trial data on the topic of extended post-discharge thromboprophylaxis in COVID-19 inpatients are reviewed, and key patient subgroups at high thrombotic risk are highlighted, with antithrombotic guidelines on the topic discussed. EXPERT OPINION COVID-19 inpatients with cardiovascular risk factors, advanced age, intensive care unit stay, or an IMPROVE VTE score of 4 or more or a score of 2 or 3 plus elevated D-dimers (> twice the upper limit of normal) or an IMPROVE-DD VTE score of ≥ 4 are at high thrombotic risk in the post-discharge period. These high risk patient subgroups benefit from extended post-discharge thromboprophylaxis, specifically with rivaroxaban 10mg daily for 35 days. Recent NIH and ISTH guidelines recommend or suggest this approach. Results from other clinical trials are pending.
Collapse
Affiliation(s)
- Alex C Spyropoulos
- Institute of Health Systems Science - Feinstein Institutes for Medical Research and The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, and Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, NY, USA
| |
Collapse
|
16
|
Woller SC, Stevens SM, Bledsoe JR, Fazili M, Lloyd JF, Snow GL, Horne BD. Biomarker derived risk scores predict venous thromboembolism and major bleeding among patients with COVID-19. Res Pract Thromb Haemost 2022; 6:e12765. [PMID: 35873221 PMCID: PMC9301476 DOI: 10.1002/rth2.12765] [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: 11/30/2021] [Revised: 05/21/2022] [Accepted: 06/19/2022] [Indexed: 12/15/2022] Open
Abstract
Background Venous thromboembolism (VTE) risk is increased in patients with COVID-19 infection. Understanding which patients are likely to develop VTE may inform pharmacologic VTE prophylaxis decision making. The hospital-associated venous thromboembolism-Intermountain Risk Score (HA-VTE IMRS) and the hospital-associated major bleeding-Intermountain Risk Score (HA-MB IMRS) are risk scores predictive of VTE and bleeding that were derived from only patient age and data found in the complete blood count (CBC) and basic metabolic panel (BMP). Objectives We assessed the HA-VTE IMRS and HA-MB IMRS for predictiveness of 90-day VTE and major bleeding, respectively, among patients diagnosed with COVID-19, and further investigated if adding D-dimer improved these predictions. We also reported 30-day outcomes. Patients/Methods We identified 5047 sequential patients with a laboratory confirmed diagnosis of COVID-19 and a CBC and BMP between 2 days before and 7 days following the diagnosis of COVID-19 from March 12, 2020, to February 28, 2021. We calculated the HA-VTE IMRS and the HA-MB IMRS for all patients. We assessed the added predictiveness of D-dimer obtained within 48 hours of the COVID test. Results The HA-VTE IMRS yielded a c-statistic of 0.70 for predicting 90-day VTE and adding D-dimer improved the c-statistic to 0.764 with the corollary sensitivity/specificity/positive/negative predictive values of 49.4%/75.7%/6.7%/97.7% and 58.8%/76.2%/10.9%/97.4%, respectively. Among hospitalized and ambulatory patients separately, the HA-VTE IMRS performed similarly. The HA-MB IMRS predictiveness for 90-day major bleeding yielded a c-statistic of 0.64. Conclusion The HA-VTE IMRS and HA-MB IMRS predict 90- and 30-day VTE and major bleeding among COVID-19 patients. Adding D-dimer improved the predictiveness of the HA-VTE IMRS for VTE.
Collapse
Affiliation(s)
- Scott C. Woller
- Department of MedicineIntermountain Medical Center, Intermountain HealthcareMurrayUtahUSA
- Department of Internal MedicineUniversity of Utah School of MedicineSalt Lake CityUtahUSA
| | - Scott M. Stevens
- Department of MedicineIntermountain Medical Center, Intermountain HealthcareMurrayUtahUSA
- Department of Internal MedicineUniversity of Utah School of MedicineSalt Lake CityUtahUSA
| | - Joseph R. Bledsoe
- Department of Emergency Medicine, Intermountain Medical CenterIntermountain HealthcareMurrayUtahUSA
- Stanford UniversityStanfordCaliforniaUSA
| | - Masarret Fazili
- Department of MedicineIntermountain Medical Center, Intermountain HealthcareMurrayUtahUSA
| | - James F. Lloyd
- Department of InformaticsIntermountain Medical Center, Intermountain HealthcareMurrayUtahUSA
| | - Greg L. Snow
- Intermountain Statistical Data Center, Intermountain Medical CenterIntermountain HealthcareMurrayUtahUSA
| | - Benjamin D. Horne
- Intermountain Medical Center Heart InstituteMurrayUtahUSA
- Division of Cardiovascular MedicineStanford UniversityStanfordCaliforniaUSA
| |
Collapse
|
17
|
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) is associated with elevated rates of major and fatal thrombotic events, postulated to be the result of a hypercoagulable state mediated through inflammatory and immunomodulatory mechanisms. Early observational studies showed that disease severity and elevated serum D-dimer levels can predict thrombotic risk in patients hospitalized with COVID-19 and reported an alarming phenomenon of breakthrough thrombosis despite standard-of-care prophylaxis, suggesting the need for enhanced thromboprophylactic strategies. AREAS OF UNCERTAINTY Data on anticoagulant agent selection, dosing, and duration for COVID-19 inpatients are now poised to inform updated professional society guidance. However, there remains limited high-quality data regarding postdischarge and especially ambulatory patients with COVID-19. DATA SOURCES This review includes published, peer-reviewed, observational, and randomized controlled trial data and major professional society guidance informing thrombosis prevention and treatment in patients with COVID-19. THERAPEUTIC ADVANCES There remains great variability in the approach to anticoagulation in COVID-19. This article will review pathogenesis of COVID-related thrombosis and the evidence guiding thromboprophylaxis particularly in inpatients, with attention to the INSPIRATION, ACTION, RAPID, HEP-COVID, and multiplatform trials. Emerging thromboprophylaxis data from the postdischarge setting (particularly the recently published MICHELLE trial), and the outpatient setting, will be examined. Finally, thrombosis treatment considerations will briefly be reviewed. CONCLUSIONS Substantial high-quality data support practice changes to COVID-19 thromboprophylaxis. Risk stratification by setting, disease severity, and biomarkers such as D-dimer is critical in considering choice, dose, and duration of anticoagulants.
Collapse
|
18
|
Commissioned Commentary on the 2021 American Society of Hematology Guidelines on use of anticoagulation in patients with COVID-19 being discharged from the hospital. Blood Adv 2022; 6:5045-5048. [PMID: 35245944 PMCID: PMC8901239 DOI: 10.1182/bloodadvances.2021006871] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 02/24/2022] [Indexed: 11/20/2022] Open
|
19
|
Forgo G, Micieli E, Ageno W, Castellucci LA, Cesarman‐Maus G, Ddungu H, De Paula EV, Dumantepe M, Guillermo Esposito MC, Konstantinides SV, Kucher N, McLintock C, Ní Áinle F, Spyropoulos AC, Urano T, Hunt BJ, Barco S. An update on the global use of risk assessment models and thromboprophylaxis in hospitalized patients with medical illnesses from the World Thrombosis Day steering committee: Systematic review and meta-analysis. J Thromb Haemost 2022; 20:409-421. [PMID: 34822215 PMCID: PMC9299991 DOI: 10.1111/jth.15607] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 11/18/2021] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Venous thromboembolism (VTE) is a leading cause of cardiovascular morbidity and mortality. The majority of VTE events are hospital-associated. In 2008, the Epidemiologic International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting (ENDORSE) multinational cross-sectional study reported that only approximately 40% of medical patients at risk of VTE received adequate thromboprophylaxis. METHODS In our systematic review and meta-analysis, we aimed at providing updated figures concerning the use of thromboprophylaxis globally. We focused on: (a) the frequency of patients with an indication to thromboprophylaxis according with individual models; (b) the use of adequate thromboprophylaxis; and (c) reported contraindications to thromboprophylaxis. Observational nonrandomized studies or surveys focusing on medically ill patients were considered eligible. RESULTS After screening, we included 27 studies from 20 countries for a total of 137 288 patients. Overall, 50.5% (95% confidence interval [CI]: 41.9-59.1, I2 99%) of patients had an indication to thromboprophylaxis: of these, 54.5% (95% CI: 46.2-62.6, I2 99%) received adequate thromboprophylaxis. The use of adequate thromboprophylaxis was 66.8% in Europe (95% CI: 50.7-81.1, I2 98%), 44.9% in Africa (95% CI: 31.8-58.4, I2 96%), 37.6% in Asia (95% CI: 25.7-50.3, I2 97%), 58.3% in South America (95% CI: 31.1-83.1, I2 99%), and 68.6% in North America (95% CI: 64.9-72.6, I2 96%). No major differences in adequate thromboprophylaxis use were found across risk assessment models. Bleeding, thrombocytopenia, and renal/hepatic failure were the most frequently reported contraindications to thromboprophylaxis. CONCLUSIONS The use of anticoagulants for VTE prevention has been proven effective and safe, but thromboprophylaxis prescriptions are still unsatisfactory among hospitalized medically ill patients around the globe with marked geographical differences.
Collapse
Affiliation(s)
- Gabor Forgo
- Department of AngiologyUniversity Hospital ZurichZurichSwitzerland
| | - Evy Micieli
- Department of AngiologyUniversity Hospital ZurichZurichSwitzerland
| | - Walter Ageno
- Department of Clinical MedicineUniversity of InsubriaVareseItaly
| | - Lana A. Castellucci
- Department of MedicineOttawa Hospital Research InstituteUniversity of OttawaOttawaONCanada
| | | | | | | | - Mert Dumantepe
- Department of Cardiovascular SurgeryUskudar University School of MedicineIstanbulTurkey
| | | | | | - Nils Kucher
- Department of AngiologyUniversity Hospital ZurichZurichSwitzerland
| | - Claire McLintock
- National Women's Health Auckland City Hospital Auckland New ZealandAucklandNew Zealand
| | - Fionnuala Ní Áinle
- Department of HaematologyMater Misericordiae University Hospital and Rotunda HospitalDublinIreland
- School of MedicineUniversity College DublinDublinIreland
| | - Alex C. Spyropoulos
- Institute for Health Innovations and Outcomes ResearchFeinstein Institutes for Medical Research and the Zucker School of Medicine at Hofstra/NorthwellNew YorkNew YorkUSA
- Department of Medicine, Anticoagulation and Clinical Thrombosis ServicesNorthwell Health at Lenox Hill HospitalNew YorkNew YorkUSA
| | - Tetsumei Urano
- Shizuoka Graduate University of Public HealthShizuokaJapan
| | - Beverley J. Hunt
- Thrombosis & Haemophilia CentreGuys & St Thomas’ NHS Foundation TrustLondonUK
| | - Stefano Barco
- Department of AngiologyUniversity Hospital ZurichZurichSwitzerland
- Center for Thrombosis and HemostasisUniversity Medical Center MainzMainzGermany
| |
Collapse
|
20
|
American Society of Hematology living guidelines on the use of anticoagulation for thromboprophylaxis in patients with COVID-19: July 2021 update on post-discharge thromboprophylaxis. Blood Adv 2021; 6:664-671. [PMID: 34727173 PMCID: PMC8566097 DOI: 10.1182/bloodadvances.2021005945] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 10/08/2021] [Indexed: 11/26/2022] Open
Abstract
Background COVID-19–related acute illness is associated with an increased risk of venous thromboembolism (VTE). Objective These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in decisions about the use of anticoagulation for thromboprophylaxis in patients with COVID-19 who do not have confirmed or suspected VTE. Methods ASH formed a multidisciplinary guideline panel, including 3 patient representatives, and applied strategies to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including performing systematic evidence reviews (up to March 2021). The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The panel used the grading of recommendations assessment, development, and evaluation (GRADE) approach to assess evidence and make recommendations, which were subject to public comment. Results The panel agreed on 1 additional recommendation. The panel issued a conditional recommendation against the use of outpatient anticoagulant prophylaxis in patients with COVID-19 who are discharged from the hospital and who do not have suspected or confirmed VTE or another indication for anticoagulation. Conclusions This recommendation was based on very low certainty in the evidence, underscoring the need for high-quality randomized controlled trials assessing the role of postdischarge thromboprophylaxis. Other key research priorities include better evidence on assessing risk of thrombosis and bleeding outcomes in patients with COVID-19 after hospital discharge.
Collapse
|
21
|
Chi G, Montazerin SM, Lee JJ. Independent and incremental prognostic value of D-dimer in hospitalized COVID-19 patients. Future Virol 2021. [PMID: 34341669 PMCID: PMC8323749 DOI: 10.2217/fvl-2021-0161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 07/22/2021] [Indexed: 01/10/2023]
Affiliation(s)
- Gerald Chi
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Sahar Memar Montazerin
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Jane J Lee
- Department of Trial Design and Development, Baim Institute for Clinical Research, Boston, MA 02215, USA
| |
Collapse
|