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Elbaz C, Hollestelle MJ, Meijer P, Liederman Z, Selby R. D-dimer-An International Assessment of the Quality of Laboratory Testing: Implications for D-dimer Use in the Real World. Semin Thromb Hemost 2024. [PMID: 39419079 DOI: 10.1055/s-0044-1791700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2024]
Abstract
D-dimer assessment has several established roles in venous thromboembolism (VTE) and disseminated intravascular coagulation diagnosis, and recently the risk stratification of coronavirus disease 2019 (COVID-19). D-dimer assays are neither standardized nor harmonized, use varying methodologies, and use different reporting units, all resulting in a lack of interchangeability and generalizability of assays. Using large multiyear datasets from an international laboratory quality assurance program, we assessed (1) common D-dimer assays in use worldwide, (2) differences in analytical performance between different methods, and (3) interlaboratory variability between positive samples. External proficiency testing results from laboratories participating in the External Quality Control for Assays and Tests (ECAT) Foundation were analyzed from 2017 to 2023. Annually, between 578 and 690 laboratories participated in the D-dimer sample surveys with response rates ranging from 88 to 97%. The three most common assays in use in 2023 were the Siemens Innovance D-dimer (42%), the IL HemosIL D-dimer HS 500 (20%), and the Diagnostica Stago (Stago) Liatest D-dimer Plus (10%)-all these are automated, quantitative, latex immunoassays expressed in fibrinogen equivalent units (FEU). The highest interlaboratory variability was observed around the typical VTE exclusion threshold of 0.5 mg/L FEU. Lower interlaboratory variability was observed at values above 0.8 mg/L FEU. Our study provides recent, international performance data on currently used D-dimer assays and describes the significant variability between assays and across D-dimer concentrations. We demonstrate that assays are not interchangeable and that using them interchangeably has the potential to result in clinically important errors. There is an urgent need to educate users about these issues and to work towards harmonizing D-dimer units and reporting.
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Affiliation(s)
- Carolyne Elbaz
- Division of Hematology, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Martine J Hollestelle
- External Quality Control for Assays and Tests (ECAT) Foundation, Voorschoten, The Netherlands
| | - Piet Meijer
- External Quality Control for Assays and Tests (ECAT) Foundation, Voorschoten, The Netherlands
| | - Zachary Liederman
- Division of Hematology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rita Selby
- Division of Hematology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
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2
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Martins PN, Lourenço MHT, Mota GPS, Cavalcanti AB, Peçanha Antonio AC, Diaz-Quijano FA. Composite endpoints in COVID-19 randomized controlled trials: a systematic review. Clin Trials 2024:17407745241276130. [PMID: 39390767 DOI: 10.1177/17407745241276130] [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: 10/12/2024]
Abstract
BACKGROUND/AIMS This study aimed to determine the prevalence of ordinal, binary, and numerical composite endpoints among coronavirus disease 2019 trials and the potential bias attributable to their use. METHODS We systematically reviewed the Cochrane COVID-19 Study Register to assess the prevalence, characteristics, and bias associated with using composite endpoints in coronavirus disease 2019 randomized clinical trials. We compared the effect measure (relative risk) of composite outcomes and that of its most critical component (i.e. death) by estimating the Bias Attributable to Composite Outcomes index [ln(relative risk for the composite outcome)/ln(relative risk for death)]. RESULTS Composite endpoints accounted for 152 out of 417 primary endpoints in coronavirus disease 2019 randomized trials, being more frequent among studies published in high-impact journals. Ordinal endpoints were the most common (54% of all composites), followed by binary or time-to-event (34%), numerical (11%), and hierarchical (1%). Composites predominated among trials enrolling patients with severe disease when compared to trials with a mild or moderate case mix (odds ratio = 1.72). Adaptations of the seven-point World Health Organization scale occurred in 40% of the ordinal primary endpoints, which frequently underwent dichotomization for the statistical analyses. Mortality accounted for a median of 24% (interquartile range: 6%-48%) of all events when included in the composite. The median point estimate of the Bias Attributable to Composite Outcomes index was 0.3 (interquartile range: -0.1 to 0.7), being significantly lower than 1 in 5 of 24 comparisons. DISCUSSION Composite endpoints were used in a significant proportion of coronavirus disease 2019 trials, especially those involving severely ill patients. This is likely due to the higher anticipated rates of competing events, such as death, in such studies. Ordinal composites were common but often not fully appreciated, reducing the potential gains in information and statistical efficiency. For studies with binary composites, death was the most frequent component, and, unexpectedly, composite outcome estimates were often closer to the null when compared to those for mortality death. Numerical composites were less common, and only two trials used hierarchical endpoints. These newer approaches may offer advantages over traditional binary and ordinal composites; however, their potential benefits warrant further scrutiny. CONCLUSION Composite endpoints accounted for more than a third of coronavirus disease 2019 trials' primary endpoints; their use was more common among studies that included patients with severe disease and their point effect estimates tended to underestimate those for mortality.
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Affiliation(s)
- Pedro Nascimento Martins
- Federal University of Juiz de Fora, Juiz de Fora, Brazil
- Department of Epidemiology, School of Public Health, University of São Paulo, São Paulo, Brazil
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3
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Dong G, Cui Y, Gamalo-Siebers M, Liao R, Liu D, Hoaglin DC, Lu Y. On approximate equality of Z-values of the statistical tests for win statistics (win ratio, win odds, and net benefit). J Biopharm Stat 2024:1-8. [PMID: 39377308 DOI: 10.1080/10543406.2024.2374857] [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: 07/23/2023] [Accepted: 06/25/2024] [Indexed: 10/09/2024]
Abstract
Dong et al. (2023) showed that the win statistics (win ratio, win odds, and net benefit) can complement each another to demonstrate the strength of treatment effects in randomized trials with prioritized multiple outcomes. This result was built on the connections among the point and variance estimates of the three statistics, and the approximate equality of Z-values in their statistical tests. However, the impact of this approximation was not clear. This Discussion refines this approach and shows that the approximate equality of Z-values for the win statistics holds more generally. Thus, the three win statistics consistently yield closely similar p-values. In addition, our simulations show an example that the naive approach without adjustment for censoring bias may produce a completely opposite conclusion from the true results, whereas the IPCW (inverse-probability-of-censoring weighting) approach can effectively adjust the win statistics to the corresponding true values (i.e. IPCW-adjusted win statistics are unbiased estimators of treatment effect).
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Affiliation(s)
| | - Ying Cui
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | | | - Ran Liao
- Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Dacheng Liu
- Boehringer Ingelheim, Ridgefield, Connecticut, USA
| | - David C Hoaglin
- Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, Massachusetts, USA
| | - Ying Lu
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
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4
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Sweeney DA, Póvoa P. What are the clinical and research lessons learned from immunomodulators and other therapies during the COVID-19 pandemic? Curr Opin Crit Care 2024; 30:420-426. [PMID: 39150024 DOI: 10.1097/mcc.0000000000001184] [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: 08/17/2024]
Abstract
PURPOSE OF REVIEW The development and use of immunomodulators and other therapies during the coronavirus disease 2019 (COVID-19) pandemic provided several lessons with respect to these therapies, and to how medical researchers and clinicians should approach the next pandemic. RECENT FINDINGS New or repurposed therapies, particularly immunomodulator treatments, for the treatment of an infectious disease will always be associated with inherent patient risk and this was the case during the COVID-19 pandemic. The concomitant development and use of effective antimicrobial therapies along with close monitoring for secondary infections is paramount for patient safety and treatment success. The development of immunomodulators and other therapies during the COVID-19 pandemic further highlighted the importance of maintaining high standards for medical research for all potential treatment with large double-blind placebo-controlled trials and peer review being the best mode of disseminating medical results rather than social media outlets. SUMMARY The next new and emerging pandemic will undoubtedly share many of the same challenges posed by COVID-19. It is important that researchers and clinicians learn from this experience, adhere to tried and true clinical care, all the while conducting high quality research aimed at developing definitive treatments.
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Affiliation(s)
- Daniel A Sweeney
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of California, San Diego, La Jolla, California, USA
| | - Pedro Póvoa
- NOVA Medical School, CHRH, NOVA University of Lisbon, Lisbon, Portugal
- Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark
- Department of Critical Care Medicine, Hospital de São Francisco Xavier, CHLO, Estrada do Forte do Alto do Duque, Lisbon, Portugal
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Schulman S, Resnick HE. "2023 ISTH update of the 2022 ISTH guidelines for antithrombotic treatment in COVID-19": reply. J Thromb Haemost 2024; 22:2672-2673. [PMID: 39174231 DOI: 10.1016/j.jtha.2024.06.009] [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: 06/10/2024] [Accepted: 06/17/2024] [Indexed: 08/24/2024]
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.
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de Barros E Silva PGM, Furtado RHM, de Alcântara Chaud MS, Macedo AVS, Bronhara B, Damiani LP, Barbosa LM, Suiama MA, Ramacciotti E, de Aquino Martins P, de Oliveira AL, Nunes VS, Ritt LEF, Rocha AT, Tramujas L, Santos SV, Diaz DRA, Viana LS, Melro LMG, Figueiredo EL, Neuenschwander FC, Dracoulakis MDA, Lima RGSD, de Souza Dantas VC, Fernandes ACS, Gebara OCE, Hernandes ME, Queiroz DAR, Veiga VC, Canesin MF, de Faria LM, Feitosa-Filho GS, Gazzana MB, Liporace IL, de Oliveira Twardowsky A, Maia LN, Machado FR, de Matos Soeiro A, Conceição-Souza GE, Armaganijan L, Guimarães PO, Rosa RG, Azevedo LCP, Alexander JH, Avezum A, Berwanger O, Cavalcanti AB, Lopes RD. Predictors of bleeding and thrombotic events among patients admitted to the hospital with COVID-19 and elevated D-dimer: insights from the ACTION randomized clinical trial. J Thromb Thrombolysis 2024; 57:1031-1039. [PMID: 38762708 DOI: 10.1007/s11239-024-02995-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2024] [Indexed: 05/20/2024]
Abstract
Therapeutic anticoagulation showed inconsistent results in hospitalized patients with COVID-19 and selection of the best patients to use this strategy still a challenge balancing the risk of thrombotic and hemorrhagic outcomes. The present post-hoc analysis of the ACTION trial evaluated the variables independently associated with both bleeding events (major bleeding or clinically relevant non-major bleeding) and the composite outcomes thrombotic events (venous thromboembolism, myocardial infarction, stroke, systemic embolism, or major adverse limb events). Variables were assessed one by one with independent logistic regressions and final models were chosen based on Akaike information criteria. The model for bleeding events showed an area under the curve of 0.63 (95% confidence interval [CI] 0.53 to 0.73), while the model for thrombotic events had an area under the curve of 0.72 (95% CI 0.65 to 0.79). Non-invasive respiratory support was associated with thrombotic but not bleeding events, while invasive ventilation was associated with both outcomes (Odds Ratio of 7.03 [95 CI% 1.95 to 25.18] for thrombotic and 3.14 [95% CI 1.11 to 8.84] for bleeding events). Beyond respiratory support, creatinine level (Odds Ratio [OR] 1.01 95% CI 1.00 to 1.02 for every 1.0 mg/dL) and history of coronary disease (OR 3.67; 95% CI 1.32 to 10.29) were also independently associated to the risk of thrombotic events. Non-invasive respiratory support, history of coronary disease, and creatinine level may help to identify hospitalized COVID-19 patients at higher risk of thrombotic complications.ClinicalTrials.gov: NCT04394377.
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Affiliation(s)
- Pedro Gabriel Melo de Barros E Silva
- Brazilian Clinical Research Institute, São Paulo, Brazil
- Hcor Research Institute, São Paulo, Brazil
- Hospital Samaritano Paulista, São Paulo, Brazil
- Centro Universitario São Camilo, São Paulo, Brazil
| | - Remo H M Furtado
- Brazilian Clinical Research Institute, São Paulo, Brazil
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Instituto Do Coração (InCor), Hospital das Clinicas da Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | | | - Bruna Bronhara
- Brazilian Clinical Research Institute, São Paulo, Brazil
| | | | | | | | | | | | | | | | - Luiz Eduardo Fonteles Ritt
- Instituto D'Or de Pesquisa E Ensino, Hospital Cárdio Pulmonar, Salvador, Brazil
- Escola Bahiana de Medicina, Salvador, Brazil
| | - Ana Thereza Rocha
- Instituto D'Or de Pesquisa E Ensino, Hospital Cárdio Pulmonar, Salvador, Brazil
- Escola Bahiana de Medicina, Salvador, Brazil
- Universidade Federal da Bahia, Salvador, Brazil
| | | | | | | | - Lorena Souza Viana
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | | | | | | | | | | | | | | | | | - Viviane C Veiga
- BP-A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
- Hospital Universitário da Universidade Estadual de Londrina, Londrina, Brazil
| | | | | | | | | | | | | | - Lilia Nigro Maia
- Pain and Intensive Care Department, Federal University of Sao Paulo (UNIFESP), São Paulo, Brazil
| | - Flávia Ribeiro Machado
- BP-A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
- Instituto Socrates Guanaes, São Paulo, Brazil
| | - Alexandre de Matos Soeiro
- Instituto Do Coração (InCor), Hospital das Clinicas da Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | | | - Patrícia O Guimarães
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Regis G Rosa
- BP-A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
- Instituto Dante Pazzanese de Cardiologia, São Paulo, Brazil
| | - Luciano C P Azevedo
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil
- BP-A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | - John H Alexander
- Duke Clinical Research Institute, Duke University Medical Center, 2400 Pratt Street, Box 3850, Durham, NC, 27705, USA
| | | | - Otávio Berwanger
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Imperial College London, London, UK
- The George Institute for Global Health UK, London, UK
| | - Alexandre B Cavalcanti
- Hcor Research Institute, São Paulo, Brazil
- BP-A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | - Renato D Lopes
- Brazilian Clinical Research Institute, São Paulo, Brazil.
- Duke Clinical Research Institute, Duke University Medical Center, 2400 Pratt Street, Box 3850, Durham, NC, 27705, USA.
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7
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Rettew A, Garrahy I, Rahimian S, Brown R, Sangha N. COVID-19 Coagulopathy. Life (Basel) 2024; 14:953. [PMID: 39202695 PMCID: PMC11355811 DOI: 10.3390/life14080953] [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: 07/03/2024] [Revised: 07/25/2024] [Accepted: 07/26/2024] [Indexed: 09/03/2024] Open
Abstract
Coronavirus disease of 2019 (COVID-19) is the respiratory viral infection caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Despite being a primary respiratory illness, it is commonly complicated by systemic involvement of the vasculature leading to arterial and venous thrombosis. In this review, we will focus on the association between COVID-19 and thrombosis. We will highlight the pathophysiology of COVID-19 coagulopathy. The clinical manifestations of COVID-19 vasculopathy will be discussed with a focus on venous and arterial thromboembolic events. COVID-19 vasculopathy and disseminated intravascular coagulation (DIC) are distinguished within, as well as areas of controversy, such as "long COVID". Finally, the current professional guidelines on prevention and treatment of thrombosis associated with SARS-CoV-2 infection will be discussed.
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Affiliation(s)
| | - Ian Garrahy
- Tower Health System, Reading Hospital, West Reading, PA 19611, USA; (A.R.); (S.R.); (R.B.); (N.S.)
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Galeano-Valle F, Demelo-Rodríguez P, Alonso-Beato R, Pedrajas JM, Fernández-Reyes JL, Chopard R, Sadeghipour P, Hirmerova J, Bikdeli B, Monreal M. Comparative analysis of COVID-19-associated venous thromboembolism outcomes: evolution from 2020 to 2021-2022. J Thromb Thrombolysis 2024:10.1007/s11239-024-03026-6. [PMID: 39078534 DOI: 10.1007/s11239-024-03026-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/16/2024] [Indexed: 07/31/2024]
Abstract
Patients with COVID-19 are at an increased risk for venous thromboembolism (VTE). With the advent of vaccinations and novel treatments from 2020 through 2022, the landscape of COVID-19 has evolved. Notably, the effects of such interventions on the outcomes of COVID-19-associated VTE have not been thoroughly examined. Data from the RIETE registry were analyzed to evaluate 90-day VTE-related outcomes (all-cause mortality, major bleeding, and VTE recurrences) in patients with COVID-19-associated VTE. We compared the periods before and after the widespread introduction of COVID-19 vaccines: March to December 2020 (pre-vaccine period) and March 2021 to December 2022 (post-vaccine period). Statistical analysis included mixed-effects parametric survival-time models. Among 1,620 patients with COVID-19-associated VTE, most (74.1%) were identified during 2020 period. The analysis revealed a more than two-fold increase in the risk of death within 90 days (adjusted hazard ratio [HR]: 2.27; 95% confidence interval, CI: 1.18-4.38) and major bleeding (adjusted HR: 2.91; 95%CI: 1.08-7.84) for patients from the 2020 period compared to those from the 2021-2022 period. Inpatient subgroup analysis confirmed the observed mortality differences. The frequency of recurrent VTE was low (1.1 vs. 0.7%, respectively), and did not show significant variation between the two periods. Our research provides a comparative perspective on the clinical outcomes of COVID-19-associated VTE before and after the introduction of vaccines. Our findings reveal a significant decrease in the incidence of 90-day mortality and major bleeding in patients with COVID-19-associated VTE in the 2021-2022 period.
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Affiliation(s)
- Francisco Galeano-Valle
- Internal Medicine Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Pablo Demelo-Rodríguez
- Internal Medicine Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Rubén Alonso-Beato
- Internal Medicine Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
- Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain.
| | | | | | - Romain Chopard
- Department of Cardiology, University Hospital Jean Minjoz, Besançon, France
| | - Parham Sadeghipour
- Department of Peripheral Vascular Diseases, Rajaie Cardiovascular Medical and Research Center, Tehran, Iran
| | - Jana Hirmerova
- Department of Internal Medicine, University Hospital Plzen, Plzen, Czech Republic
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital/Yale, New Haven, CT, USA
| | - Manuel Monreal
- Chair for the Study of Thromboembolic Disease, Faculty of Health Sciences, UCAM, Universidad Católica San Antonio de Murcia, Murcia, Spain
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
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9
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Olson MG, Park TD, Alvarez R, Hogan EA, Ovard O, Khanna O, Youssef AS. The effect of SARS-CoV-2 on the incidence of post-operative venous sinus thrombosis following skull base procedures. Acta Neurochir (Wien) 2024; 166:302. [PMID: 39037618 DOI: 10.1007/s00701-024-06197-6] [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: 04/26/2024] [Accepted: 07/07/2024] [Indexed: 07/23/2024]
Abstract
PURPOSE Sinus thrombosis is a common post-operative finding after posterior fossa surgery performed in the vicinity of the dural venous sinuses. The SARS-CoV-2 virus has been shown to confer an increased risk of venous thromboembolic events owing to eliciting a hyper-inflammatory and pro-thrombotic state. In this study, we examine the incidence of post-operative venous sinus thrombosis in patients undergoing peri-sigmoid posterior fossa surgery in the pre- and post-COVID era and investigate whether COVID infection confers an increased risk of sinus thrombosis. METHODS A retrospective review of a single institution case series of patients underwent peri-sigmoid surgery (retrosigmoid, translabyrinthine, or far lateral) approach. Relevant clinical variables were investigated that may confer an increased risk of sinus thrombosis. RESULTS A total of 311 patients (178 in the pre-COVID era, and 133 operated on after the pandemic began in March 2020) are included in the study. The composite incidence of sinus thrombosis seen on post-operative imaging was 7.8%. The incidence of sinus thrombosis in the pre-COVID cohort was N = 12 patients (6.7%) versus N = 12 (9%) in the post-COVID cohort (p = 0.46). A history of COVID infection was not shown to confer an increased risk of post-operative sinus thrombosis (OR: 0.61; 95% CI: 0.08-4.79, p = 0.64). Only a small number of patients (N = 7, 2.3%) required either medical or surgical intervention for post-operative sinus thrombosis. CONCLUSION The overall incidence of post-operative sinus thrombosis is similar in the pre- and post-COVID era. The findings of this study suggest that COVID infection is not associated with a higher risk of venous sinus thrombosis.
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Affiliation(s)
- Madeline G Olson
- University of Colorado Anschutz School of Medicine, Aurora, CO, USA
| | - Tyler D Park
- University of Colorado Anschutz School of Medicine, Aurora, CO, USA
| | - Reinier Alvarez
- Department of Neurosurgery, University of Colorado Anschutz School of Medicine, Aurora, CO, USA
| | - Elizabeth A Hogan
- Department of Neurosurgery, University of Colorado Anschutz School of Medicine, Aurora, CO, USA
| | - Olivia Ovard
- University of Colorado Anschutz School of Medicine, Aurora, CO, USA
| | - Omaditya Khanna
- Department of Neurosurgery, University of Colorado Anschutz School of Medicine, Aurora, CO, USA
| | - A Samy Youssef
- Department of Neurosurgery, University of Colorado Anschutz School of Medicine, Aurora, CO, USA.
- Department of Otolaryngology, University of Colorado Anschutz School of Medicine, Aurora, CO, USA.
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Amin L, Qayyum K, Uzair M, Khan F, Sethi P, Hanif L, Azhar A, Mazhar S, Ejaz U, Jawad S. Factor Xa inhibitors versus low-molecular-weight heparin for preventing coagulopathy following COVID-19: a systematic review and meta-analysis of randomized controlled trials. Ann Med Surg (Lond) 2024; 86:4075-4082. [PMID: 38989229 PMCID: PMC11230789 DOI: 10.1097/ms9.0000000000002079] [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: 01/28/2024] [Accepted: 04/05/2024] [Indexed: 07/12/2024] Open
Abstract
Background Hospitalized patients with COVID-19 have shown a significant occurrence of thromboembolism and a heightened risk of death. It remains unclear whether factor Xa inhibitors are superior to enoxaparin in this context. Hence, there is a need for a direct comparison to assess the preventive effects and safety of factor Xa inhibitors versus enoxaparin in hospitalized COVID-19 patients. Methods MEDLINE, Embase, and Cochrane Central databases were searched for randomized controlled trials (RCTs) or retrospective studies that compared the effectiveness or safety of factor Xa inhibitors and enoxaparin in preventing thromboembolism in hospitalized patients with COVID-19. Embolic incidence, incidence of bleeding, and all-cause mortality were among the outcomes of interest. Mantel-Haenszel weighted random-effects model was used to calculate relative risks (RRs) with 95 percent CIs. Results The analysis included six RCTs and two retrospective studies containing 4048 patients. Meta-analysis showed a statistically significant reduction among patients on factor Xa inhibitors compared with low-molecular-weight heparin (LMWH) in the embolic incidence [risk ratio (RR) 0.64 (95%, CI 0.42, 0.98); P=0.04, I2=12%]. Upon subgroup analysis by type of study design, no significant reductions were noted in patients on factor Xa inhibitors in RCTs (RR: 0.62; 95% CI: 0.33-1.17; P=0.14) or observational studies (RR: 0.53; 95% CI: 0.23-1.26; P=0.15) when compared with enoxaparin Factor Xa inhibitors were not significantly associated with incidence of bleeding [RR 0.76 (95% CI 0.36, 1.61); P=0.47, I2=0%] or all-cause mortality (RR: 0.81; 95% CI: 0.48-1.36; P=0.43). Consistent results were obtained upon subgroup analysis by the type of study design. Conclusion Factor Xa inhibitors are more effective than enoxaparin in preventing thromboembolism among patients with COVID-19 who are not acutely ill and are hospitalized. Additional rigorous RCTs comparing factor Xa inhibitors with enoxaparin are warranted.
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Affiliation(s)
- Laraib Amin
- Department of Medicine, Northwest General Hospital And Research Centre, Peshawar
| | - Komal Qayyum
- Department of Medicine, Northwest General Hospital And Research Centre, Peshawar
| | - Muhammad Uzair
- Department of Medicine, Northwest General Hospital And Research Centre, Peshawar
| | - Fatima Khan
- Department of Medicine, Northwest General Hospital And Research Centre, Peshawar
| | - Parkha Sethi
- Department of Medicine, Northwest General Hospital And Research Centre, Peshawar
| | - Laiba Hanif
- Department of Medicine, Pakistan Institute of Medical Sciences, Islamabad
| | - Aima Azhar
- Department of Medicine, King Edward Medical University, Lahore, Pakistan
| | - Saad Mazhar
- Department of Medicine, King Edward Medical University, Lahore, Pakistan
| | - Umer Ejaz
- Department of Medicine, Rawalpindi Medical University, Rawalpindi, Pakistan
| | - Sayed Jawad
- Department of Medicine, Kabul University of Health Sciences, Kabul, Afghanistan
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11
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Schnipper JL, Oreper S, Hubbard CC, Kurbegov D, Egloff SAA, Najafi N, Valdes G, Siddiqui Z, O 'Leary KJ, Horwitz LI, Lee T, Auerbach AD. Analysis of Clinical Criteria for Discharge Among Patients Hospitalized for COVID-19: Development and Validation of a Risk Prediction Model. J Gen Intern Med 2024:10.1007/s11606-024-08856-x. [PMID: 38937368 DOI: 10.1007/s11606-024-08856-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 06/03/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Patients hospitalized with COVID-19 can clinically deteriorate after a period of initial stability, making optimal timing of discharge a clinical and operational challenge. OBJECTIVE To determine risks for post-discharge readmission and death among patients hospitalized with COVID-19. DESIGN Multicenter retrospective observational cohort study, 2020-2021, with 30-day follow-up. PARTICIPANTS Adults admitted for care of COVID-19 respiratory disease between March 2, 2020, and February 11, 2021, to one of 180 US hospitals affiliated with the HCA Healthcare system. MAIN MEASURES Readmission to or death at an HCA hospital within 30 days of discharge was assessed. The area under the receiver operating characteristic curve (AUC) was calculated using an internal validation set (33% of the HCA cohort), and external validation was performed using similar data from six academic centers associated with a hospital medicine research network (HOMERuN). KEY RESULTS The final HCA cohort included 62,195 patients (mean age 61.9 years, 51.9% male), of whom 4704 (7.6%) were readmitted or died within 30 days of discharge. Independent risk factors for death or readmission included fever within 72 h of discharge; tachypnea, tachycardia, or lack of improvement in oxygen requirement in the last 24 h; lymphopenia or thrombocytopenia at the time of discharge; being ≤ 7 days since first positive test for SARS-CoV-2; HOSPITAL readmission risk score ≥ 5; and several comorbidities. Inpatient treatment with remdesivir or anticoagulation were associated with lower odds. The model's AUC for the internal validation set was 0.73 (95% CI 0.71-0.74) and 0.66 (95% CI 0.64 to 0.67) for the external validation set. CONCLUSIONS This large retrospective study identified several factors associated with post-discharge readmission or death in models which performed with good discrimination. Patients 7 or fewer days since test positivity and who demonstrate potentially reversible risk factors may benefit from delaying discharge until those risk factors resolve.
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Affiliation(s)
- Jeffrey L Schnipper
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
- COVID-19 Consortium of HCA Healthcare and Academia for Research Generation (CHARGE), Nashville, TN, USA.
| | - Sandra Oreper
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, CA, USA
- COVID-19 Consortium of HCA Healthcare and Academia for Research Generation (CHARGE), Nashville, TN, USA
| | - Colin C Hubbard
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, CA, USA
- COVID-19 Consortium of HCA Healthcare and Academia for Research Generation (CHARGE), Nashville, TN, USA
| | - Dax Kurbegov
- COVID-19 Consortium of HCA Healthcare and Academia for Research Generation (CHARGE), Nashville, TN, USA
- HCA Healthcare, Sarah Cannon Research Institute (SCRI), Nashville, TN, USA
| | - Shanna A Arnold Egloff
- COVID-19 Consortium of HCA Healthcare and Academia for Research Generation (CHARGE), Nashville, TN, USA
- HCA Healthcare, Sarah Cannon Research Institute (SCRI), Nashville, TN, USA
- HCA Healthcare, HCA Healthcare Research Institute (HRI), Kansas City, MO, USA
| | - Nader Najafi
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, CA, USA
- COVID-19 Consortium of HCA Healthcare and Academia for Research Generation (CHARGE), Nashville, TN, USA
| | - Gilmer Valdes
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, CA, USA
- COVID-19 Consortium of HCA Healthcare and Academia for Research Generation (CHARGE), Nashville, TN, USA
| | - Zishan Siddiqui
- Division of Hospital Medicine, John Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kevin J O 'Leary
- Division of Hospital Medicine, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Leora I Horwitz
- Department of Population Health, Department of Medicine, NYU Grossman School of Medicine; Center for Healthcare Innovation and Delivery Science, NYU Langone Health, New York City, NY, USA
| | - Tiffany Lee
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, CA, USA
- COVID-19 Consortium of HCA Healthcare and Academia for Research Generation (CHARGE), Nashville, TN, USA
| | - Andrew D Auerbach
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, CA, USA
- COVID-19 Consortium of HCA Healthcare and Academia for Research Generation (CHARGE), Nashville, TN, USA
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12
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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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13
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Iba T, Levy JH, Maier CL, Connors JM, Levi M. Four years into the pandemic, managing COVID-19 patients with acute coagulopathy: what have we learned? J Thromb Haemost 2024; 22:1541-1549. [PMID: 38428590 DOI: 10.1016/j.jtha.2024.02.013] [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: 12/11/2023] [Revised: 02/14/2024] [Accepted: 02/20/2024] [Indexed: 03/03/2024]
Abstract
Coagulopathy alongside micro- and macrovascular thrombotic events were frequent characteristics of patients presenting with acute COVID-19 during the initial stages of the pandemic. However, over the past 4 years, the incidence and manifestations of COVID-19-associated coagulopathy have changed due to immunity from natural infection and vaccination and the appearance of new SARS-CoV-2 variants. Diagnostic criteria and management strategies based on early experience and studies for COVID-19-associated coagulopathy thus require reevaluation. As many other infectious disease states are also associated with hemostatic dysfunction, the coagulopathy associated with COVID-19 may be compounded, especially throughout the winter months, in patients with diverse etiologies of COVID-19 and other infections. This commentary examines what we have learned about COVID-19-associated coagulopathy throughout the pandemic and how we might best prepare to mitigate the hemostatic consequences of emerging infection agents.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Cheryl L Maier
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jean M Connors
- Hematology Division Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marcel Levi
- Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands; Department of Medicine, University College London Hospitals NHS Foundation Trust, Cardio-metabolic Programme-National Institute for Health and Care Research University College London Hospitals/University College London Biomedical Research Center, London, United Kingdom
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14
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Meng J, Tang H, Xiao Y, Liu W, Wu Y, Xiong Y, Gao S. Appropriate thromboprophylaxis strategy for COVID-19 patients on dosage, antiplatelet therapy, outpatient, and postdischarge prophylaxis: a meta-analysis of randomized controlled trials. Int J Surg 2024; 110:3910-3922. [PMID: 38549227 PMCID: PMC11175823 DOI: 10.1097/js9.0000000000001307] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 02/25/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND There was controversy surrounding the optimal thromboprophylaxis strategy for coronavirus disease 2019 (COVID-19) patients. This included debates on the dosage of anticoagulants for thromboembolism prophylaxis, the requirement for additional antiplatelet therapy, and the necessity of prophylaxis for outpatients and postdischarge. To explore this, the authors performed a meta-analysis of randomized controlled trials. METHODS PubMed, Cochrane Library, Embase, and Web of Science were last searched on 26 July 2023 for studies comparing the effect of different dose of anticoagulation, additional antiplatelet, and postdischarge prophylaxis for COVID-19 patients. The results of eligible studies were analyzed in terms of thromboembolism events, major bleeding and all-cause mortality during follow-up. RESULTS Our study included a total of 25 randomized controlled trials, involving 17 911 patients. Our results revealed that, compared to prophylactic dose, therapeutic dose showed lower thrombotic risk (RR, 0.66; 95% CI: 0.45-0.96) but had similar major bleeding risk for critically ill patients with COVID-19. On the other hand, intermediate dose and prophylactic dose demonstrated similar thromboembolism risk and major bleeding risk. For noncritically ill patients with COVID-19, therapeutic dose of anticoagulants was associated with lower thrombotic risk (RR, 0.50; 95% CI: 0.34-0.72) but, at the same time, increased the risk of major bleeding (RR, 2.01; 95% CI: 1.22-3.33). However, intermediate dose showed lower thromboembolism risk (RR, 0.38; 95% CI: 0.21-0.69) while maintaining a similar major bleeding risk. In critically ill patients, additional antiplatelet therapy showed similar thromboembolism, major bleeding risk, and mortality when compared to no treatment. For outpatients, additional prophylactic anticoagulation showed similar thromboembolism, major bleeding risk, and mortality when compared to no treatment. For postdischarge patients, postdischarge prophylaxis reduced thromboembolism risk (RR, 0.49; 95% CI: 0.31-0.76) but increased major bleeding risk (RR, 2.63; 95% CI: 1.13-6.14). CONCLUSION For noncritically ill patients, therapeutic dose prophylactic anticoagulation significantly reduced venous thromboembolism but increases major bleeding risk. Intermediate dose effectively lowered venous thromboembolism without raising major bleeding risk. The optimal dose and need for additional antiplatelet therapy in critically ill patients, as well as the necessity of prophylactic anticoagulation in outpatient and postdischarge patients, required further investigation and confirmation through rigorous evidence studies.
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Affiliation(s)
- Jiahao Meng
- Department of Orthopaedics, Xiangya Hospital, Central South University
| | - Hang Tang
- Department of Orthopaedics, Xiangya Hospital, Central South University
| | - Yifan Xiao
- Department of Orthopaedics, Xiangya Hospital, Central South University
| | - Weijie Liu
- Department of Orthopaedics, Xiangya Hospital, Central South University
| | - Yumei Wu
- Department of Orthopaedics, Xiangya Hospital, Central South University
| | - Yilin Xiong
- Department of Orthopaedics, Xiangya Hospital, Central South University
| | - Shuguang Gao
- Department of Orthopaedics, Xiangya Hospital, Central South University
- Hunan Key Laboratory of Joint Degeneration and Injury
- Hunan Engineering Research Center of Osteoarthritis
- National Clinical Research Center of Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, People’s Republic of China
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15
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Carmichael A, Hale JT, Notta S, Haddadin T, Jbara MH. COVID-19 Infection and ST-Elevation Myocardial Infarction: Lessons in Disease Management During a Pandemic. Cureus 2024; 16:e62008. [PMID: 38984012 PMCID: PMC11233153 DOI: 10.7759/cureus.62008] [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] [Accepted: 06/07/2024] [Indexed: 07/11/2024] Open
Abstract
The emergence of the SARS-CoV-2 virus, causing the COVID-19 pandemic, has profoundly impacted global health, resulting in significant morbidity and mortality worldwide. This paper presents a case study highlighting the heightened risk of severe cardiovascular complications following COVID-19 infection. A 61-year-old male with hyperlipidemia was discharged after COVID-19 pneumonia treatment and experienced a severe ST-elevated myocardial infarction (STEMI) within a day of discharge. A retrospective chart review, supplemented by a literature review, revealed a pattern of increased severity in STEMI cases associated with COVID-19, particularly in patients with pre-existing cardiovascular comorbidities. SARS-CoV-2 induces a prothrombotic state, which causes endothelial dysfunction and systemic inflammation, potentially precipitating thrombotic events. Managing concurrent COVID-19 and STEMI poses unique challenges, emphasizing the critical role of timely intervention, such as percutaneous coronary intervention (PCI), in improving patient outcomes. Despite advancements, uncertainty persists regarding optimal thromboembolism prophylaxis post COVID-19, necessitating ongoing research and meticulous clinical management. While COVID-19 infection rates have declined since the pandemic, this case report hopes to emphasize the need for continued awareness in recognizing the potential thrombotic risks of COVID-19 infection and underscore the need for further investigation into cardiovascular risk as new viral strains develop in the future.
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Affiliation(s)
- Anna Carmichael
- Cardiology, East Tennessee State University Quillen College of Medicine, Johnson City, USA
| | - Joseph T Hale
- Cardiology, East Tennessee State University Quillen College of Medicine, Johnson City, USA
| | - Shahnawaz Notta
- Internal Medicine, East Tennessee State University Quillen College of Medicine, Johnson City, USA
| | - Tariq Haddadin
- Cardiology, East Tennessee State University Quillen College of Medicine, Johnson City, USA
| | - Manar H Jbara
- Cardiology, East Tennessee State University Quillen College of Medicine, Johnson City, USA
- Internal Medicine, East Tennessee State University Quillen College of Medicine, Johnson City, USA
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16
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Poloni A, Casalini G, Pozza G, Giacomelli A, Colaneri M, Carrozzo G, Caloni B, Ciubotariu CL, Zacheo M, Rabbione A, Pieruzzi M, Barone F, Passerini M, Ridolfo AL, Rizzardini G, Gori A, Antinori S. Major Bleeding Events in Hospitalized COVID-19 Patients: A Retrospective Observational Study. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:814. [PMID: 38792997 PMCID: PMC11122796 DOI: 10.3390/medicina60050814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/08/2024] [Accepted: 05/14/2024] [Indexed: 05/26/2024]
Abstract
Thromboprophylaxis/anticoagulation treatment is often required in hospitalized COVID-19 patients. We aimed to estimate the prevalence of major bleeding events in hospitalized COVID-19 patients. This was a retrospective observational study including all COVID-19 hospitalized patients ≥18 years of age at one reference center in northern Italy. The crude prevalence (between February 2020-2022) of major bleeding events was estimated as the number of major bleeding episodes divided by patients at risk. Uni- and multivariable Cox models were built to assess factors potentially associated with major bleeding events. Twenty-nine (0.98%) out of 2,945 COVID-19 patients experienced a major bleeding event [prevalence of 0.55% (95%CI 0.37-0.79)], of which five were fatal. Patients who experienced a major bleeding event were older [78 years (72-84 IQR) vs. 67 years (55-78 IQR), p-value < 0.001] and more frequently exposed to anti-aggregating therapy (44.8% vs. 20.0%, p-value 0.002) when compared to those who did not. In the multivariable Cox model, age [per 1 year more AHR 1.05 (CI95% 1.02-1.09)] was independently associated with an increased risk of major bleeding events. A strict monitoring of older hospitalized COVID-19 patients is warranted due to the risk of major bleeding events.
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Affiliation(s)
- Andrea Poloni
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20122 Milan, Italy; (A.P.); (G.P.); (G.C.); (B.C.); (C.L.C.); (M.Z.); (A.R.); (M.P.); (F.B.); (A.G.); (S.A.)
- III Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy; (G.C.); (A.L.R.)
| | - Giacomo Casalini
- III Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy; (G.C.); (A.L.R.)
| | - Giacomo Pozza
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20122 Milan, Italy; (A.P.); (G.P.); (G.C.); (B.C.); (C.L.C.); (M.Z.); (A.R.); (M.P.); (F.B.); (A.G.); (S.A.)
- III Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy; (G.C.); (A.L.R.)
| | - Andrea Giacomelli
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20122 Milan, Italy; (A.P.); (G.P.); (G.C.); (B.C.); (C.L.C.); (M.Z.); (A.R.); (M.P.); (F.B.); (A.G.); (S.A.)
- III Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy; (G.C.); (A.L.R.)
| | - Marta Colaneri
- II Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy; (M.C.); (M.P.)
| | - Giorgia Carrozzo
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20122 Milan, Italy; (A.P.); (G.P.); (G.C.); (B.C.); (C.L.C.); (M.Z.); (A.R.); (M.P.); (F.B.); (A.G.); (S.A.)
- III Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy; (G.C.); (A.L.R.)
| | - Beatrice Caloni
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20122 Milan, Italy; (A.P.); (G.P.); (G.C.); (B.C.); (C.L.C.); (M.Z.); (A.R.); (M.P.); (F.B.); (A.G.); (S.A.)
- III Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy; (G.C.); (A.L.R.)
| | - Cosmin Lucian Ciubotariu
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20122 Milan, Italy; (A.P.); (G.P.); (G.C.); (B.C.); (C.L.C.); (M.Z.); (A.R.); (M.P.); (F.B.); (A.G.); (S.A.)
- III Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy; (G.C.); (A.L.R.)
| | - Martina Zacheo
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20122 Milan, Italy; (A.P.); (G.P.); (G.C.); (B.C.); (C.L.C.); (M.Z.); (A.R.); (M.P.); (F.B.); (A.G.); (S.A.)
- III Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy; (G.C.); (A.L.R.)
| | - Andrea Rabbione
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20122 Milan, Italy; (A.P.); (G.P.); (G.C.); (B.C.); (C.L.C.); (M.Z.); (A.R.); (M.P.); (F.B.); (A.G.); (S.A.)
- III Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy; (G.C.); (A.L.R.)
| | - Margherita Pieruzzi
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20122 Milan, Italy; (A.P.); (G.P.); (G.C.); (B.C.); (C.L.C.); (M.Z.); (A.R.); (M.P.); (F.B.); (A.G.); (S.A.)
- III Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy; (G.C.); (A.L.R.)
| | - Federico Barone
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20122 Milan, Italy; (A.P.); (G.P.); (G.C.); (B.C.); (C.L.C.); (M.Z.); (A.R.); (M.P.); (F.B.); (A.G.); (S.A.)
- III Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy; (G.C.); (A.L.R.)
| | - Matteo Passerini
- II Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy; (M.C.); (M.P.)
| | - Anna Lisa Ridolfo
- III Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy; (G.C.); (A.L.R.)
| | - Giuliano Rizzardini
- I Division of Infectious Diseases, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy;
| | - Andrea Gori
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20122 Milan, Italy; (A.P.); (G.P.); (G.C.); (B.C.); (C.L.C.); (M.Z.); (A.R.); (M.P.); (F.B.); (A.G.); (S.A.)
- II Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy; (M.C.); (M.P.)
- Centre for Multidisciplinary Research in Health Science (MACH), Università degli Studi di Milano, 20122 Milan, Italy
| | - Spinello Antinori
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20122 Milan, Italy; (A.P.); (G.P.); (G.C.); (B.C.); (C.L.C.); (M.Z.); (A.R.); (M.P.); (F.B.); (A.G.); (S.A.)
- III Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy; (G.C.); (A.L.R.)
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17
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Othman HY, Zaki IAH, Isa MR, Ming LC, Zulkifly HH. A systematic review of thromboembolic complications and outcomes in hospitalised COVID-19 patients. BMC Infect Dis 2024; 24:484. [PMID: 38730292 PMCID: PMC11088167 DOI: 10.1186/s12879-024-09374-1] [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: 11/14/2023] [Accepted: 05/03/2024] [Indexed: 05/12/2024] Open
Abstract
Thromboembolic (TE) complications [myocardial infarction (MI), stroke, deep vein thrombosis (DVT), and pulmonary embolism (PE)] are common causes of mortality in hospitalised COVID-19 patients. Therefore, this review was undertaken to explore the incidence of TE complications and mortality associated with TE complications in hospitalised COVID-19 patients from different studies. A literature search was performed using ScienceDirect and PubMed databases using the MeSH term search strategy of "COVID-19", "thromboembolic complication", "venous thromboembolism", "arterial thromboembolism", "deep vein thrombosis", "pulmonary embolism", "myocardial infarction", "stroke", and "mortality". There were 33 studies included in this review. Studies have revealed that COVID-19 patients tend to develop venous thromboembolism (PE:1.0-40.0% and DVT:0.4-84%) compared to arterial thromboembolism (stroke:0.5-15.2% and MI:0.8-8.7%). Lastly, the all-cause mortality of COVID-19 patients ranged from 4.8 to 63%, whereas the incidence of mortality associated with TE complications was between 5% and 48%. A wide range of incidences of TE complications and mortality associated with TE complications can be seen among hospitalized COVID-19 patients. Therefore, every patient should be assessed for the risk of thromboembolic complications and provided with an appropriate thromboprophylaxis management plan tailored to their individual needs.
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Affiliation(s)
- Hanies Yuhana Othman
- Department of Clinical Pharmacy, Fakulti Farmasi, Universiti Teknologi MARA Cawangan Selangor, Kampus Puncak Alam, Bandar Puncak Alam, Selangor, Malaysia
| | - Izzati Abdul Halim Zaki
- Department of Clinical Pharmacy, Fakulti Farmasi, Universiti Teknologi MARA Cawangan Selangor, Kampus Puncak Alam, Bandar Puncak Alam, Selangor, Malaysia
- Cardiology Therapeutics Research Group, Universiti Teknologi MARA, Puncak Alam, Selangor, Malaysia
| | - Mohamad Rodi Isa
- Faculty of Medicine, Universiti Teknologi MARA Selangor, Sungai Buloh Campus, Sungai Buloh, Selangor, Malaysia
| | - Long Chiau Ming
- School of Medical and Life Sciences, Sunway University, Sunway City, Selangor, Malaysia
| | - Hanis Hanum Zulkifly
- Department of Clinical Pharmacy, Fakulti Farmasi, Universiti Teknologi MARA Cawangan Selangor, Kampus Puncak Alam, Bandar Puncak Alam, Selangor, Malaysia.
- Cardiology Therapeutics Research Group, Universiti Teknologi MARA, Puncak Alam, Selangor, Malaysia.
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18
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Boutkourt F, van Haaps T, Brüggemann R, Bhoelan S, ten Cate H, Kruip MJHA, Spaetgens B, van Es N, Roest T, Joling KJ, Meijer K, Hugtenburg J. The effect of current antithrombotic therapy on mortality in nursing home residents with COVID-19: a multicentre retrospective cohort study. Age Ageing 2024; 53:afae094. [PMID: 38748450 PMCID: PMC11095411 DOI: 10.1093/ageing/afae094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 01/31/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND The first wave of COVID led to an alarmingly high mortality rate among nursing home residents (NHRs). In hospitalised patients, the use of anticoagulants may be associated with a favourable prognosis. However, it is unknown whether the use of antithrombotic medication also protected NHRs from COVID-19-related mortality. OBJECTIVES To investigate the effect of current antithrombotic therapy in NHRs with COVID-19 on 30-day all-cause mortality during the first COVID-19 wave. METHODS We performed a retrospective cohort study linking electronic health records and pharmacy data in NHRs with COVID-19. A propensity score was used to match NHRs with current use of therapeutic dose anticoagulants to NHRs not using anticoagulant medication. The primary outcome was 30-day all-cause mortality, which was evaluated using a logistic regression model. In a secondary analysis, multivariable logistic regression was performed in the complete study group to compare NHRs with current use of therapeutic dose anticoagulants and those with current use of antiplatelet therapy to those without such medication. RESULTS We included 3521 NHRs with COVID-19 based on a positive RT-PCR for SARS-CoV-2 or with a well-defined clinical suspicion of COVID-19. In the matched propensity score analysis, NHRs with current use of therapeutic dose anticoagulants had a significantly lower all-cause mortality (OR = 0.73; 95% CI: 0.58-0.92) compared to NHRs who did not use therapeutic anticoagulants. In the secondary analysis, current use of therapeutic dose anticoagulants (OR: 0.62; 95% CI: 0.48-0.82) and current use of antiplatelet therapy (OR 0.80; 95% CI: 0.64-0.99) were both associated with decreased mortality. CONCLUSIONS During the first COVID-19 wave, therapeutic anticoagulation and antiplatelet use were associated with a reduced risk of all-cause mortality in NHRs. Whether these potentially protective effects are maintained in vaccinated patients or patients with other COVID-19 variants, remains unknown.
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Affiliation(s)
- Firdaouss Boutkourt
- Department of Clinical Pharmacology and Pharmacy, Amsterdam UMC, location VUmc, De Boelelaan 1117, Amsterdam, The Netherlands
- Farmadam Pharmacy Group, Contactweg 127, Amsterdam, The Netherlands
| | - Thijs van Haaps
- Department of Vascular Medicine, Amsterdam UMC, location AMC Meibergdreef 9, Amsterdam, The Netherlands
- Pulmonary Hypertension & Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Reneé Brüggemann
- Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Soerajja Bhoelan
- Department of Hematology, UMC Groningen, University of Groningen, The Netherlands
| | - Hugo ten Cate
- Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Marieke J H A Kruip
- Department of Hematology, Erasmus MC Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bart Spaetgens
- Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Nick van Es
- Department of Vascular Medicine, Amsterdam UMC, location AMC Meibergdreef 9, Amsterdam, The Netherlands
- Pulmonary Hypertension & Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Tineke Roest
- Farmadam Pharmacy Group, Contactweg 127, Amsterdam, The Netherlands
| | - Karlijn J Joling
- Amsterdam Public Health Research Institute, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands, Department of Medicine for Older People, Amsterdam UMC, Location VUmc, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Karina Meijer
- Department of Hematology, UMC Groningen, University of Groningen, The Netherlands
| | - Jacqueline Hugtenburg
- Department of Clinical Pharmacology and Pharmacy, Amsterdam UMC, location VUmc, De Boelelaan 1117, Amsterdam, The Netherlands
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Kondo T, Jhund PS, Gasparyan SB, Yang M, Claggett BL, McCausland FR, Tolomeo P, Vadagunathan M, Heerspink HJL, Solomon SD, McMurray JJV. A hierarchical kidney outcome using win statistics in patients with heart failure from the DAPA-HF and DELIVER trials. Nat Med 2024; 30:1432-1439. [PMID: 38710952 PMCID: PMC11108780 DOI: 10.1038/s41591-024-02941-8] [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: 11/13/2023] [Accepted: 03/21/2024] [Indexed: 05/08/2024]
Abstract
Win statistics offer a new approach to the analysis of outcomes in clinical trials, allowing the combination of time-to-event and longitudinal measurements and taking into account the clinical importance of the components of composite outcomes, as well as their relative timing. We examined this approach in a post hoc analysis of two trials that compared dapagliflozin to placebo in patients with heart failure and reduced ejection fraction (DAPA-HF) and mildly reduced or preserved ejection fraction (DELIVER). The effect of dapagliflozin on a hierarchical composite kidney outcome was assessed, including the following: (1) all-cause mortality; (2) end-stage kidney disease; (3) a decline in estimated glomerular filtration rate (eGFR) of ≥57%; (4) a decline in eGFR of ≥50%; (5) a decline in eGFR of ≥40%; and (6) participant-level eGFR slope. For this outcome, the win ratio was 1.10 (95% confidence interval (CI) = 1.06-1.15) in the combined dataset, 1.08 (95% CI = 1.01-1.16) in the DAPA-HF trial and 1.12 (95% CI = 1.05-1.18) in the DELIVER trial; that is, dapagliflozin was superior to placebo in both trials. The benefits of treatment were consistent in participants with and without baseline kidney disease, and with and without type 2 diabetes. In heart failure trials, win statistics may provide the statistical power to evaluate the effect of treatments on kidney as well as cardiovascular outcomes.
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Affiliation(s)
- Toru Kondo
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Samvel B Gasparyan
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Mingming Yang
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
- Department of Cardiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Finnian R McCausland
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Paolo Tolomeo
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Muthiah Vadagunathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.
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20
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Landsteiner I, Pinheiro JA, Felix N, Gewehr DM, Cardoso R. Chronic Anticoagulation in Patients with Atrial Fibrillation and COVID-19: A Systematic Review and Meta-Analysis. Arq Bras Cardiol 2024; 121:e20230470. [PMID: 38695466 PMCID: PMC11081175 DOI: 10.36660/abc.20230470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 10/29/2023] [Accepted: 11/14/2023] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) is associated with hypercoagulability. It remains uncertain whether ongoing anticoagulation for atrial fibrillation (AF) in patients who later contract COVID-19 improves clinical outcomes. OBJECTIVES To compare chronic oral anticoagulation with no previous anticoagulation in patients with AF who contracted a COVID-19 infection concerning the outcomes of all-cause mortality, COVID-19 mortality, intensive care unit (ICU) admission, and hospitalization. METHODS We systematically searched PubMed, Embase, and Cochrane Library for eligible studies from inception to December 2022. We included studies comparing COVID-19 outcomes in patients with versus without prior chronic anticoagulation for AF. Risk ratios (RR) with 95% confidence intervals (CI) were pooled with a random-effects model. The level of significance was set at p < 0.05. Quality assessment and risk of bias were performed according to Cochrane recommendations. RESULTS Ten studies comprising 1,177,858 patients with COVID-19 and AF were identified, of whom 893,772 (75.9%) were on prior chronic anticoagulation for AF. In patients with COVID-19, being on chronic anticoagulation for AF significantly reduced all-cause mortality (RR 0.75; 95% CI 0.57 to 0.99; p = 0.048; I2 = 89%) and COVID-19-related mortality (RR 0.76; 95% CI 0.72 to 0.79; p < 0.001; I2 = 0%) when compared with no prior anticoagulation. In contrast, there was no difference between groups regarding hospitalization (RR 1.08; 95% CI 0.82 to 1.41; p = 0.587; I2 = 95%) or ICU admission (RR 0.86; 95% CI 0.68 to 1.09; p = 0.216; I2 = 69%). CONCLUSIONS In this meta-analysis, chronic anticoagulation for patients with AF who contracted COVID-19 was associated with significantly lower rates of all-cause mortality and COVID-19-related mortality as compared with no previous anticoagulation.
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Affiliation(s)
- Isabela Landsteiner
- Massachusetts General HospitalBostonMassachusettsEUAMassachusetts General Hospital, Boston, Massachusetts – EUA
| | - Jonathan A. Pinheiro
- Universidade de FortalezaFortalezaCEBrasilUniversidade de Fortaleza, Fortaleza, CE – Brasil
| | - Nicole Felix
- Universidade Federal de Campina GrandeCampina GrandePBBrasilUniversidade Federal de Campina Grande, Campina Grande, PB – Brasil
| | - Douglas Mesadri Gewehr
- Instituto do Coração de CuritibaCuritibaPRBrasilInstituto do Coração de Curitiba, Curitiba, PR, Brasil
| | - Rhanderson Cardoso
- Brigham and Women's Hospital and Harvard Medical School BostonBostonMassachusettsEUABrigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts – EUA
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21
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Song Q, Liu H, Tan H, Yang B, Zhang H, Liu L, Fan C. Prophylactic-dose direct oral anticoagulants for non-hospitalised people with COVID-19: A meta-analysis of randomised controlled trials. J Glob Health 2024; 14:05015. [PMID: 38665058 PMCID: PMC11046256 DOI: 10.7189/jogh.14.05015] [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: 04/28/2024] Open
Abstract
Background Several reviews have been conducted on thromboprophylaxis in non-hospitalised patients with coronavirus disease 2019 (COVID-19). In this systematic review and meta-analysis, we sought to investigate the impact of prophylactic-dose direct oral anticoagulants (DOACs) in this population. Methods We searched PubMed, Web of Science, EMBASE and Cochrane Library for randomised controlled trials (RCTs) comparing prophylactic-dose DOACs with placebo or no treatment in non-hospitalised patients with COVID-19 until September 2023. The primary efficacy outcome was a composite of all-cause mortality and thromboembolic events, while major bleeding events were the primary safety outcome. We expressed continuous outcome data as mean differences (MDs) with 95% confidence intervals (CIs) and dichotomous outcome data as risk ratios (RRs) with 95% CIs. Results We included six RCTs involving 4307 patients. Prophylactic-dose DOAC therapy compared with placebo or no treatment was associated with significantly decreased risks of the composite outcome of all-cause mortality and thromboembolic events (1.43% vs 2.67% (RR = 0.53; 95% CI = 0.34-0.82, P = 0.004, I2 = 3%)). Major bleeding events were infrequent, and we detected no significant differences between patients assigned to prophylactic-dose DOACs vs placebo or no treatment (0.19% vs 0.05% (RR = 2.50; 95% CI = 0.49-12.87, P = 0.27, I2 = 0%)). The use of prophylactic-dose DOACs was also associated with a reduction in venous thromboembolism, with no difference in all-cause mortality, arterial thromboembolism, hospitalisations, and clinically relevant nonmajor bleeding between two groups. Sensitivity analyses with the leave-one-out method for the primary efficacy and safety outcome did not change the effect estimate substantially. Conclusions We found that prophylaxis-dose DOACs could significantly improve clinical outcomes and reduce venous thrombotic events without increasing the risk of major bleeding events compared with placebo or no treatment in non-hospitalised patients with COVID-19. Registration PROSPERO: CRD42023466889.
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Affiliation(s)
- Qingchun Song
- Department of Cardiovascular Surgery, the Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Hongduan Liu
- Department of Cardiovascular Surgery, the Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Haoyu Tan
- Department of Cardiovascular Surgery, the Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Benli Yang
- Department of Cardiovascular Surgery, the Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Hao Zhang
- Department of Cardiovascular Surgery, the Second Xiangya Hospital, Central South University, Changsha, Hunan, China
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22
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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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23
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Shen X, Qiu E, Liu Z, Zhu X, Zeng Y. Effectiveness and safety of rivaroxaban for anticoagulation therapy in COVID-19: A meta-analysis of randomized controlled trials. Saudi Med J 2024; 45:341-348. [PMID: 38657982 PMCID: PMC11147572 DOI: 10.15537/smj.2024.45.4.20230728] [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: 10/06/2023] [Accepted: 02/16/2024] [Indexed: 04/26/2024] Open
Abstract
OBJECTIVES To evaluate the effectiveness and safety of rivaroxaban anticoagulation in COVID-19 patients. METHODS PubMed, Embase, Cochrane Library electronic databases, and ClinicalTrials.gov were searched to identify all relevant randomized controlled trial studies from December 2019 to July 2023. RESULTS A total of 6 randomized controlled trials, which included a total of 3323 patients, were considered for evaluation. Overall, short-term all-cause mortality and hospitalization rates were not significantly different between the rivaroxaban and control groups. Thrombotic events were significantly reduced in the rivaroxaban prophylaxis group compared to the placebo control group. However, the reduction in thrombotic events was not significantly different between rivaroxaban therapy and heparin or low-molecular-weight heparin (LMWH). Rivaroxaban prophylaxis and the therapeutic dose may be associated with a higher rate of overall bleeding rate, but major bleeding rates did not differ substantially. CONCLUSION Rivaroxaban may reduce thrombotic events in COVID-19 patients, but it does not appear to have an advantage over heparin or LMWH, and it may increase the risk of bleeding.INPLASY Reg. No.: INPLASY 202370097.
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Affiliation(s)
- Xiangbo Shen
- From the Department of Pulmonary and Critical Care Medicine (Shen), Jiangxi PingXiang People’s Hospital, Pingxiang, Jiangxi Province, from the Department of Trauma Center (Qiu, Zhu, Zeng); and from the Department of Critical Care Medicine (Liu), Zhuzhou Central Hospital, Zhuzhou, Hunan Province, China.
| | - Eryue Qiu
- From the Department of Pulmonary and Critical Care Medicine (Shen), Jiangxi PingXiang People’s Hospital, Pingxiang, Jiangxi Province, from the Department of Trauma Center (Qiu, Zhu, Zeng); and from the Department of Critical Care Medicine (Liu), Zhuzhou Central Hospital, Zhuzhou, Hunan Province, China.
| | - Zhao Liu
- From the Department of Pulmonary and Critical Care Medicine (Shen), Jiangxi PingXiang People’s Hospital, Pingxiang, Jiangxi Province, from the Department of Trauma Center (Qiu, Zhu, Zeng); and from the Department of Critical Care Medicine (Liu), Zhuzhou Central Hospital, Zhuzhou, Hunan Province, China.
| | - Xiaopeng Zhu
- From the Department of Pulmonary and Critical Care Medicine (Shen), Jiangxi PingXiang People’s Hospital, Pingxiang, Jiangxi Province, from the Department of Trauma Center (Qiu, Zhu, Zeng); and from the Department of Critical Care Medicine (Liu), Zhuzhou Central Hospital, Zhuzhou, Hunan Province, China.
| | - Yiqian Zeng
- From the Department of Pulmonary and Critical Care Medicine (Shen), Jiangxi PingXiang People’s Hospital, Pingxiang, Jiangxi Province, from the Department of Trauma Center (Qiu, Zhu, Zeng); and from the Department of Critical Care Medicine (Liu), Zhuzhou Central Hospital, Zhuzhou, Hunan Province, China.
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24
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Monzo L, Levy B, Duarte K, Baudry G, Combes A, Ouattara A, Delmas C, Kimmoun A, Girerd N. Use of the Win Ratio Analysis in Critical Care Trials. Am J Respir Crit Care Med 2024; 209:798-804. [PMID: 38285595 DOI: 10.1164/rccm.202309-1644cp] [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: 09/19/2023] [Accepted: 01/25/2024] [Indexed: 01/31/2024] Open
Abstract
Composite outcomes are commonly used in critical care trials to estimate the treatment effect of an intervention. A significant limitation of classical analytic approaches is that they assign equal statistical importance to each component in a composite, even if these do not have the same clinical importance (i.e., in a composite of death and organ failure, death is clearly more important). The win ratio (WR) method has been proposed as an alternative for trial outcomes evaluation, as it effectively assesses events based on their clinical relevance (i.e., hierarchical order) by comparing each patient in the intervention group with their counterparts in the control group. This statistical approach is increasingly used in cardiovascular outcome trials. However, WR may be useful to unveil treatment effects also in the critical care setting, because these trials are typically moderately sized, thus limiting the statistical power to detect small differences between groups, and often rely on composite outcomes that include several components of different clinical importance. Notably, the advantages of this approach may be offset by several drawbacks (such as ignoring ties and difficulties in selecting and ranking endpoints) and challenges in appropriate clinical interpretation (i.e., establishing clinical meaningfulness of the observed effect size). In this perspective article, we present some key elements to implementing WR statistics in critical care trials, providing an overview of strengths, drawbacks, and potential applications of this method. To illustrate, we conduct a reevaluation of the HYPO-ECMO (Hypothermia during Venoarterial Extracorporeal Membrane Oxygenation) trial using the WR framework as a case example.
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Affiliation(s)
- Luca Monzo
- Université de Lorraine, Centre d'Investigations Cliniques Plurithématique, Institut National de la Santé et de la Recherche Médicale U1116, Nancy, France
- Centre Hospitalier Régional Universitaire de Nancy, Institut Lorrain du Coeur et des Vaisseaux, Nancy, France
- INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN (French Clinical Research Infrastructure Network), Nancy, France
| | - Bruno Levy
- Centre Hospitalier Régional Universitaire de Nancy, Institut Lorrain du Coeur et des Vaisseaux, Nancy, France
- Université de Lorraine, Institut National de la Santé et de la Recherche Médicale U1116, Nancy, France
| | - Kevin Duarte
- Université de Lorraine, Centre d'Investigations Cliniques Plurithématique, Institut National de la Santé et de la Recherche Médicale U1116, Nancy, France
| | - Guillaume Baudry
- Université de Lorraine, Centre d'Investigations Cliniques Plurithématique, Institut National de la Santé et de la Recherche Médicale U1116, Nancy, France
- Centre Hospitalier Régional Universitaire de Nancy, Institut Lorrain du Coeur et des Vaisseaux, Nancy, France
- INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN (French Clinical Research Infrastructure Network), Nancy, France
| | - Alain Combes
- Service de Médecine Intensive-Réanimation Hôpital Pitié-Salpêtrière, Institut de Cardiologie, Paris, France
| | - Alexandre Ouattara
- Centre Hospitalier Universitaire Bordeaux, Department of Anaesthesia and Critical Care, Magellan Medico-Surgical Centre, Bordeaux, France
- University Bordeaux, Institut National de la Santé et de la Recherche Médicale, Unités Mixtes de Recherche 1034, Biology of Cardiovascular Diseases, Pessac, France
| | - Clément Delmas
- Intensive Cardiac Care Unit, Rangueil University Hospital, Toulouse, France; and
| | - Antoine Kimmoun
- Centre Hospitalier Régional Universitaire de Nancy, Institut Lorrain du Coeur et des Vaisseaux, Nancy, France
- Université de Lorraine, Institut National de la Santé et de la Recherche Médicale U1116, Nancy, France
| | - Nicolas Girerd
- Université de Lorraine, Centre d'Investigations Cliniques Plurithématique, Institut National de la Santé et de la Recherche Médicale U1116, Nancy, France
- Centre Hospitalier Régional Universitaire de Nancy, Institut Lorrain du Coeur et des Vaisseaux, Nancy, France
- INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN (French Clinical Research Infrastructure Network), Nancy, France
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25
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Yamashita Y, Yachi S, Takeyama M, Nishimoto Y, Tsujino I, Nakamura J, Yamamoto N, Nakata H, Ikeda S, Umetsu M, Aikawa S, Hayashi H, Satokawa H, Okuno Y, Iwata E, Ogihara Y, Ikeda N, Kondo A, Iwai T, Yamada N, Ogawa T, Kobayashi T, Mo M. Prophylactic Anticoagulation and Thrombosis in Hospitalized Patients with Clinically Stable COVID-19 at Admission: From the Practice-Based Observational Study. Ann Vasc Dis 2024; 17:1-8. [PMID: 38628927 PMCID: PMC11018098 DOI: 10.3400/avd.oa.23-00031] [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: 04/17/2023] [Accepted: 10/29/2023] [Indexed: 04/19/2024] Open
Abstract
Objectives: The potential benefit of routine prophylactic anticoagulation for all hospitalized patients with clinically stable coronavirus disease 2019 (COVID-19) is still controversial. Method: The CLOT-COVID Study was a multicenter observational study enrolling 2894 consecutive hospitalized patients with COVID-19. The current study population consisted of 1738 hospitalized patients with mild COVID-19 at admission not requiring oxygen administration, who were divided into 2 groups: patients with prophylactic anticoagulation (n = 326) and those without (n = 1412). Results: Patients with prophylactic anticoagulation had more severe status of the worst severity of COVID-19 during hospitalization compared with those without (mild: 38% versus 82%, moderate: 55% versus 17%, and severe or death at discharge: 6.4% versus 0.7%, P <0.001). During hospitalization, 8 patients (0.5%) developed thrombosis, and the incidences of thrombosis were numerically higher in patients with more severe status of worst severity of COVID-19 during hospitalization (mild: 0.2%, moderate: 1.2%, and severe or death at discharge: 3.2%). Conclusions: Among hospitalized patients with clinically stable COVID-19 at admission, patients who did not worsen in COVID-19 severity after admission rarely developed thrombosis, although patients with worsening of COVID-19 severity after admission more often received prophylactic anticoagulation and might have a higher risk of thrombosis.
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Affiliation(s)
- Yugo Yamashita
- Department of Cardiovascular Medicine, Kyoto University Hospital, Kyoto, Kyoto, Japan
| | - Sen Yachi
- Japan Community Health Care Organization Tokyo Shinjuku Medical Center, Tokyo, Japan
| | - Makoto Takeyama
- Japan Community Health Care Organization Tokyo Shinjuku Medical Center, Tokyo, Japan
| | - Yuji Nishimoto
- Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo, Japan
| | | | | | | | - Hiroko Nakata
- Yokosuka General Hospital Uwamachi, Yokosuka, Kanagawa, Japan
| | - Satoshi Ikeda
- Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Nagasaki, Japan
| | | | - Shizu Aikawa
- Tsukuba Medical Center Hospital, Tsukuba, Ibaraki, Japan
| | - Hiroya Hayashi
- Osaka Metropolitan University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hirono Satokawa
- Fukushima Medical University, School of Medicine, Fukushima, Fukushima, Japan
| | - Yoshinori Okuno
- Department of Cardiovascular Medicine, Kyoto University Hospital, Kyoto, Kyoto, Japan
| | - Eriko Iwata
- Nankai Medical Center Japan Community Health Care Organization, Saiki, Oita, Japan
| | | | | | - Akane Kondo
- Shikoku Medical Center for Children and Adults, Zentsuji, Kagawa, Japan
| | | | | | | | | | - Makoto Mo
- Yokohama Minami Kyosai Hospital, Yokohama, Kanagawa, Japan
| | - on behalf of the Clot-COVID Study Investigators
- Department of Cardiovascular Medicine, Kyoto University Hospital, Kyoto, Kyoto, Japan
- Japan Community Health Care Organization Tokyo Shinjuku Medical Center, Tokyo, Japan
- Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo, Japan
- Hokkaido University Hospital, Sapporo, Hokkaido, Japan
- Hamamatsu Medical Center, Hamamatsu, Shizuoka, Japan
- Yokosuka General Hospital Uwamachi, Yokosuka, Kanagawa, Japan
- Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Nagasaki, Japan
- Tohoku University Hospital, Sendai, Miyagi, Japan
- Tsukuba Medical Center Hospital, Tsukuba, Ibaraki, Japan
- Osaka Metropolitan University Graduate School of Medicine, Suita, Osaka, Japan
- Fukushima Medical University, School of Medicine, Fukushima, Fukushima, Japan
- Nankai Medical Center Japan Community Health Care Organization, Saiki, Oita, Japan
- Mie University Hospital, Tsu, Mie, Japan
- Toho University Ohashi Medical Center, Tokyo, Japan
- Shikoku Medical Center for Children and Adults, Zentsuji, Kagawa, Japan
- Tsukuba Vascular Center, Moriya, Ibaraki, Japan
- Kuwana City Medical Center, Kuwana, Mie, Japan
- Fukushima Daiich Hospital, Fukushima, Fukushima, Japan
- Yokohama Minami Kyosai Hospital, Yokohama, Kanagawa, Japan
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26
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Cezard GI, Denholm RE, Knight R, Wei Y, Teece L, Toms R, Forbes HJ, Walker AJ, Fisher L, Massey J, Hopcroft LEM, Horne EMF, Taylor K, Palmer T, Arab MA, Cuitun Coronado JI, Ip SHY, Davy S, Dillingham I, Bacon S, Mehrkar A, Morton CE, Greaves F, Hyams C, Davey Smith G, Macleod J, Chaturvedi N, Goldacre B, Whiteley WN, Wood AM, Sterne JAC, Walker V. Impact of vaccination on the association of COVID-19 with cardiovascular diseases: An OpenSAFELY cohort study. Nat Commun 2024; 15:2173. [PMID: 38467603 PMCID: PMC10928172 DOI: 10.1038/s41467-024-46497-0] [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: 07/21/2023] [Accepted: 02/29/2024] [Indexed: 03/13/2024] Open
Abstract
Infection with SARS-CoV-2 is associated with an increased risk of arterial and venous thrombotic events, but the implications of vaccination for this increased risk are uncertain. With the approval of NHS England, we quantified associations between COVID-19 diagnosis and cardiovascular diseases in different vaccination and variant eras using linked electronic health records for ~40% of the English population. We defined a 'pre-vaccination' cohort (18,210,937 people) in the wild-type/Alpha variant eras (January 2020-June 2021), and 'vaccinated' and 'unvaccinated' cohorts (13,572,399 and 3,161,485 people respectively) in the Delta variant era (June-December 2021). We showed that the incidence of each arterial thrombotic, venous thrombotic and other cardiovascular outcomes was substantially elevated during weeks 1-4 after COVID-19, compared with before or without COVID-19, but less markedly elevated in time periods beyond week 4. Hazard ratios were higher after hospitalised than non-hospitalised COVID-19 and higher in the pre-vaccination and unvaccinated cohorts than the vaccinated cohort. COVID-19 vaccination reduces the risk of cardiovascular events after COVID-19 infection. People who had COVID-19 before or without being vaccinated are at higher risk of cardiovascular events for at least two years.
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Affiliation(s)
- Genevieve I Cezard
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Victor Phillip Dahdaleh Heart and Lung Research Institute, University of Cambridge, Cambridge, UK
| | - Rachel E Denholm
- Population Health Sciences, University of Bristol, Bristol, UK
- NIHR Bristol Biomedical Research Centre, Bristol, UK
- Health Data Research UK South-West, Bristol, UK
| | - Rochelle Knight
- Population Health Sciences, University of Bristol, Bristol, UK
- NIHR Bristol Biomedical Research Centre, Bristol, UK
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
- The National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston, Bristol, UK
| | - Yinghui Wei
- Centre for Mathematical Sciences, School of Engineering, Computing and Mathematics, University of Plymouth, Plymouth, UK
| | - Lucy Teece
- Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - Renin Toms
- Population Health Sciences, University of Bristol, Bristol, UK
- Population Wellbeing, School of Health Sciences, Cardiff Metropolitan University, Cardiff, UK
| | - Harriet J Forbes
- Faculty of Epidemiology and Population Health, London School of Hygiene & tropical Medicine, London, UK
| | - Alex J Walker
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Louis Fisher
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jon Massey
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Elsie M F Horne
- Population Health Sciences, University of Bristol, Bristol, UK
- NIHR Bristol Biomedical Research Centre, Bristol, UK
| | - Kurt Taylor
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Tom Palmer
- Population Health Sciences, University of Bristol, Bristol, UK
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
| | - Marwa Al Arab
- Population Health Sciences, University of Bristol, Bristol, UK
| | | | - Samantha H Y Ip
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Victor Phillip Dahdaleh Heart and Lung Research Institute, University of Cambridge, Cambridge, UK
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Simon Davy
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Iain Dillingham
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sebastian Bacon
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Amir Mehrkar
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Caroline E Morton
- Digital Environment Research Institute, Queen Mary University of London, London, UK
| | - Felix Greaves
- National Institute for Health and Care Excellence, London, UK
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Catherine Hyams
- Population Health Sciences, University of Bristol, Bristol, UK
| | - George Davey Smith
- Population Health Sciences, University of Bristol, Bristol, UK
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
| | - John Macleod
- Population Health Sciences, University of Bristol, Bristol, UK
- Health Data Research UK South-West, Bristol, UK
- The National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston, Bristol, UK
| | - Nishi Chaturvedi
- MRC Unit for Lifelong Health and Ageing, University College London, London, UK
| | - Ben Goldacre
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - William N Whiteley
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Angela M Wood
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Victor Phillip Dahdaleh Heart and Lung Research Institute, University of Cambridge, Cambridge, UK
- British Heart Foundation Centre of Research Excellence, University of Cambridge, Cambridge, UK
- National Institute for Health and Care Research Blood and Transplant Research Unit in Donor Health and Behaviour, University of Cambridge, Cambridge, UK
- Health Data Research UK Cambridge, Wellcome Genome Campus and University of Cambridge, Cambridge, UK
- Cambridge Centre of Artificial Intelligence in Medicine, Cambridge, UK
| | - Jonathan A C Sterne
- Population Health Sciences, University of Bristol, Bristol, UK.
- NIHR Bristol Biomedical Research Centre, Bristol, UK.
- Health Data Research UK South-West, Bristol, UK.
| | - Venexia Walker
- Population Health Sciences, University of Bristol, Bristol, UK
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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27
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Zheng R, Solomon A, DiLorenzo M, Rajendran I, Park J, Dhongade V, Garcia MA, Eberhardt RT, Sloan JM, Weinberg J, Klings ES. The Association of Anticoagulation Intensity with Outcomes in Hospitalized COVID-19 Patients. Adv Hematol 2024; 2024:8838308. [PMID: 38500844 PMCID: PMC10948223 DOI: 10.1155/2024/8838308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 02/16/2024] [Accepted: 02/21/2024] [Indexed: 03/20/2024] Open
Abstract
Venous thromboembolism (VTE) risk is increased in patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A key question was whether increased intensity of anticoagulation would help prevent VTE and improve patient outcomes, including transfer to the intensive care unit (ICU) and mortality. At the start of the coronavirus disease-19 (COVID-19) pandemic, our institution, Boston Medical Center, instituted a VTE risk stratification protocol based on patients' initial D-dimer levels, medical history, and presence of thrombosis to determine whether they should receive standard-dose prophylaxis, high-dose prophylaxis, or therapeutic anticoagulation. We performed a retrospective observational cohort study examining the association of degree of anticoagulation with outcomes in 915 hospitalized COVID-19 patients hospitalized initially on the general inpatient wards between March 1,, 2020, and June 1, 2020. Patients directly hospitalized in the ICU were excluded. Most, 813 patients (89%), in our cohort were on standard-dose prophylaxis; 32 patients (3.5%) received high-dose prophylaxis; 70 patients (7.7%), were treated with therapeutic anticoagulation. VTE occurred in 45 patients (4.9%), and the overall in-hospital mortality rate was 5.4% (49 deaths). On multivariable analysis of clinical outcomes in relation to type of anticoagulation, in the high-dose prophylaxis group, there was a trend towards increased in-hospital mortality (odds ratio 2.4 (0.8-7.5, 95% CI)) and increased ICU transfer (odds ratio 2.2 (0.9-5.7, 95% CI)). Our results suggest that patients receiving high-dose prophylaxis had more severe disease that was not mitigated by intermediate-dose anticoagulation.
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Affiliation(s)
- Rena Zheng
- UMass Chan Medical School, UMass Medical Center, Department of Medicine, Division of Hematology-Oncology, Worcester, MA, USA
| | | | - Madeline DiLorenzo
- New York University Grossman School of Medicine, Department of Medicine, Division of Infectious Diseases and Immunology, New York, NY, USA
| | - Iniya Rajendran
- University of Arizona, College of Medicine, Department of Medicine, Division of Cardiology, Tucson, AZ, USA
| | - Joseph Park
- Brigham and Women's Hospital, Department of Medicine, Boston, MA, USA
| | - Vrushali Dhongade
- Brigham and Women's Hospital, Department of Neurology, Boston, MA, USA
| | - Michael A. Garcia
- Valley Medical Center Pulmonary & Sleep Disorder Clinic, Covington, WA, USA
| | - Robert T. Eberhardt
- Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Department of Medicine, Section of Cardiovascular Medicine, Boston, MA, USA
| | - John Mark Sloan
- Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Department of Medicine, Section of Hematology & Medical Oncology, Boston, MA, USA
| | - Janice Weinberg
- Boston University School of Public Health, Department of Biostatistics, Boston, MA, USA
| | - Elizabeth S. Klings
- Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Department of Medicine, The Pulmonary Center, Boston, MA, USA
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28
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Godoy LC, Neal MD, Goligher EC, Cushman M, Houston BL, Bradbury CA, McQuilten ZK, Tritschler T, Kahn SR, Berry LR, Lorenzi E, Jensen T, Higgins AM, Kornblith LZ, Berger JS, Gong MN, Paul JD, Castellucci LA, Le Gal G, Lother SA, Rosenson RS, Derde LP, Kumar A, McVerry BJ, Nicolau JC, Leifer E, Escobedo J, Huang DT, Reynolds HR, Carrier M, Kim KS, Hunt BJ, Slutsky AS, Turgeon AF, Webb SA, McArthur CJ, Farkouh ME, Hochman JS, Zarychanski R, Lawler PR. Heparin Dose Intensity and Organ Support-Free Days in Patients Hospitalized for COVID-19. JACC. ADVANCES 2024; 3:100780. [PMID: 38938844 PMCID: PMC11198374 DOI: 10.1016/j.jacadv.2023.100780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 08/30/2023] [Accepted: 09/28/2023] [Indexed: 06/29/2024]
Abstract
Background Clinical trials suggest that therapeutic-dose heparin may prevent critical illness and vascular complications due to COVID-19, but knowledge gaps exist regarding the efficacy of therapeutic heparin including its comparative effect relative to intermediate-dose anticoagulation. Objectives The authors performed 2 complementary secondary analyses of a completed randomized clinical trial: 1) a prespecified per-protocol analysis; and 2) an exploratory dose-based analysis to compare the effect of therapeutic-dose heparin with low- and intermediate-dose heparin. Methods Patients who received initial anticoagulation dosed consistently with randomization were included. The primary outcome was organ support-free days (OSFDs), a combination of in-hospital death and days free of organ support through day 21. Results Among 2,860 participants, 1,761 (92.8%) noncritically ill and 857 (89.1%) critically ill patients were treated per-protocol. Among noncritically ill per-protocol patients, the posterior probability that therapeutic-dose heparin improved OSFDs as compared with usual care was 99.3% (median adjusted OR: 1.36; 95% credible interval [CrI]: 1.07-1.74). Therapeutic heparin had a high posterior probability of efficacy relative to both low- (94.6%; adjusted OR: 1.26; 95% CrI: 0.95-1.64) and intermediate- (99.8%; adjusted OR: 1.80; 95% CrI: 1.22-2.62) dose thromboprophylaxis. Among critically ill per-protocol patients, the posterior probability that therapeutic heparin improved outcomes was low. Conclusions Among noncritically ill patients hospitalized for COVID-19 who were randomized to and initially received therapeutic-dose anticoagulation, heparin, compared with usual care, was associated with improved OSFDs, a combination of in-hospital death and days free of organ support. Therapeutic heparin appeared superior to both low- and intermediate-dose thromboprophylaxis.
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Affiliation(s)
- Lucas C. Godoy
- Peter Munk Cardiac Centre at the University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
- Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | | | - Ewan C. Goligher
- University of Toronto, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | - Mary Cushman
- Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Brett L. Houston
- University of Manitoba, Winnipeg, Canada
- CancerCare Manitoba, Winnipeg, Canada
| | - Charlotte A. Bradbury
- University of Bristol, Bristol, United Kingdom
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| | - Zoe K. McQuilten
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Tobias Tritschler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Susan R. Kahn
- McGill University Health Centre, Montreal, Québec, Canada
| | | | | | - Tom Jensen
- Berry Consultants, LLC, Austin, Texas, USA
| | - Alisa M. Higgins
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Lucy Z. Kornblith
- Zuckerberg San Francisco General Hospital/University of California, San Francisco, California, USA
| | - Jeffrey S. Berger
- New York University Grossman School of Medicine, New York, New York, USA
| | - Michelle N. Gong
- Montefiore Medical Center, Bronx, New York, USA
- Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - Lana A. Castellucci
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
| | - Grégoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
| | | | | | - Lennie P.G. Derde
- University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | | | | | | | - Eric Leifer
- National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - Jorge Escobedo
- Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - David T. Huang
- University of Pittsburgh Medical Center, Pittsburgh, USA
| | | | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
- Institut du Savoir Montfort, Ottawa, Ontario, Canada
| | - Keri S. Kim
- University of Illinois, Chicago, Illinois, USA
| | - Beverley J. Hunt
- King's College and University Guy & St. Thomas Hospital, London, United Kingdom
| | - Arthur S. Slutsky
- University of Toronto, Toronto, Ontario, Canada
- St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Alexis F. Turgeon
- Université Laval, Québec City, Québec, Canada
- Centre Hospitalier Universitaire de Québec–Université Laval Research Center, Québec City, Québec, Canada
| | - Steven A. Webb
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Colin J. McArthur
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- Auckland City Hospital, Auckland, New Zealand
| | - Michael E. Farkouh
- Peter Munk Cardiac Centre at the University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
- Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Judith S. Hochman
- New York University Grossman School of Medicine, New York, New York, USA
| | - Ryan Zarychanski
- University of Manitoba, Winnipeg, Canada
- CancerCare Manitoba, Winnipeg, Canada
| | - Patrick R. Lawler
- Peter Munk Cardiac Centre at the University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
- McGill University Health Centre, Montreal, Québec, Canada
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29
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Sager P, Kaiser A, Schumann S, Ludescher B, Niedermaier M, Schmidt I, Och K, Dings C, Lehr T, Brysch W. Efficacy and safety of MP1032 plus standard-of-care compared to standard-of-care in hospitalised patients with COVID-19: a multicentre, randomised double-blind, placebo-controlled phase 2a trial. THE LANCET REGIONAL HEALTH. EUROPE 2024; 37:100810. [PMID: 38076629 PMCID: PMC10704330 DOI: 10.1016/j.lanepe.2023.100810] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/17/2023] [Accepted: 11/20/2023] [Indexed: 06/27/2024]
Abstract
BACKGROUND SARS-CoV-2 infections still have a significant impact on the global population. The existing vaccinations have contributed to reducing the severe disease courses, decreasing hospitalisations, and lowering the mortality rate. However, due to the variability of COVID-19 symptoms, the emergence of new variants and the uneven global distribution of vaccines there is still a great need for new therapy options. One promising approach is provided by host-directed therapies. We assessed here the efficacy and safety of MP1032, a host-directed anti-viral/anti-inflammatory drug in hospitalised patients with moderate to severe COVID-19. METHODS In a randomised, double-blind, placebo-controlled, Phase IIa study, patients were randomised 2:1 to receive either 300 mg MP032 bid + Standard-of-Care (SoC) or placebo bid + SoC for 28 days. Eligible patients were ≥18 years old, tested positive for SARS-CoV-2, and had moderate to severe COVID-19 symptoms. The study spanned 20 sites in six countries (Bulgaria, France, Hungary, Italy, Romania, Spain), assessing disease progression according the NIAID scale as the primary outcome on day 14. Secondary objectives included disease progression (day 28), disease resolution (days 14 and 28), mortality rate, COVID-19 related parameters and safety. Exposure-response analyses were performed, linking MP1032 to COVID-19 biomarkers (eGFR, D-dimer). FINDINGS 132 patients were enrolled to receive MP1032 + SoC (n = 87) or placebo + SoC (n = 45). The patients were all white or Caucasian with a mean (median) age of 60.5 (63) years. Overall, only 10 patients were vaccinated, 5 in each group. No significant risk difference of disease progression could be detected between groups on both day 14 (9.8% MP1032 vs. 11.6% placebo) and day 28 with MH common risk differences of -0.276% (95% CI, -11.634 to 11.081; p = 0.962) and 1.722% (95% CI, -4.576 to 8.019; p = 0.592), respectively.The treatment with MP1032 + SoC was safe and well-tolerated. Overall, 182 TEAEs including 10 SAEs were reported in 53.5% (46/86) of patients of the verum group and in 57.8% (26/45) of patients of the placebo group; the SAEs occurred in 5.8% (5/86) and 6.7% (3/45) of verum and placebo patients, respectively. None of the SAEs was considered as related. INTERPRETATION Despite the study's limitation in size and the variation in concurrent SoCs, these findings warrant further investigation of MP1032 as a host-directed anti-viral drug candidate. FUNDING The study was funded by the COVID-19 Horizon Europe work programme and MetrioPharm AG.
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Affiliation(s)
- Petra Sager
- MetrioPharm Deutschland GmbH, Am Borsigturm 100, 13507, Berlin, Germany
| | - Astrid Kaiser
- MetrioPharm Deutschland GmbH, Am Borsigturm 100, 13507, Berlin, Germany
| | - Sara Schumann
- MetrioPharm Deutschland GmbH, Am Borsigturm 100, 13507, Berlin, Germany
| | - Beate Ludescher
- MetrioPharm Deutschland GmbH, Am Borsigturm 100, 13507, Berlin, Germany
| | | | - Ivo Schmidt
- MetrioPharm Deutschland GmbH, Am Borsigturm 100, 13507, Berlin, Germany
| | - Katharina Och
- Saarmetrics GmbH, Starterzentrum 1, Universität des Saarlandes, 66123, Saarbrücken, Germany
- Department of Clinical Pharmacy, Saarland University, 66123, Saarbrücken, Germany
| | - Christiane Dings
- Saarmetrics GmbH, Starterzentrum 1, Universität des Saarlandes, 66123, Saarbrücken, Germany
- Department of Clinical Pharmacy, Saarland University, 66123, Saarbrücken, Germany
| | - Thorsten Lehr
- Saarmetrics GmbH, Starterzentrum 1, Universität des Saarlandes, 66123, Saarbrücken, Germany
- Department of Clinical Pharmacy, Saarland University, 66123, Saarbrücken, Germany
| | - Wolfgang Brysch
- MetrioPharm Deutschland GmbH, Am Borsigturm 100, 13507, Berlin, Germany
- MetrioPharm AG, Europaallee 41, Zurich 8004, Switzerland
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30
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Chakabva MS, Polina S, Brauner M, McGuire M, Brown Z, Akthar T, Todt M, Polina A, Nova FF. Comparison of Standard Versus Intermediate Prophylaxis Dose for Venous Thromboembolism Prophylaxis in Patients Hospitalized With COVID-19 Infection. Hosp Pharm 2024; 59:94-101. [PMID: 38223865 PMCID: PMC10786052 DOI: 10.1177/00185787231194997] [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: 01/16/2024]
Abstract
Background: COVID-19 infection is associated with a high risk of venous thromboembolism (VTE) events. VTE prophylaxis reduces the risk of these events. The optimal dose of VTE prophylaxis however remains uncertain. Objectives: To compare the incidence of VTE in patients treated with either standard dose VTE versus intermediate dose VTE prophylaxis. Methods: In this retrospective cohort study, we analyzed data from 1786 adult patients admitted into the hospital with polymerase chain reaction confirmed COVID-19 infection between April 2020 to September 2021. For analysis, patients were divided into 2 cohorts: either standard dose prophylaxis treatment group (patients who received either unfractionated heparin 5000units 3 times a day or enoxaparin 30-40 mg daily subcutaneously) or intermediate dose VTE prophylaxis group (patients received either unfractionated heparin 7500 units 3 times daily or enoxaparin 30-40 mg twice a day subcutaneously). The primary outcome was incidence of VTE events described as either deep vein thrombosis (DVT) or pulmonary embolism (PE). Secondary outcome was bleeding events. Results: During the study period, 398 (22%) patients were primarily treated with standard dose VTE prophylaxis, whereas 1388 (78%) patients were treated with intermediate dose VTE prophylaxis. There was a significantly higher incidence of venous thromboembolism events noted in the standard dose prophylaxis treatment group when compared with the intermediate dose prophylaxis group (25/398 (6.3%) vs 35/1388 (2.5%) P < .001, [Odds Ratio 2.6197, 95% confidence interval = 1.5482-4.4327]). Multivariable-adjusted logistic regression, adjusting for age, obesity, and smoking, with the intermediate dose prophylaxis treatment group as the referent category revealed higher odds for incident venous thromboembolism events in the standard dose prophylaxis group. There was no statistically significant difference in bleeding events between the 2 treatment groups (9 (2.3%) for standard dose prophylaxis group vs 46 (3.3%) for intermediate dose prophylaxis group P = .26). Conclusions: Among patients hospitalized with COVID-19 infection, patients receiving intermediate dose VTE prophylaxis experienced lower incident rates of venous thromboembolism events compared to those receiving standard dose VTE prophylaxis without a statistically significant increase in the risk of bleeding events.
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Affiliation(s)
| | | | | | | | | | | | | | - Aws Polina
- Wayne State/Detroit Medical Center Internal Medicine Residency, Detroit, MI, USA
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31
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Porres-Aguilar M, Mukherjee D, Didia SC, Lazo-Langner A. Which are the optimal thromboprophylaxis strategies for hospitalized patients with COVID-19? current controversies. Vascular 2024; 32:220-225. [PMID: 36076354 PMCID: PMC9459371 DOI: 10.1177/17085381221126235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Novel coronavirus 2019 (COVID-19) represents a significant risk factor for the development of venous thromboembolism (VTE) in hospitalized with both moderate and severe/critical COVID-19. Herein, we present a brief updated review on emerging robust data on diverse thromboprophylaxis strategies used to mitigate VTE complications, as well as a personal point of view of current controversies in regards the use of therapeutic and prophylactic anticoagulation strategies, particularly in the moderately-ill subgroup of patients with COVID-19.
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Affiliation(s)
- Mateo Porres-Aguilar
- Department of Internal Medicine,
Divisions of Hospital and Adult Clinical Thrombosis Medicine, Texas Tech University Health Sciences
Center and Paul L. Foster School of Medicine, El Paso, TX, USA
| | - Debabrata Mukherjee
- Division of Cardiovascular
Diseases, Texas Tech University Health Sciences
Center and Paul L. Foster School of Medicine, El Paso, TX, USA
| | - S. Claudia Didia
- Department of Internal Medicine,
Divisions of Hospital and Adult Clinical Thrombosis Medicine, Texas Tech University Health Sciences
Center and Paul L. Foster School of Medicine, El Paso, TX, USA
| | - Alejandro Lazo-Langner
- Division of Hematology, Departments
of Medicine and Epidemiology/Biostatistics, Western University, London, ON, Canada
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32
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Del Vecchio L, Balafa O, Dounousi E, Ekart R, Fernandez BF, Mark PB, Sarafidis P, Valdivielso JM, Ferro CJ, Mallamaci F. COVID-19 and cardiovascular disease in patients with chronic kidney disease. Nephrol Dial Transplant 2024; 39:177-189. [PMID: 37771078 PMCID: PMC10828215 DOI: 10.1093/ndt/gfad170] [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: 05/18/2023] [Indexed: 09/30/2023] Open
Abstract
Millions of people worldwide have chronic kidney disease (CKD). Affected patients are at high risk for cardiovascular (CV) disease for several reasons. Among various comorbidities, CKD is associated with the more severe forms of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. This is particularly true for patients receiving dialysis or for kidney recipients. From the start of the SARS-CoV-2 pandemic, several CV complications have been observed in affected subjects, spanning acute inflammatory manifestations, CV events, thrombotic episodes and arrythmias. Several pathogenetic mechanisms have been hypothesized, including direct cytopathic viral effects on the myocardium, endothelial damage and hypercoagulability. This spectrum of disease can occur during the acute phase of the infection, but also months after recovery. This review is focussed on the CV complications of coronavirus disease 2019 (COVID-19) with particular interest in their implications for the CKD population.
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Affiliation(s)
- Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant'Anna Hospital, ASST Lariana, Como, Italy
| | - Olga Balafa
- Department of Nephrology, University Hospital of Ioannina, Ioannina, Greece
| | - Evangelia Dounousi
- Department of Nephrology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Robert Ekart
- Department of Dialysis, Clinic for Internal Medicine, University Medical Center Maribor, Maribor, Slovenia
| | | | - Patrick B Mark
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Pantelis Sarafidis
- 1st Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Jose M Valdivielso
- Vascular and Renal Translational Research Group, Institute for Biomedical Research on Lleida (IRBLleida), Lleida, Spain
| | - Charles J Ferro
- Department of Renal Medicine, University Hospitals Birmingham and Institute of Cardiovascular Sciences, University of Birmingham, Birmingham,UK
| | - Francesca Mallamaci
- Francesca Mallamaci Department of Nephrology, Dialysis, and Transplantation Azienda Ospedaliera “Bianchi-Melacrino-Morelli” & CNR-IFC, Reggio Calabria, Italy
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Boentert M, Berger KI, Díaz-Manera J, Dimachkie MM, Hamed A, Riou França L, Thibault N, Shukla P, Ishak J, Caro JJ. Applying the win ratio method in clinical trials of orphan drugs: an analysis of data from the COMET trial of avalglucosidase alfa in patients with late-onset Pompe disease. Orphanet J Rare Dis 2024; 19:14. [PMID: 38216959 PMCID: PMC10785533 DOI: 10.1186/s13023-023-02974-1] [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: 11/30/2022] [Accepted: 11/18/2023] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND Clinical trials for rare diseases often include multiple endpoints that capture the effects of treatment on different disease domains. In many rare diseases, the primary endpoint is not standardized across trials. The win ratio approach was designed to analyze multiple endpoints of interest in clinical trials and has mostly been applied in cardiovascular trials. Here, we applied the win ratio approach to data from COMET, a phase 3 trial in late-onset Pompe disease, to illustrate how this approach can be used to analyze multiple endpoints in the orphan drug context. METHODS All possible participant pairings from both arms of COMET were compared sequentially on changes at week 49 in upright forced vital capacity (FVC) % predicted and six-minute walk test (6MWT). Each participant's response for the two endpoints was first classified as a meaningful improvement, no meaningful change, or a meaningful decline using thresholds based on published minimal clinically important differences (FVC ± 4% predicted, 6MWT ± 39 m). Each comparison assessed whether the outcome with avalglucosidase alfa (AVA) was better than (win), worse than (loss), or equivalent to (tie) the outcome with alglucosidase alfa (ALG). If tied on FVC, 6MWT was compared. In this approach, the treatment effect is the ratio of wins to losses ("win ratio"), with ties excluded. RESULTS In the 2499 possible pairings (51 receiving AVA × 49 receiving ALG), the win ratio was 2.37 (95% confidence interval [CI], 1.30-4.29, p = 0.005) when FVC was compared before 6MWT. When the order was reversed, the win ratio was 2.02 (95% CI, 1.13-3.62, p = 0.018). CONCLUSION The win ratio approach can be used in clinical trials of rare diseases to provide meaningful insight on treatment benefits from multiple endpoints and across disease domains.
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Affiliation(s)
- Matthias Boentert
- Department of Neurology and Institute of Translational Neurology, Münster University Hospital, Münster, Germany
| | - Kenneth I Berger
- Division of Pulmonary, Critical Care and Sleep Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Jordi Díaz-Manera
- John Walton Muscular Dystrophy Research Centre, Newcastle University Centre for Life, Newcastle Upon Tyne, UK
| | - Mazen M Dimachkie
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
| | | | | | | | | | | | - J Jaime Caro
- Evidera, Boston, MA, USA.
- McGill University, Montreal, QC, Canada.
- London School of Economics, London, UK.
- Evidera, 500 Totten Pond Rd, Waltham, MA, 02451, USA.
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Velásquez PA, Hernandez JC, Galeano E, Hincapié-García J, Rugeles MT, Zapata-Builes W. Effectiveness of Drug Repurposing and Natural Products Against SARS-CoV-2: A Comprehensive Review. Clin Pharmacol 2024; 16:1-25. [PMID: 38197085 PMCID: PMC10773251 DOI: 10.2147/cpaa.s429064] [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: 08/26/2023] [Accepted: 11/14/2023] [Indexed: 01/11/2024] Open
Abstract
The Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is a betacoronavirus responsible for the COVID-19 pandemic, causing respiratory disorders, and even death in some individuals, if not appropriately treated in time. To face the pandemic, preventive measures have been taken against contagions and the application of vaccines to prevent severe disease and death cases. For the COVID-19 treatment, antiviral, antiparasitic, anticoagulant and other drugs have been reused due to limited specific medicaments for the disease. Drug repurposing is an emerging strategy with therapies that have already tested safe in humans. One promising alternative for systematic experimental screening of a vast pool of compounds is computational drug repurposing (in silico assay). Using these tools, new uses for approved drugs such as chloroquine, hydroxychloroquine, ivermectin, zidovudine, ribavirin, lamivudine, remdesivir, lopinavir and tenofovir/emtricitabine have been conducted, showing effectiveness in vitro and in silico against SARS-CoV-2 and some of these, also in clinical trials. Additionally, therapeutic options have been sought in natural products (terpenoids, alkaloids, saponins and phenolics) with promising in vitro and in silico results for use in COVID-19 disease. Among these, the most studied are resveratrol, quercetin, hesperidin, curcumin, myricetin and betulinic acid, which were proposed as SARS-CoV-2 inhibitors. Among the drugs reused to control the SARS-CoV2, better results have been observed for remdesivir in hospitalized patients and outpatients. Regarding natural products, resveratrol, curcumin, and quercetin have demonstrated in vitro antiviral activity against SARS-CoV-2 and in vivo, a nebulized formulation has demonstrated to alleviate the respiratory symptoms of COVID-19. This review shows the evidence of drug repurposing efficacy and the potential use of natural products as a treatment for COVID-19. For this, a search was carried out in PubMed, SciELO and ScienceDirect databases for articles about drugs approved or under study and natural compounds recognized for their antiviral activity against SARS-CoV-2.
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Affiliation(s)
- Paula Andrea Velásquez
- Grupo Infettare, Facultad de Medicina, Universidad Cooperativa de Colombia, Medellín, Colombia
- Grupo Inmunovirología, Facultad de Medicina, Universidad de Antioquia UdeA, Medellín, Colombia
| | - Juan C Hernandez
- Grupo Infettare, Facultad de Medicina, Universidad Cooperativa de Colombia, Medellín, Colombia
- Grupo Inmunovirología, Facultad de Medicina, Universidad de Antioquia UdeA, Medellín, Colombia
| | - Elkin Galeano
- Grupo Productos Naturales Marinos, Departamento de Farmacia, Facultad de Ciencias Farmacéuticas y Alimentarias, Universidad de Antioquia UdeA, Medellín, Colombia
| | - Jaime Hincapié-García
- Grupo de investigación, Promoción y prevención farmacéutica, Facultad de Ciencias Farmacéuticas y Alimentarias, Universidad de Antioquia UdeA, Medellín, Colombia
| | - María Teresa Rugeles
- Grupo Inmunovirología, Facultad de Medicina, Universidad de Antioquia UdeA, Medellín, Colombia
| | - Wildeman Zapata-Builes
- Grupo Infettare, Facultad de Medicina, Universidad Cooperativa de Colombia, Medellín, Colombia
- Grupo Inmunovirología, Facultad de Medicina, Universidad de Antioquia UdeA, Medellín, Colombia
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Malik A, Ha NB, Barnes GD. Choice and Duration of Anticoagulation for Venous Thromboembolism. J Clin Med 2024; 13:301. [PMID: 38202308 PMCID: PMC10779515 DOI: 10.3390/jcm13010301] [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: 12/12/2023] [Revised: 01/01/2024] [Accepted: 01/03/2024] [Indexed: 01/12/2024] Open
Abstract
Venous thromboembolism (VTE) is a prevalent medical condition with high morbidity, mortality, and associated costs. Anticoagulation remains the main treatment for VTE, though the decision on when, how, and for how long to administer anticoagulants is increasingly complex. This review highlights the different phases of VTE management, with special circumstances for consideration such as antiphospholipid syndrome, coronary artery disease, cancer-associated thrombus, COVID-19, and future anticoagulation options. Anticoagulation management will continue to be a complex decision, applying evidence-based medicine to individual patients with the hope of maximizing effectiveness while minimizing risks.
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Affiliation(s)
- Aroosa Malik
- Department of Internal Medicine, Division of Cardiovascular Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI 48109, USA
| | - Nghi B. Ha
- Pharmacy Innovations & Partnerships, University of Michigan, Ann Arbor, MI 48108, USA;
| | - Geoffrey D. Barnes
- Department of Internal Medicine, Division of Cardiovascular Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI 48109, USA
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Guarino G, Sgromolo N, Giladi AM. Considerations for Perioperative Thromboembolic Risk Mitigation in Actively and Recently COVID-19-Positive Patients Undergoing Hand Surgery. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2024; 6:103-106. [PMID: 38313610 PMCID: PMC10837296 DOI: 10.1016/j.jhsg.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 10/18/2023] [Indexed: 02/06/2024] Open
Abstract
Coronavirus Disease 2019 (COVID) induces a hypercoagulable state causing an increased risk of venous and arterial thromboses. Distal limb and microvascular circulation are critical to the success of many hand surgeries, and patients who are actively or recently infected with COVID may be at a higher risk for perioperative thrombotic events. Little information is available regarding how to handle actively or recently infected COVID patients, including preoperative risk assessment, intraoperative decision making, and postoperative considerations regarding thrombotic risk. Our aim was to review the literature to determine how the hand surgeon can best prepare for and manage the actively or recently COVID-positive patients undergoing hand surgeries.
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Affiliation(s)
- Gianna Guarino
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD
| | - Nicole Sgromolo
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD
| | - Aviram M. Giladi
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD
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Bruno AM, Horns JJ, Metz TD. Coronavirus Disease 2019 (COVID-19) and Venous Thromboembolism During Pregnancy and Postpartum. Obstet Gynecol 2024; 143:139-142. [PMID: 38096554 PMCID: PMC10730116 DOI: 10.1097/aog.0000000000005387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 06/22/2023] [Indexed: 12/18/2023]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is associated with increased risk for macro- and micro-thrombi. Consensus guidelines recommend use of thromboprophylaxis in nonobstetric patients with SARS-CoV-2 infection admitted to the hospital. National-level studies evaluating venous thromboembolism (VTE) among pregnant and postpartum individuals with and without SARS-CoV-2 infection have not been completed. We performed a retrospective cohort study of individuals aged 18 years or older delivering at more than 20 weeks of gestation with data in the MarketScan Commercial Insurance Database from 2016 through 2020. Of 811,008 deliveries, SARS-CoV-2 infection during pregnancy or through 6 weeks postpartum was associated with increased risk for VTE compared with no infection (1.0% vs 0.5%, adjusted hazard ratio 2.62, 95% CI 1.60-4.29). Findings support further consideration of thromboprophylaxis in the obstetric population with SARS-CoV-2 infection.
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Affiliation(s)
- Ann M Bruno
- University of Utah Health, Salt Lake City, and Intermountain Healthcare, Murray, Utah
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Ferrandis R, Sierra P, Gomez-Luque A. COVID-19 thromboprophylaxis. New evidence. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:34-47. [PMID: 37678450 DOI: 10.1016/j.redare.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 11/17/2022] [Indexed: 09/09/2023]
Abstract
Recent publications have questioned the efficacy of using therapeutic or intermediate doses of low molecular weight heparin (LMWH) in COVID-19 patients, especially in the most severe patients. In order to update these recommendations, a non-systematic review has been carried out in the main medical databases. A total of 14 randomized clinical trials, 14 meta-analyses and the recommendations of 12 scientific societies were selected, stratified according to the type of patient (outpatient, hospitalized, admitted to critical care or post-discharge). The efficacy of LMWH and other therapeutic approaches (rivaroxaban, apixaban, sulodexide, acetylsalicylic acid and P2Y12 inhibitors) has been analyzed. The findings recommend using standard doses of LMWH as thromboprophylaxis in critically hospitalized COVID-19 patients and therapeutic doses in non-critically hospitalized patients if the risk of bleeding is low. In outpatients and those discharged from the hospital, LMWH could be used at a prophylactic dose if there are thrombotic risk factors, and the bleeding risk is low. It is not recommended to associate antiplatelet agents with LMWH unless previously indicated.
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Affiliation(s)
- R Ferrandis
- Servicio de Anestesiología-Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, SEDAR, Valencia, Spain; SEDAR Haemostasis, Transfusion Medicine and Fluid Therapy Division, Valencia, Spain
| | - P Sierra
- Servicio de Anestesiología-Reanimación y Terapéutica del Dolor, Hospital Universitario Virgen de la Victoria, SEDAR, Málaga, Spain; Servicio de Anestesiología-Reanimación y Terapéutica del Dolor, Fundació Puigvert, SEDAR, Barcelona, Spain
| | - A Gomez-Luque
- SEDAR Haemostasis, Transfusion Medicine and Fluid Therapy Division, Valencia, Spain; Servicio de Anestesiología-Reanimación y Terapéutica del Dolor, Hospital Universitario Virgen de la Victoria, SEDAR, Málaga, Spain.
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van de Veerdonk FL. COVID-19 Pneumonia and Cytokine Storm Syndrome. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1448:307-319. [PMID: 39117824 DOI: 10.1007/978-3-031-59815-9_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
Virus-associated cytokine storm syndrome (CSS) has been recognized for a long time and the classic viruses associated are the herpes viruses EBV, CMV, and HHV-8 as described in chapters IVa,b. In addition, pandemic viruses such as influenza, SARS, and MERS can result in severe CSS that might ultimately lead to severe acute respiratory distress syndrome (ARDS) and death [1-3]. A new pandemic caused by SARS-CoV-2 that started in 2019 has defined another chapter in the virus-associated CSS. The clinical spectrum of SARS-CoV-2 infection has many faces. In most people, it will be asymptomatic, but it can also result in severe COVID-19 pneumonia, ARDS, and multiorgan failure depending on age, comorbidities, and immune status [4]. In addition, this pandemic has known many different stages and developed in a unique way in the first 2 years. It started in a setting where there was no immunity to the virus and after a year, highly effective vaccines were introduced and herd immunity built up over time. However, vaccine effectiveness was waning over time depending on multiple factors, and novel variant strains of the virus circulated across different areas in the world. Antiviral therapy was developed and introduced, and treatment changed from giving no immunomodulatory treatment, followed by the introduction of corticosteroids [5], and later the addition of more targeted strategies such as JAK inhibitors [6] and blocking IL-6 signaling [7]. Therefore, the scientific literature published on COVID-19 must be seen in the context of a highly dynamic and rapidly changing pandemic, making it difficult to compare results from early studies to more recent reports even within 2 years. Still, a lot has been learned over a very short period. It has become apparent that severe COVID-19 is predominantly a disease of immune dysregulation with components that can be defined as CSS. It has unique features and overlapping characteristics with other CSSs, and immunological treatment addressing the CSS has been extensively explored, which will be described here.
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Falavigna M, de Araujo CLP, Barbosa AN, Belli KC, Colpani V, Dal-Pizzol F, da Silva RM, de Azevedo LCP, Dias MBS, do Amaral JLG, Dorneles GP, Ferreira JC, Freitas APDR, Gräf DD, Guimarães HP, Lobo SMA, Machado FR, Nunes MS, de Oliveira MS, Parahiba SM, Rosa RG, Santos VCC, Sobreira ML, Veiga VC, Xavier RM, Zavascki AP, Stein C, de Carvalho CRR. The II Brazilian Guidelines for the pharmacological treatment of patients hospitalized with COVID-19 Joint Guidelines of the Associação Brasileira de Medicina de Emergência, Associação de Medicina Intensiva Brasileira, Associação Médica Brasileira, Sociedade Brasileira de Angiologia e Cirurgia Vascular, Sociedade Brasileira de Infectologia, Sociedade Brasileira de Pneumologia e Tisiologia and Sociedade Brasileira de Reumatologia. CRITICAL CARE SCIENCE 2023; 35:243-255. [PMID: 38133154 PMCID: PMC10734807 DOI: 10.5935/2965-2774.20230136-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/09/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE To update the recommendations to support decisions regarding the pharmacological treatment of patients hospitalized with COVID-19 in Brazil. METHODS Experts, including representatives of the Ministry of Health and methodologists, created this guideline. The method used for the rapid development of guidelines was based on the adoption and/or adaptation of existing international guidelines (GRADE ADOLOPMENT) and supported by the e-COVID-19 RecMap platform. The quality of the evidence and the preparation of the recommendations followed the GRADE method. RESULTS Twenty-one recommendations were generated, including strong recommendations for the use of corticosteroids in patients using supplemental oxygen and conditional recommendations for the use of tocilizumab and baricitinib for patients on supplemental oxygen or on noninvasive ventilation and anticoagulants to prevent thromboembolism. Due to suspension of use authorization, it was not possible to make recommendations regarding the use of casirivimab + imdevimab. Strong recommendations against the use of azithromycin in patients without suspected bacterial infection, hydroxychloroquine, convalescent plasma, colchicine, and lopinavir + ritonavir and conditional recommendations against the use of ivermectin and remdesivir were made. CONCLUSION New recommendations for the treatment of hospitalized patients with COVID-19 were generated, such as those for tocilizumab and baricitinib. Corticosteroids and prophylaxis for thromboembolism are still recommended, the latter with conditional recommendation. Several drugs were considered ineffective and should not be used to provide the best treatment according to the principles of evidence-based medicine and to promote resource economy.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Juliana Carvalho Ferreira
- Sociedade Brasileira de Pneumologia e Tisiologia - São Paulo
(SP), Brazil
- Associação de Medicina Intensiva Brasileira -
São Paulo (SP), Brazil
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Cinara Stein
- Hospital Moinhos de Vento - Porto Alegre (RS), Brazil
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Harte JV, Coleman-Vaughan C, Crowley MP, Mykytiv V. It's in the blood: a review of the hematological system in SARS-CoV-2-associated COVID-19. Crit Rev Clin Lab Sci 2023; 60:595-624. [PMID: 37439130 DOI: 10.1080/10408363.2023.2232010] [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: 04/10/2023] [Accepted: 06/27/2023] [Indexed: 07/14/2023]
Abstract
The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has led to an unprecedented global healthcare crisis. While SARS-CoV-2-associated COVID-19 affects primarily the respiratory system, patients with COVID-19 frequently develop extrapulmonary manifestations. Notably, changes in the hematological system, including lymphocytopenia, neutrophilia and significant abnormalities of hemostatic markers, were observed early in the pandemic. Hematological manifestations have since been recognized as important parameters in the pathophysiology of SARS-CoV-2 and in the management of patients with COVID-19. In this narrative review, we summarize the state-of-the-art regarding the hematological and hemostatic abnormalities observed in patients with SARS-CoV-2-associated COVID-19, as well as the current understanding of the hematological system in the pathophysiology of acute and chronic SARS-CoV-2-associated COVID-19.
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Affiliation(s)
- James V Harte
- Department of Haematology, Cork University Hospital, Wilton, Cork, Ireland
- School of Biochemistry & Cell Biology, University College Cork, Cork, Ireland
| | | | - Maeve P Crowley
- Department of Haematology, Cork University Hospital, Wilton, Cork, Ireland
- Irish Network for Venous Thromboembolism Research (INViTE), Ireland
| | - Vitaliy Mykytiv
- Department of Haematology, Cork University Hospital, Wilton, Cork, Ireland
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Piskac Zivkovic N, Mutvar A, Kuster D, Lucijanic M, Ljilja Posavec A, Cvetkovic Kucic D, Lalic K, Vergles M, Udovicic M, Barsic B, Rudan D, Luksic I, Lang IM, Skoro-Sajer N. Longitudinal analysis of chest Q-SPECT/CT in patients with severe COVID-19. Respir Med 2023; 220:107461. [PMID: 37951314 DOI: 10.1016/j.rmed.2023.107461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 11/04/2023] [Accepted: 11/05/2023] [Indexed: 11/13/2023]
Abstract
INTRODUCTION Patients with COVID-19 have an increased risk for microvascular lung thrombosis. In order to evaluate the type and prevalence of perfusion defects, we performed a longitudinal analysis of combined perfusion single-photon emission and low-dose computed tomography (Q-SPECT/CT scan) in patients with COVID-19 pneumonia. METHODS Consecutive patients with severe COVID-19 (B.1.1.7 variant SARS-CoV-2) and respiratory insufficiency underwent chest Q-SPECT/CT during hospitalization, and 3 months after discharge. At follow-up (FU), Q-SPECT/CT were analyzed and compared with pulmonary function tests (PFT), blood analysis (CRP, D-dimers, ferritin), modified Medical Research Council (mMRC) dyspnea scale, and high-resolution CT scans (HRCT). Patients with one or more segmental perfusion defects outside the area of inflammation (PDOI) were treated with anticoagulation until FU. RESULTS At baseline, PDOI were found in 50 of 105 patients (47.6 %). At FU, Q-SPECT/CT scans had improved significantly (p < 0.001) and PDOI were recorded in 14 of 77 (18.2 %) patients. There was a significant correlation between mMRC score and the number of segmental perfusion defects (r = 0.511, p < 0.001), and a weaker correlation with DLCO (r = -0.333, p = 0.002) and KCO (r = -0.373, p = 0.001) at FU. Neither corticosteroid therapy nor HRCT results showed an influence on Q-SPECT/CT changes (p = 0.94, p = 0.74). CRP, D-Dimers and ferritin improved but did not show any association with the FU Q-SPECT/CT results (p = 0.08). CONCLUSION Segmental mismatched perfusion defects are common in severe COVID-19 and are correlated with the degree of dyspnea. Longitudinal analyses of Q-SPECT/CT scans in severe COVID-19 may help understand possible mechanisms of long COVID and prolonged dyspnea.
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Affiliation(s)
| | - Andrea Mutvar
- Primary Respiratory-Intensive Care Center, Dubrava University Hospital, Zagreb, Croatia
| | - Dinka Kuster
- Primary Respiratory-Intensive Care Center, Dubrava University Hospital, Zagreb, Croatia
| | - Marko Lucijanic
- Primary Respiratory-Intensive Care Center, Dubrava University Hospital, Zagreb, Croatia
| | - Anja Ljilja Posavec
- Primary Respiratory-Intensive Care Center, Dubrava University Hospital, Zagreb, Croatia
| | - Daria Cvetkovic Kucic
- Primary Respiratory-Intensive Care Center, Dubrava University Hospital, Zagreb, Croatia
| | - Kristina Lalic
- Primary Respiratory-Intensive Care Center, Dubrava University Hospital, Zagreb, Croatia
| | - Mirna Vergles
- Primary Respiratory-Intensive Care Center, Dubrava University Hospital, Zagreb, Croatia
| | - Mario Udovicic
- Primary Respiratory-Intensive Care Center, Dubrava University Hospital, Zagreb, Croatia
| | - Bruno Barsic
- Primary Respiratory-Intensive Care Center, Dubrava University Hospital, Zagreb, Croatia
| | - Diana Rudan
- Primary Respiratory-Intensive Care Center, Dubrava University Hospital, Zagreb, Croatia
| | - Ivica Luksic
- Primary Respiratory-Intensive Care Center, Dubrava University Hospital, Zagreb, Croatia
| | - Irene Marthe Lang
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Medical University of Vienna, Austria
| | - Nika Skoro-Sajer
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Medical University of Vienna, Austria.
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Potpara T, Angiolillo DJ, Bikdeli B, Capodanno D, Cole O, Yataco AC, Dan GA, Harrison S, Iaccarino JM, Moores LK, Ntaios G, Lip GYH. Antithrombotic Therapy in Arterial Thrombosis and Thromboembolism in COVID-19: An American College of Chest Physicians Expert Panel Report. Chest 2023; 164:1531-1550. [PMID: 37392958 DOI: 10.1016/j.chest.2023.06.032] [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: 03/02/2023] [Revised: 06/08/2023] [Accepted: 06/19/2023] [Indexed: 07/03/2023] Open
Abstract
BACKGROUND Evidence increasingly shows that the risk of thrombotic complications in COVID-19 is associated with a hypercoagulable state. Several organizations have released guidelines for the management of COVID-19-related coagulopathy and prevention of VTE. However, an urgent need exists for practical guidance on the management of arterial thrombosis and thromboembolism in this setting. RESEARCH QUESTION What is the current available evidence informing the prevention and management of arterial thrombosis and thromboembolism in patients with COVID-19? STUDY DESIGN AND METHODS A group of approved panelists developed key clinical questions by using the Population, Intervention, Comparator, and Outcome (PICO) format that address urgent clinical questions regarding prevention and management of arterial thrombosis and thromboembolism in patients with COVID-19. Using MEDLINE via PubMed, a literature search was conducted and references were screened for inclusion. Data from included studies were summarized and reviewed by the panel. Consensus for the direction and strength of recommendations was achieved using a modified Delphi survey. RESULTS The review and analysis of the literature based on 11 PICO questions resulted in 11 recommendations. Overall, a low quality of evidence specific to the population with COVID-19 was found. Consequently, many of the recommendations were based on indirect evidence and prior guidelines in similar populations without COVID-19. INTERPRETATION The existing evidence and panel consensus do not suggest a major departure from the management of arterial thrombosis according to recommendations predating the COVID-19 pandemic. Data on the optimal strategies for prevention and management of arterial thrombosis and thromboembolism in patients with COVID-19 are sparse. More high-quality evidence is needed to inform management strategies in these patients.
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Affiliation(s)
- Tatjana Potpara
- School of Medicine, University of Belgrade, Belgrade, Serbia; Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia.
| | | | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Yale/YNHH Center for Outcomes Research & Evaluation, New Haven, CT; Cardiovascular Research Foundation, New York, NY
| | - Davide Capodanno
- Azienda Ospedalielo-Universitaria Policlinico "G- Rodolico-San Marco", University of Catania, Catania, Italy
| | - Oana Cole
- Liverpool Heart and Chest Hospital, Liverpool, England
| | - Angel Coz Yataco
- Departments of Critical Care and of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Gheorghe-Andrei Dan
- "Carol Davila" University of Medicine, Colentina University Hospital, Bucharest, Romania
| | - Stephanie Harrison
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, Liverpool, England
| | - Jonathan M Iaccarino
- The Pulmonary Center, Boston University School of Medicine, Boston, MA; American College of Chest Physicians, Glenview, IL
| | - Lisa K Moores
- The Uniformed Services University of the Health Sciences, Bethesda, MD
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, Liverpool, England; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Landi A, Morici N, Vranckx P, Frigoli E, Bonacchini L, Omazzi B, Tresoldi M, Camponovo C, Moccetti T, Valgimigli M. Edoxaban and/or colchicine in outpatients with COVID-19: rationale and design of the CONVINCE trial. J Cardiovasc Med (Hagerstown) 2023; 24:920-930. [PMID: 37942793 DOI: 10.2459/jcm.0000000000001556] [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: 11/10/2023]
Abstract
BACKGROUND An excessive inflammatory response and a hypercoagulable state are not infrequent in patients with coronavirus disease-2019 (COVID-19) and are associated with adverse clinical outcomes. However, the optimal treatment strategy for COVID-19 patients managed in the out-of-hospital setting is still uncertain. DESIGN The CONVINCE (NCT04516941) is an investigator-initiated, open-label, blinded-endpoint, 2 × 2 factorial design randomized trial aimed at assessing two independently tested hypotheses (anticoagulation and anti-inflammatory ones) in COVID-19 patients. Adult symptomatic patients (≥18 years of age) within 7 days from reverse transcription-PCR (RT-PCR) diagnosis of SARS-CoV-2 infection managed at home or in nursery settings were considered for eligibility. Eligible patients fulfilling all inclusion and no exclusion criteria were randomized to edoxaban versus no treatment (anticoagulation hypothesis) and colchicine versus no treatment (anti-inflammatory hypothesis) in a 1 : 1:1 : 1 ratio. The study had two co-primary endpoints (one for each randomization), including the composite of major vascular thrombotic events at 25 ± 3 days for the anticoagulation hypothesis and the composite of SARS-CoV-2 detection rates at 14 ± 3 days by RT-PCR or freedom from death or hospitalizations (anti-inflammatory hypothesis). Study endpoints will be adjudicated by a blinded Clinical Events Committee. With a final sample size of 420 patients, this study projects an 80% power for each of the two primary endpoints appraised separately. CONCLUSION The CONVINCE trial aims at determining whether targeting anticoagulation and/or anti-inflammatory pathways may confer benefit in COVID-19 patients managed in the out-of-hospital setting. TRIAL REGISTRATION ClinicalTrials.gov number, NCT04516941.
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Affiliation(s)
- Antonio Landi
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale (EOC)
- Department of Biomedical Sciences, University of Italian Switzerland, Lugano, Switzerland
| | - Nuccia Morici
- IRCCS S. Maria Nascente - Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | - Pascal Vranckx
- the Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Enrico Frigoli
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale (EOC)
| | - Luca Bonacchini
- Emergency Department, ASST Great Metropolitan Hospital Niguarda, Milan
| | - Barbara Omazzi
- Emergency Unit, ASST Rhodense, Garbagnate Milanese, Italy
| | - Moreno Tresoldi
- Unit of General Medicine and Advanced Care, IRCCS San Raffaele Hospital, Milan
| | - Claudio Camponovo
- Department of Anesthesiology, Clinica Ars Medica, Genolier Swiss Medical Network, Gravesano
| | | | - Marco Valgimigli
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale (EOC)
- Department of Biomedical Sciences, University of Italian Switzerland, Lugano, Switzerland
- University of Bern, Bern, Switzerland
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45
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de Maistre E, Savard P, Guinot PG. COVID-19 and the Concept of Thrombo-Inflammation: Review of the Relationship between Immune Response, Endothelium and Coagulation. J Clin Med 2023; 12:7245. [PMID: 38068297 PMCID: PMC10706970 DOI: 10.3390/jcm12237245] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 11/10/2023] [Accepted: 11/16/2023] [Indexed: 09/11/2024] Open
Abstract
COVID-19, caused by the SARS-CoV-2 virus, has revealed a complex interplay between inflammation and coagulation, leading to the emergence of the concept of thrombo-inflammation. This concept recognizes that COVID-19 is not solely a respiratory illness, but a systemic disease with significant vascular and hematological components. COVID-19 is associated with an unusual prothrombotic state, with intense endothelial activation leading to vasculopathy, cytokine storm, complement system activation and a hypercoagulability state (the activation of platelets and the coagulation cascade, impaired fibrinolysis). The aim of this review is to discuss the different pathological pathways described in COVID-19 that lead to thromboembolic events. Widespread vaccination and post-COVID-19 immunization allows control over the severity of this pandemic. A better understanding of the pathophysiology of COVID-19 can improve the management of frail patients who are hospitalized in intensive care units.
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Affiliation(s)
| | - Philippe Savard
- Haemostais Unit, Dijon University Hospital, F-21000 Dijon, France;
| | - Pierre-Gregoire Guinot
- Department of Anesthesiology and Intensive Care, Dijon University Hospital, F-21000 Dijon, France;
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46
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Unat ÖS, Karimov Z, Serçe Unat D, Damar G, Çağlayan P, Teymurlu F, Sezai Taşbakan M, Korkmaz Ekren P, Başoğlu Ö, Sayıner A. What is the Optimal Treatment Regimen of Low-MolecularWeight Heparin in Coronavirus Disease 2019 Pneumonia? THORACIC RESEARCH AND PRACTICE 2023; 25. [PMID: 37970682 PMCID: PMC11158007 DOI: 10.5152/thoracrespract.2023.23039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 09/06/2023] [Indexed: 11/17/2023]
Abstract
OBJECTIVE The optimal anticoagulant treatment regimen in hospitalized coronavirus disease 2019 (COVID-19) patients is uncertain. This study aimed to compare the rates of disease progression and mortality in patients treated with low-molecular-weight heparin (LMWH) according to baseline d-dimer levels and in those who received a fixed-dose regimen irrespective of the d-dimer level. MATERIAL AND METHODS This was a retrospective analysis of all patients admitted to a university hospital for COVID-19 pneumonia during a 1-year period. The protocol for d-dimer-driven therapy (on-protocol) was as follows: prophylactic dose when the baseline level is <1000 ng/mL, intermediate dose when the level is between 1000 and 3000 ng/mL, and therapeutic dose when the level is >3000 ng/mL. We compared the progression and mortality rates between the on-protocol and off-protocol treatment groups. The offprotocol group consisted of patients that received a fixed-dose LMWH regimen, which was not in accordance with the defined protocol. RESULTS Of 384 patients (mean age 61.5 ± 15.9 years, 216 male), 294 patients with complete data composed the study group, and 174 patients were treated on-protocol and 120 patients were treated off-protocol. The on-protocol group had lower C-reactive protein (CRP), ferritin, lactate dehydrogenase (LDH), and d-dimer levels and higher SpO2/FiO2 levels at admission. Disease progression developed in 45/174 on-protocol patients (25.9%) vs. 53/120 off-protocol patients (44.2%) during the follow-up (P = .001), and mortality was 29 (16.7%) vs. 32 (26.7%), respectively (P = .041). Logistic regression analysis was performed and included age, presence of comorbidities, LMWH regimen, baseline SpO2/FiO2, CRP, and LDH levels as independent variables. The presence of cardiac comorbidity, age, CRP, and LDH levels, but not the LMWH treatment regimen, were associated with both disease progression and mortality. CONCLUSION A d-dimer-driven LMWH treatment protocol is not associated with better clinical outcomes in hospitalized COVID-19 patients.
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Affiliation(s)
- Ömer Selim Unat
- Department of Pulmonology, Ege University Faculty of Medicine, İzmir, Turkey
| | - Ziya Karimov
- Medicine Program, Ege University Faculty of Medicine, İzmir, Turkey
| | - Damla Serçe Unat
- Department of Pulmonology, İzmir Kemalpaşa State Hospital, İzmir, Turkey
| | - Gizem Damar
- Department of Pulmonology, Ege University Faculty of Medicine, İzmir, Turkey
| | - Pakize Çağlayan
- Department of Pulmonology, Ege University Faculty of Medicine, İzmir, Turkey
| | - Faik Teymurlu
- Department of Pulmonology, Ege University Faculty of Medicine, İzmir, Turkey
| | | | | | - Özen Başoğlu
- Department of Pulmonology, Ege University Faculty of Medicine, İzmir, Turkey
| | - Abdullah Sayıner
- Department of Pulmonology, Ege University Faculty of Medicine, İzmir, Turkey
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Wang D, Zheng S, Cui Y, He N, Chen T, Huang B. Adjusted win ratio using the inverse probability of treatment weighting. J Biopharm Stat 2023:1-16. [PMID: 37947400 DOI: 10.1080/10543406.2023.2275759] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 10/22/2023] [Indexed: 11/12/2023]
Abstract
The win ratio method has been increasingly applied in the design and analysis of clinical trials. However, the win ratio method is a univariate approach that does not allow for adjusting for baseline imbalances in covariates, although a stratified win ratio can be calculated when the number of strata is small. This paper proposes an adjusted win ratio to control for such imbalances by inverse probability of treatment weighting (IPTW) method. We derive the adjusted win ratio with its variance and suggest three IPTW adjustments: IPTW-average treatment effect (IPTW-ATE), stabilized IPTW-ATE (SIPTW-ATE) and IPTW-average treatment effect in the treated (IPTW-ATT). The proposed adjusted methods are applied to analyse a composite outcome in the CHARM trial. The statistical properties of the methods are assessed through simulations. Results show that adjusted win ratio methods can correct the win ratio for covariate imbalances at baseline. Simulation results show that the three proposed adjusted win ratios have similar power to detect the treatment difference and have slightly lower power than the corresponding adjusted Cox models when the assumption of proportional hazards holds true but have consistently higher power than adjusted Cox models when the proportional hazard assumption is violated.
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Affiliation(s)
- Duolao Wang
- Biostatistics Unit, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke, UK
| | - Sirui Zheng
- Biostatistics Unit, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke, UK
| | - Ying Cui
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia, USA
| | - Nengjie He
- Biostatistics Unit, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke, UK
| | - Tao Chen
- Centre for Health Economics, University of York, York, UK
| | - Bo Huang
- Pfizer Research & Development, Pfizer Inc, Groton, Connecticut, USA
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48
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Klenk C, Erber J, Fresacher D, Röhrl S, Lengl M, Heim D, Irl H, Schlegel M, Haller B, Lahmer T, Diepold K, Rasch S, Hayden O. Platelet aggregates detected using quantitative phase imaging associate with COVID-19 severity. COMMUNICATIONS MEDICINE 2023; 3:161. [PMID: 37935793 PMCID: PMC10630365 DOI: 10.1038/s43856-023-00395-6] [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: 04/15/2023] [Accepted: 10/25/2023] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND The clinical spectrum of acute SARS-CoV-2 infection ranges from an asymptomatic to life-threatening disease. Considering the broad spectrum of severity, reliable biomarkers are required for early risk stratification and prediction of clinical outcomes. Despite numerous efforts, no COVID-19-specific biomarker has been established to guide further diagnostic or even therapeutic approaches, most likely due to insufficient validation, methodical complexity, or economic factors. COVID-19-associated coagulopathy is a hallmark of the disease and is mainly attributed to dysregulated immunothrombosis. This process describes an intricate interplay of platelets, innate immune cells, the coagulation cascade, and the vascular endothelium leading to both micro- and macrothrombotic complications. In this context, increased levels of immunothrombotic components, including platelet and platelet-leukocyte aggregates, have been described and linked to COVID-19 severity. METHODS Here, we describe a label-free quantitative phase imaging approach, allowing the identification of cell-aggregates and their components at single-cell resolution within 30 min, which prospectively qualifies the method as point-of-care (POC) testing. RESULTS We find a significant association between the severity of COVID-19 and the amount of platelet and platelet-leukocyte aggregates. Additionally, we observe a linkage between severity, aggregate composition, and size distribution of platelets in aggregates. CONCLUSIONS This study presents a POC-compatible method for rapid quantitative analysis of blood cell aggregates in patients with COVID-19.
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Affiliation(s)
- Christian Klenk
- Heinz-Nixdorf-Chair of Biomedical Electronics, School of Computation, Information and Technology, Technical University of Munich, TranslaTUM, 81675, Munich, Germany
| | - Johanna Erber
- TUM School of Medicine and Health, Department of Clinical Medicine - Clinical Department for Internal Medicine II, University Medical Centre, Technical University of Munich, 81675, Munich, Germany
| | - David Fresacher
- Heinz-Nixdorf-Chair of Biomedical Electronics, School of Computation, Information and Technology, Technical University of Munich, TranslaTUM, 81675, Munich, Germany
- Chair for Data Processing, School of Computation, Information and Technology, Technical University of Munich, 80333, Munich, Germany
| | - Stefan Röhrl
- Chair for Data Processing, School of Computation, Information and Technology, Technical University of Munich, 80333, Munich, Germany
| | - Manuel Lengl
- Chair for Data Processing, School of Computation, Information and Technology, Technical University of Munich, 80333, Munich, Germany
| | - Dominik Heim
- Heinz-Nixdorf-Chair of Biomedical Electronics, School of Computation, Information and Technology, Technical University of Munich, TranslaTUM, 81675, Munich, Germany
| | - Hedwig Irl
- TUM School of Medicine and Health, Department of Clinical Medicine - Clinical Department of Anaesthesiology and Intensive Care Medicine, University Medical Centre, Technical University of Munich, 81675, Munich, Germany
| | - Martin Schlegel
- TUM School of Medicine and Health, Department of Clinical Medicine - Clinical Department of Anaesthesiology and Intensive Care Medicine, University Medical Centre, Technical University of Munich, 81675, Munich, Germany
| | - Bernhard Haller
- TUM School of Medicine and Health, Department of Clinical Medicine - Institute of AI and Informatics in Medicine, University Medical Centre, Technical University of Munich, 81675, Munich, Germany
| | - Tobias Lahmer
- TUM School of Medicine and Health, Department of Clinical Medicine - Clinical Department for Internal Medicine II, University Medical Centre, Technical University of Munich, 81675, Munich, Germany
| | - Klaus Diepold
- Chair for Data Processing, School of Computation, Information and Technology, Technical University of Munich, 80333, Munich, Germany
| | - Sebastian Rasch
- TUM School of Medicine and Health, Department of Clinical Medicine - Clinical Department for Internal Medicine II, University Medical Centre, Technical University of Munich, 81675, Munich, Germany
| | - Oliver Hayden
- Heinz-Nixdorf-Chair of Biomedical Electronics, School of Computation, Information and Technology, Technical University of Munich, TranslaTUM, 81675, Munich, Germany.
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49
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Dushianthan A, Bracegirdle L, Cusack R, Cumpstey AF, Postle AD, Grocott MPW. Alveolar Hyperoxia and Exacerbation of Lung Injury in Critically Ill SARS-CoV-2 Pneumonia. Med Sci (Basel) 2023; 11:70. [PMID: 37987325 PMCID: PMC10660857 DOI: 10.3390/medsci11040070] [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: 09/26/2023] [Revised: 10/17/2023] [Accepted: 10/30/2023] [Indexed: 11/22/2023] Open
Abstract
Acute hypoxic respiratory failure (AHRF) is a prominent feature of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) critical illness. The severity of gas exchange impairment correlates with worse prognosis, and AHRF requiring mechanical ventilation is associated with substantial mortality. Persistent impaired gas exchange leading to hypoxemia often warrants the prolonged administration of a high fraction of inspired oxygen (FiO2). In SARS-CoV-2 AHRF, systemic vasculopathy with lung microthrombosis and microangiopathy further exacerbates poor gas exchange due to alveolar inflammation and oedema. Capillary congestion with microthrombosis is a common autopsy finding in the lungs of patients who die with coronavirus disease 2019 (COVID-19)-associated acute respiratory distress syndrome. The need for a high FiO2 to normalise arterial hypoxemia and tissue hypoxia can result in alveolar hyperoxia. This in turn can lead to local alveolar oxidative stress with associated inflammation, alveolar epithelial cell apoptosis, surfactant dysfunction, pulmonary vascular abnormalities, resorption atelectasis, and impairment of innate immunity predisposing to secondary bacterial infections. While oxygen is a life-saving treatment, alveolar hyperoxia may exacerbate pre-existing lung injury. In this review, we provide a summary of oxygen toxicity mechanisms, evaluating the consequences of alveolar hyperoxia in COVID-19 and propose established and potential exploratory treatment pathways to minimise alveolar hyperoxia.
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Affiliation(s)
- Ahilanandan Dushianthan
- NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; (L.B.); (R.C.); (A.F.C.); (A.D.P.); (M.P.W.G.)
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
| | - Luke Bracegirdle
- NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; (L.B.); (R.C.); (A.F.C.); (A.D.P.); (M.P.W.G.)
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
| | - Rebecca Cusack
- NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; (L.B.); (R.C.); (A.F.C.); (A.D.P.); (M.P.W.G.)
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
| | - Andrew F. Cumpstey
- NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; (L.B.); (R.C.); (A.F.C.); (A.D.P.); (M.P.W.G.)
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
| | - Anthony D. Postle
- NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; (L.B.); (R.C.); (A.F.C.); (A.D.P.); (M.P.W.G.)
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
| | - Michael P. W. Grocott
- NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; (L.B.); (R.C.); (A.F.C.); (A.D.P.); (M.P.W.G.)
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
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50
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Kondo T, Gasparyan SB, Jhund PS, Bengtsson O, Claggett BL, de Boer RA, Hernandez AF, Inzucchi SE, Kosiborod MN, Køber L, Lam CSP, Langkilde AM, Martinez FA, Petersson M, Ponikowski P, Sabatine MS, Shah SJ, Sjostrand M, Wilderang U, Vaduganathan M, Solomon SD, McMurray JJV. Use of Win Statistics to Analyze Outcomes in the DAPA-HF and DELIVER Trials. NEJM EVIDENCE 2023; 2:EVIDoa2300042. [PMID: 38320525 DOI: 10.1056/evidoa2300042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND: The primary end point in most heart failure (HF) trials is a composite of time to a first worsening HF event or cardiovascular death. Prevention of recurrent events and improvements in symptoms/quality of life are also important for patients but are usually analyzed separately. Win statistics can integrate all these outcomes into a single composite end point, which is analyzed in hierarchical order, reflecting the clinical importance of each component. METHODS: The Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure (DAPA-HF, n=4744) and Dapagliflozin Evaluation to Improve the Lives of Patients with Preserved Ejection Fraction Heart Failure (DELIVER, n=6263) trials enrolled patients with New York Heart Association class II, III, or IV HF, elevated natriuretic peptides, and either an ejection fraction of 40% or less (DAPA-HF) or greater than 40% and left atrial enlargement/left ventricular hypertrophy (DELIVER). We examined the effects of dapagliflozin compared with placebo on a hierarchical composite outcome, including cardiovascular death, total (first and recurrent) HF hospitalizations, total urgent HF visits, and improvement/deterioration in Kansas City Cardiomyopathy Questionnaire total symptom score (KCCQ-TSS; range from 0 to 100, with a higher score indicating fewer symptoms and physical limitations) at 8 months. RESULTS: For this composite outcome, the win ratio was 1.30 (95% confidence interval [CI], 1.23 to 1.36) in the pooled cohort, 1.33 (95% CI, 1.23 to 1.43) in the DAPA-HF trial, and 1.27 (95% CI, 1.18 to 1.36) in the DELIVER trial. Win odds and net benefit in overall patients were 1.19 (95% CI, 1.14 to 1.24) and 8.7% (95% CI, 6.6 to 10.9%), respectively. In the overall pooled cohort, the majority of wins and losses were accounted for by KCCQ-TSS; 52.4% were settled by the KCCQ-TSS tier in the pooled cohort. CONCLUSIONS: In both the DAPA-HF and DELIVER trials, dapagliflozin led to a significant improvement in composite outcomes that incorporated patient-reported outcomes along with total HF events, as well as cardiovascular deaths. These analyses provided a comprehensive presentation of win statistics and illustrated the utility and flexibility of win statistics in describing the effects of dapagliflozin in two recent clinical trials in patients with HF. (Funded by British Heart Foundation Centre of Research Excellence and others; clinical trial registration numbers, NCT03036124 and NCT03619213.)
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Affiliation(s)
- Toru Kondo
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Samvel B Gasparyan
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Olof Bengtsson
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston
| | | | | | | | | | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen
| | - Carolyn S P Lam
- National Heart Centre Singapore & Duke-National University of Singapore, Singapore
| | - Anna Maria Langkilde
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | | | - Magnus Petersson
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Piotr Ponikowski
- Department of Heart Disease, Wroclaw Medical University, Wroclaw, Poland
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston
| | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago
| | - Mikaela Sjostrand
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Ulrica Wilderang
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
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