[Thrombotic Risk and Covid-19: Review of Current Evidence for a Better Diagnostic and Therapeutic Approach]

A Delphi consensus on the management of anticoagulation in the COVID-19 pandemic: the MONACO study

Background

During the COVID-19 pandemic, guideline documents on the management of anticoagulation were rapidly published. However, these documents did not follow a structured methodology, and significant differences existed between the guidelines. The aim of this expert consensus was to provide recommendations on the clinical management of oral anticoagulation in patients in the context of the COVID-19 pandemic.

Methods

A two-round Delphi study was conducted using an online survey. In the first round, panellists expressed their level of agreement with the items on a 9-point Likert scale. Items were selected if they received approval from ≥66.6% of panellists and if they were agreed by the scientific committee. In the second round, panellists revaluated those items that did not meet consensus in the first round.

Results

A total of 147 panellists completed the first round, and 144 of them completed the second round. Consensus was reached on 161 items included in five dimensions. These dimensions addressed: (I) management of anticoagulation in patients with atrial fibrillation (AF) without mechanical valves or moderate/severe mitral stenosis during COVID-19 infection; (II) thromboprophylaxis in patients hospitalised for COVID-19; (III) management of anticoagulation at hospital discharge/after COVID-19; (IV) anticoagulation monitoring in the COVID-19 pandemic setting; and (V) role of telemedicine in the management and follow-up of patients with AF in the COVID-19 pandemic setting.

Conclusions

These areas of collective agreement could specially guide clinicians in making decisions regarding anticoagulation in patients with COVID-19 during hospitalisation and at discharge, where results from clinical trials are still limited and, in some cases, conflicting.

Effectiveness of antithrombotic prophylaxis in hospitalised patients with SARS-CoV-2 infection

BACKGROUND

Antithrombotic prophylaxis in hospitalised patients with SARS-CoV-2 acute infection has increased. Currently, most of the evidence relates to patients in intensive care units; however, there is little information on patients admitted to hospital wards and there is no consensus protocol on thromboprophylaxis during admission and after discharge.

OBJECTIVE

To assess the effectiveness of antithrombotic prophylaxis in patients admitted with COVID-19 and 30 days after discharge.

METHOD

A prospective observational study was conducted of patients admitted with COVID-19 in which the hospital thromboprophylaxis protocol was applied, classifying the patients as having a standard or high risk of thrombosis. Pharmacists performed a daily follow-up and actively intervened during admission and at discharge. The main outcome measure was the global incidence of symptomatic venous thromboembolism (VTE) related to hospitalisation.

RESULTS

A total of 113 patients were included, 98.23% of whom were admitted to a hospital ward. The incidence of hospital-acquired VTE was 1.77%. In 75.22% of the subjects, thromboprophylaxis was adjusted to the protocol during admission. A total of 23 pharmaceutical interventions were conducted, with an adherence of 52.17%. At discharge, 94.28% of the patients who had no haemorrhage and ≥4 points on the Padua Prediction Score required thromboprophylaxis, aligning with the protocol. The global incidence of haemorrhagic events during the follow-up period was 0.88%.

CONCLUSION

The incidence of hospital-acquired VTE was lower than that described in the literature. Although it cannot be certain that it is directly related to the instituted protocol, the data can show that the management of prevention of VTE is being optimally performed at the hospital. Long-term studies are needed to evaluate the incidence after discharge, as well as to agree on a specific protocol in the COVID-19 population for the prevention of these events during hospitalisation and post-discharge.

Assessment of pulmonary embolism related to active SARS-CoV-2 infection in pregnant women

AIM

To analyze a sample of pregnant patients who underwent pulmonary perfusion scintigraphy to rule out suspicion of pulmonary embolism (PE) during the acute COVID-19 infection hospitalization period in our hospital.

MATERIAL AND METHODS

SPECT scintigraphy with a reduced dose (111MBq) of 99mTc-macroaggregated albumin was performed in all the patients (n=5). The images obtained were interpreted by comparing the findings with the radiological images according to the PISAPED criteria.

RESULTS

Only one of the 5 patients was diagnosed with PE. Two patients showed pathological scintigraphy findings attributable to radiological alterations due to COVID-19 pneumonia, and the other two had normal pulmonary perfusion.

CONCLUSION

Given the non-specific features of the clinical manifestations and d-dimer values ​​in COVID-19, as well as their similarity to those of PE, pulmonary perfusion scintigraphy plays a crucial role in the screening of PE in these patients due to its high sensitivity and lower irradiation compared to CT. Despite the limited number of patients, the results obtained have special relevance due to the absence of scientific publications in this group of patients within the exceptional context of the COVID-19 pandemic.

[Assessment of pulmonary embolism related to active SARS-CoV-2 infection in pregnant women.]

AIM

To analyze the sample of pregnant patients who underwent pulmonary perfusion scintigraphy to rule out the pulmonary embolism (PE) suspicion during the acute COVID-19 infection hospitalization period in our hospital.

MATERIAL AND METHODS

SPECT scintigraphy with a reduced dose (111 MBq) of 99mTc-macroaggregated albumin was performed in all of the patients (n=5). The obtained images were interpreted by comparing the findings with the radiological images according to the PISAPED criteria.

RESULTS

Only one of the 5 patients was diagnosed with PE. Two patients obtained pathological findings of the scintigraphy attributable to radiological alterations due to COVID-19 pneumonia, and the other two had normal pulmonary perfussion.

CONCLUSION

Given the non-specific features of the clinical manifestations and D-dimer values in COVID-19, as well as their similarity to those of PE, the pulmonary perfusion scintigraphy plays a crucial role in the screening of PE in these patients due to its high sensitivity and lower irradiation compared to CT. Despite the limited number of patients, the results obtained have special relevance related to the absence of scientific publications on this group of patients within the context of COVID-19 pandemic exceptional situation.

Impact of the SARS-CoV-2 Virus Pandemic on Patients with Bronchiectasis: A Multicenter Study

BACKGROUND

Infection by SARS-CoV-2 has unquestionably had an impact on the health of patients with chronic respiratory airway diseases, such as COPD and asthma, but little information is available about its impact on patients with bronchiectasis. The objective of the present study was to analyze the effect of the SARS-CoV-2 pandemic on the state of health, characteristics, and clinical severity (including the number and severity of exacerbations) of patients with non-cystic fibrosis bronchiectasis.

METHODS

This study was multicenter, observational, and ambispective (with data collected before and during the SARS-CoV-2 pandemic), and included 150 patients diagnosed with non-cystic fibrosis bronchiectasis.

RESULTS

A significant drop was observed in the number and severity of the exacerbations (57% in all exacerbations and 50% in severe exacerbations) in the E-FACED and BSI multidimensional scores, in the pandemic, compared with the pre-pandemic period. There was also a drop in the percentage of sputum samples positive for pathogenic microorganisms in general (from 58% to 44.7%) and, more specifically, Pseudomonas aeruginosa (from 23.3% to 13.3%) and Haemophilus influenzae (from 21.3% to 14%).

CONCLUSIONS

During the SARS-CoV-2 period, a significant reduction was observed in the exacerbations, severity, and isolations of pathogenic microorganisms in patients with bronchiectasis.

Short and Long-Term Impact of COVID-19 Infection on Previous Respiratory Diseases

On March 11, 2020, the World Health Organization declared Coronavirus Disease 2019 (COVID-19) a pandemic. Till now, it affected 452.4 million (Spain, 11.18 million) persons all over the world with a total of 6.04 million of deaths (Spain, 100,992). It is observed that 75% of hospitalized COVID-19 patients have at least one COVID-19 associated comorbidity. It was shown that people with underlying chronic illnesses are more likely to get it and grow seriously ill. Individuals with COVID-19 who have a past medical history of cardiovascular disorder, cancer, obesity, chronic lung disease, diabetes, or neurological disease had the worst prognosis and are more likely to develop acute respiratory distress syndrome or pneumonia. COVID-19 can affect the respiratory system in a variety of ways and across a spectrum of levels of disease severity, depending on a person's immune system, age and comorbidities. Symptoms can range from mild, such as cough, shortness of breath and fever, to critical disease, including respiratory failure, shock and multi-organ system failure. So, COVID-19 infection can cause overall worsening of these previous respiratory diseases, such as asthma, chronic obstructive pulmonary disease (COPD), interstitial lung disease, etc. This review aims to provide information on the impact of the COVID-19 disease on pre-existing lung comorbidities.

Plasma D-dimer value corrected by inflammatory markers in patients with SARS-CoV-2 infection: Its prognostic value in the diagnosis of venous thromboembolism

INTRODUCTION

D-dimer levels are elevated in COVID 19 and they correlate to the levels of other inflammatory markers such us ferritin, fibrinogen and C-reactive protein. It may be possible to correct D-dimer value in function of inflammatory markers, thus identifying patients at higher risk of venous thromboembolism (VTE). Our objectives are estimating a corrected value of plasma D-dimer as a linear function of ferritin, C-reactive protein and fibrinogen and stablishing a cut-off point of high probability of VTE.

PATIENTS AND METHODS

Age and sex matched case-control study of all patients diagnosed with COVID 19 and VTE between March and May 2020 in a tertiary hospital in Madrid (Spain). Using linear regression, the best predictive model will be estimated and residual D-dimer values will be obtained and analyzed using ROC curves to determine its discriminative performance.

RESULTS

Thirty-eight cases and seventy-six controls were included. There was 63.2% of men and mean age was 68.2. D-dimer was best predicted by a linear model including fibrinogen, ferritin and C-reactive protein. Using residual values, the optimal cutoff point was 2165ng/mL, with a sensitivity of 57.9% and specificity of 98.7%.

CONCLUSION

It is possible to estimate a D-dimer corrected value in function of ferritin, C-reactive protein and fibrinogen. Using the observed and estimated value we can obtain a residual value that performs well as a screening method to detect patients who would benefit for further VTE diagnostic testing.

Plasma D-dimer value corrected by inflammatory markers in patients with SARS-CoV-2 infection: Its prognostic value in the diagnosis of venous thromboembolism

Introduction

D-dimer levels are elevated in COVID 19 and they correlate to the levels of other inflammatory markers such us ferritin, fibrinogen and C-reactive protein. It may be possible to correct D-dimer value in function of inflammatory markers, thus identifying patients at higher risk of venous thromboembolism (VTE). Our objectives are estimating a corrected value of plasma D-dimer as a linear function of ferritin, C-reactive protein and fibrinogen and stablishing a cut-off point of high probability of VTE.

Patients and methods

Age and sex matched case-control study of all patients diagnosed with COVID 19 and VTE between March and May 2020 in a tertiary hospital in Madrid (Spain). Using linear regression, the best predictive model will be estimated and residual D-dimer values will be obtained and analyzed using ROC curves to determine its discriminative performance.

Results

Thirty-eight cases and seventy-six controls were included. There was 63.2% of men and mean age was 68.2. D-dimer was best predicted by a linear model including fibrinogen, ferritin and C-reactive protein. Using residual values, the optimal cutoff point was 2165 ng/mL, with a sensitivity of 57.9% and specificity of 98.7%.

Conclusion

It is possible to estimate a D-dimer corrected value in function of ferritin, C-reactive protein and fibrinogen. Using the observed and estimated value we can obtain a residual value that performs well as a screening method to detect patients who would benefit for further VTE diagnostic testing.

Mechanical Valve Thrombosis Secondary to Severe Acute Respiratory Syndrome Coronavirus 2 Infection: A Case Report

Although the association of coronavirus disease 2019 (COVID-19) and thromboembolic disease is well known, cases of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and mechanical valve thrombosis have not been described enough. Mechanical valve thrombosis is a medical emergency that is associated with a great impact on patients' morbidity and mortality. Here, we report a case of a patient with mechanical valve thrombosis secondary to SARS-CoV-2 infections that required valve replacement with satisfactory postoperative recovery.

A 52-year old female patient was presented with a previously implanted mechanical prosthesis (type - St. Jude Medical 29 mm; St. Paul, MN: St. Jude Medical, Inc.) eight years ago due to rheumatic fever, under anticoagulation with warfarin and valvular atrial fibrillation (permanent), congenital single kidney (glomerular filtration rate {GFR}: 89.9 mL/min), and hypothyroidism. She was admitted to the hospital with a high level of complexity due to respiratory difficulty and generalized edematous syndrome, and a reverse transcription-polymerase chain reaction (RT-PCR) confirmed COVID-19 infection (20 days before admission); the patient was anticoagulated with warfarin (international normalized ratio {INR} at admission was 2.63 seconds). As per protocol, a CT-chest scan tomography was performed and showed organized pneumonia in the right apical lobe. We performed a transesophageal echocardiogram, which showed a thrombus (20 x 15 x 20 mm) in the lateral disc of the mechanical prosthesis, restricting its mobility. The patient presented signs of hypoperfusion (lactate levels: 4 mmol/L; urine per hour: 1 cc/kg) with associated low cardiac output syndrome, requiring double vasopressor support at the maximum dose (achieving a mean arterial pressure of 72 mmHg) due to the clinical condition and the large size of the thrombus, the cardiovascular surgeon, in agreement with the family, decides to carry out emergency valve replacement surgery with replacement of a mechanical prosthesis replacement (St. Jude No. 29; St. Paul, MN: St. Jude Medical, Inc.). The patient presented a satisfactory postoperative recovery, achieving INR goals, with subsequent discharge and follow-up at two months with transthoracic ultrasound, where normofunctional mitral prosthesis was demonstrated, without evidence of thrombi or intracavitary masses.

Mechanical mitral valve thrombosis, secondary to SARS-CoV-2 infection is a serious complication with poor prognosis that requires a high rate of suspicion, and timely diagnostic aids are essential to confirm the diagnosis. Managing this issue should be interdisciplinary and individualized considering the clinical condition of the patient and the associated comorbidities.

[SEPAR Recommendations for COVID-19 Vaccination in Patients With Respiratory Diseases]

The Spanish Society of Pneumonology and Thoracic Surgery (SEPAR) has elaborated this document of recommendations for COVID-19 vaccination in patients with respiratory diseases aimed to help healthcare personnel make decisions about how to act in case of COVID-19 vaccination in these patients.The recommendations have been developed by a group of experts in this field after reviewing the materials published up to March 7, 2021, the information provided by different scientific societies, drug agencies and the strategies of the governmental bodies up to this date.We can conclude that COVID-19 vaccines are not only safe and effective, but also prior in vulnerable patients with chronic respiratory diseases. In addition, an active involvement of healthcare professionals, who manage these diseases, in the vaccination strategy is the key to achieve good adherence and high vaccination coverage.