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Iba T, Connors JM, Levy JH. What Role Does Microthrombosis Play in Long COVID? Semin Thromb Hemost 2024; 50:527-536. [PMID: 37748518 DOI: 10.1055/s-0043-1774795] [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: 09/27/2023]
Abstract
Soon after the outbreak of coronavirus disease 2019 (COVID-19), unexplained sustained fatigue, cognitive disturbance, and muscle ache/weakness were reported in patients who had recovered from acute COVID-19 infection. This abnormal condition has been recognized as "long COVID (postacute sequelae of COVID-19 [PASC])" with a prevalence estimated to be from 10 to 20% of convalescent patients. Although the pathophysiology of PASC has been studied, the exact mechanism remains obscure. Microclots in circulation can represent one of the possible causes of PASC. Although hypercoagulability and thrombosis are critical mechanisms of acute COVID-19, recent studies have reported that thromboinflammation continues in some patients, even after the virus has cleared. Viral spike proteins and RNA can be detected months after patients have recovered, findings that may be responsible for persistent thromboinflammation and the development of microclots. Despite this theory, long-term results of anticoagulation, antiplatelet therapy, and vascular endothelial protection are inconsistent, and could not always show beneficial treatment effects. In summary, PASC reflects a heterogeneous condition, and microclots cannot explain all the presenting symptoms. After clarification of the pathomechanisms of each symptom, a symptom- or biomarker-based stratified approach should be considered for future studies.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Jean M Connors
- Division of Hematology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina
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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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3
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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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Mazzeffi M, Levy JH. Antithrombin Deficiency during Venoarterial Extracorporeal Membrane Oxygenation: Extremely Common, but Does It Matter? Anesthesiology 2024; 140:1065-1067. [PMID: 38742999 DOI: 10.1097/aln.0000000000004948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Affiliation(s)
- Michael Mazzeffi
- University of Virginia School of Medicine, Department of Anesthesiology, Charlottesville, Virginia
| | - Jerrold H Levy
- Departments of Anesthesiology, Critical Care, and Surgery Duke University School of Medicine, Durham, North Carolina
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Schulman S, Arnold DM, Bradbury CA, Broxmeyer L, Connors JM, Falanga A, Iba T, Kaatz S, Levy JH, Middeldorp S, Minichiello T, Nazy I, Ramacciotti E, Resnick HE, Samama CM, Sholzberg M, Thachil J, Zarychanski R, Spyropoulos AC. 2023 ISTH update of the 2022 ISTH guidelines for antithrombotic treatment in COVID-19. J Thromb Haemost 2024; 22:1779-1797. [PMID: 38503600 DOI: 10.1016/j.jtha.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 01/31/2024] [Accepted: 02/13/2024] [Indexed: 03/21/2024]
Abstract
Based on emerging evidence from the COVID-19 pandemic, the International Society on Thrombosis and Haemostasis (ISTH) guidelines for antithrombotic treatment in COVID-19 were published in 2022. Since then, at least 16 new randomized controlled trials have contributed additional evidence, which necessitated a modification of most of the previous recommendations. We used again the American College of Cardiology Foundation/American Heart Association methodology for assessment of level of evidence (LOE) and class of recommendation (COR). Five recommendations had the LOE upgraded to A and 2 new recommendations on antithrombotic treatment for patients with COVID-19 were added. Furthermore, a section was added to answer questions about COVID-19 vaccination and vaccine-induced immune thrombotic thrombocytopenia (VITT), for which studies have provided some evidence. We only included recommendations with LOE A or B. Panelists agreed on 19 recommendations, 4 for nonhospitalized, 5 for noncritically ill hospitalized, 3 for critically ill hospitalized, and 2 for postdischarge patients, as well as 5 for vaccination and VITT. A strong recommendation (COR 1) was given for (a) use of prophylactic dose of low-molecular-weight heparin or unfractionated heparin in noncritically ill patients hospitalized for COVID-19, (b) for select patients in this group, use of therapeutic-dose low-molecular-weight heparin/unfractionated heparin in preference to prophylactic dose, and (c) for use of antiplatelet factor 4 enzyme immunoassays for diagnosing VITT. A strong recommendation was given against (COR 3) the addition of an antiplatelet agent in hospitalized, noncritically ill patients. These international guidelines provide recommendations for countries with diverse healthcare resources and COVID-19 vaccine availability.
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Affiliation(s)
- Sam Schulman
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Obstetrics and Gynecology and Perinatal Medicine, I.M. Sechenov First Moscow State Medical University, Moscow, Russia.
| | - Donald M Arnold
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | | | - Lisa Broxmeyer
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Jean Marie Connors
- Division of Hematology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Anna Falanga
- Department of Transfusion Medicine and Hematology, Hospital Papa Giovanni XXIII, Bergamo, Italy; University of Milan Bicocca, Monza, Italy
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University, Tokyo, Japan
| | - Scott Kaatz
- Division of Hospital Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Jerrold H Levy
- Departments of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, North Carolina, USA
| | - Saskia Middeldorp
- Department of Internal Medicine and Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Tracy Minichiello
- Division of Hematology, San Francisco VA Medical Center, University of California, San Francisco, San Francisco, California, USA
| | - Ishac Nazy
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Eduardo Ramacciotti
- Science Valley Research Institute, São Paulo, Brazil; Hospital e Maternidade Christóvão da Gama, Grupo Leforte, Santo André, São Paulo, Brazil
| | | | - Charles Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, Groupe Hospitalo-Universitaire, Assistance Publique-Hôpitaux de Paris Centre -Université Paris Cité, Cochin Hospital, Paris, France
| | - Michelle Sholzberg
- Departments of Medicine and Laboratory Medicine and Pathobiology, St Michael's Hospital, Li Ka Shing Knowledge Institute, University of Toronto, Toronto, Ontario, Canada
| | - Jecko Thachil
- Department of Haematology, Manchester University Hospitals, Manchester, United Kingdom
| | - Ryan Zarychanski
- Sections of Hematology/Oncology and Critical Care, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alex C Spyropoulos
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA; Institute of Health System Science, Feinstein Institutes for Medical Research, Manhasset, New York, USA
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Dorgalaleh A, Safdari SM, Tabibian S, Shams M, Dabbagh A, Rezazadeh A. Congenital Bleeding Disorders and COVID-19-A Systematic Literature Review. Semin Thromb Hemost 2024; 50:552-568. [PMID: 37758179 DOI: 10.1055/s-0043-1775733] [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: 10/03/2023]
Abstract
Hypercoagulability is a prominent feature of coronavirus disease 2019 (COVID-19) and can lead to fatal consequences. Although the impact of COVID-19 on several disorders is well-established, its effect on congenital bleeding disorders (CBDs) is not well-documented. To address this ambiguity, a systematic review was conducted on the available studies to determine the impact of COVID-19 and vaccination aimed to prevent COVID-19 on patients with CBDs. We performed a systematic literature review using relevant keywords and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) protocol. We conducted our search on the PubMed, Scopus, and Web of Science databases until July 2023. Out of 31 included studies, 12 case series covering 770 patients with CBD and COVID-19 were further analyzed. The majority of the patients had hemophilia A (n = 352, ∼46%) or hemophilia B (n = 74, ∼10%), while the remaining patients had von Willebrand disease (n = 43, 5.6%) or rare bleeding disorders (n = 27, 3.5%). A total of 25 deaths (3.2%) and 22 intensive care unit admissions (2.8%) were recorded. Bleeding complications were reported in the majority of the 12 case series (n = 7, 58.3%) and in most of the case reports (n = 8, ∼57%), while thrombotic complications were only reported in two studies (16.6%). The mortality rate ranged from 0% in five studies (41.6%) to 5.7% and the rate of hospitalization ranged from 0 to 40%. Bleeding complications were reported in a range of 0 to 81%, while the thrombotic complication rate in one study was 6.9%. The mortality rate varied from 0 to 5.7%, and the hospitalization rate ranged from 0 to 40%. Bleeding complications were reported in a range of 0 to 81%, while the rate of thrombotic complications in one study was 6.9%. Vaccination was reported in five case series, which included 821 patients with CBDs with the majority having hemophilia A (n = 479; 67.2%) and hemophilia B (n = 85; ∼12%). The most frequently reported side effects were myalgia (6.5%), flu-like symptoms (4.8%), fever (4.7%), and headache (4%). COVID-19 in patients with CBDs appears to provoke thrombotic complications and bleeding events more frequently, as well as a higher rate of hospitalization, which may be partially due to the increased risk of bleeding events. Although it seems that patients with CBD have lower mortality rates, further studies are necessary to fully understand this, especially considering comorbidities and low number of available studies.
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Affiliation(s)
| | - Seyed Mehrab Safdari
- Departments of Hematology and Blood Transfusion, School of Allied Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Shadi Tabibian
- Iranian Comprehensive Hemophilia Care Center, Blood and Viral Research Center, Tehran, Iran
| | - Mahmood Shams
- Cellular and Molecular Biology Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Ali Dabbagh
- Department of Anesthesia and Anesthesia Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Azadeh Rezazadeh
- Department of Biology, Science and Research Branch, Islamic Azad University, Tehran, Iran
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Davila J, O'Brien SH, Mitchell WB, Manwani D. Evaluating thromboprophylaxis in the sickle cell disease population: Navigating the evidence gap. Br J Haematol 2024; 204:2184-2193. [PMID: 38578212 DOI: 10.1111/bjh.19428] [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: 10/02/2023] [Revised: 02/08/2024] [Accepted: 03/14/2024] [Indexed: 04/06/2024]
Abstract
Sickle cell disease (SCD) arises from beta-globin gene mutations, with global estimates indicating around 500 000 affected neonates in 2021. In the United States, it is considered rare, impacting fewer than 200 000 individuals. The key pathogenic flaw lies in mutant haemoglobin S, prone to polymerization under low oxygen conditions, causing erythrocytes to adopt a sickled shape. This leads to complications like vascular occlusion, haemolytic anaemia, inflammation and organ damage. Beyond erythrocyte abnormalities however, there is a body of literature highlighting the hypercoagulable state that is likely a contributor to many of the complications we see in SCD. The persistent activation of the coagulation cascade results in thromboembolic events, notably venous thromboembolism (VTE) which is independently associated with increased mortality in both adults and children with SCD. While the increased risk of VTE in the SCD population seems well established, there is a lack of guidelines for thromboprophylaxis in this population. This Wider Perspective will describe the hypercoagulable state and increased thrombosis risk in the SCD population, as well as advocate for the development of evidence-based guidelines to aid in the prevention of VTE in SCD.
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Affiliation(s)
- Jennifer Davila
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, New York, USA
| | - Sarah H O'Brien
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital/The Ohio State University, Columbus, Ohio, USA
| | - William B Mitchell
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, New York, USA
| | - Deepa Manwani
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, New York, USA
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Roberts LN, Arya R, Hunt BJ. Advances and current research in primary thromboprophylaxis to prevent hospital-associated venous thromboembolism. Br J Haematol 2024; 204:1635-1648. [PMID: 38577829 DOI: 10.1111/bjh.19424] [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: 02/09/2024] [Revised: 03/13/2024] [Accepted: 03/13/2024] [Indexed: 04/06/2024]
Abstract
Hospital-associated venous thromboembolism (VTE) is defined as any case of VTE occurring during hospital admission and for up to 90 days post discharge. It accounts for over 50% of all cases of VTE internationally; indeed, there are an estimated 10 million cases of hospital-associated VTE annually. Over the last decade, there has been increasing interest in improving VTE risk assessment and thromboprophylaxis. This review summarises all the recent and ongoing major research studies and future challenges in the different areas, including medical, surgical and obstetric patients, as well as special areas such as lower limb immobilisation. We include sections on both pharmacological and mechanical thromboprophylaxis.
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Affiliation(s)
- Lara N Roberts
- Department of Haematological Medicine, King's Thrombosis Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Roopen Arya
- Department of Haematological Medicine, King's Thrombosis Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Beverley J Hunt
- Thrombosis & Haemophilia Centre, St Thomas' Hospital, London, UK
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9
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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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Iba T, Maier CL, Helms J, Ferrer R, Thachil J, Levy JH. Managing sepsis and septic shock in an endothelial glycocalyx-friendly way: from the viewpoint of surviving sepsis campaign guidelines. Ann Intensive Care 2024; 14:64. [PMID: 38658435 PMCID: PMC11043313 DOI: 10.1186/s13613-024-01301-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 04/19/2024] [Indexed: 04/26/2024] Open
Abstract
Maintaining tissue perfusion in sepsis depends on vascular integrity provided by the endothelial glycocalyx, the critical layer covering the luminal surface of blood vessels. The glycocalyx is composed of proteoglycans, glycosaminoglycans, and functional plasma proteins that are critical for antithrombogenicity, regulating tone, controlling permeability, and reducing endothelial interactions with leukocytes and platelets. Degradation of the glycocalyx in sepsis is substantial due to thromboinflammation, and treatments for sepsis and septic shock may exacerbate endotheliopathy via additional glycocalyx injury. As a result, therapeutic strategies aimed at preserving glycocalyx integrity should be considered, including modifications in fluid volume resuscitation, minimizing catecholamine use, controlling hyperglycemia, and potential use of corticosteroids and anticoagulants. In this review, we explore treatment strategies aligned with the recommendations outlined in the Surviving Sepsis Campaign Guidelines 2021 with a special emphasis on evidence regarding glycocalyx protection.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo Bunkyo-Ku, Tokyo, 113-8421, Japan.
| | - Cheryl L Maier
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Julie Helms
- Strasbourg University Hospital, Medical Intensive Care Unit-NHC, INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg University (UNISTRA), Strasbourg, France
| | - Ricard Ferrer
- Intensive Care Department, Hospital Universitari Vall d'Hebron Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jecko Thachil
- Department of Haematology, Manchester University Hospitals, Oxford Road, Manchester, UK
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC, USA
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Beurton A, Kooistra EJ, De Jong A, Schiffl H, Jourdain M, Garcia B, Vimpère D, Jaber S, Pickkers P, Papazian L. Specific and Non-specific Aspects and Future Challenges of ICU Care Among COVID-19 Patients with Obesity: A Narrative Review. Curr Obes Rep 2024:10.1007/s13679-024-00562-3. [PMID: 38573465 DOI: 10.1007/s13679-024-00562-3] [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: 03/16/2024] [Indexed: 04/05/2024]
Abstract
PURPOSE OF REVIEW Since the end of 2019, the coronavirus disease 2019 (COVID-19) pandemic has infected nearly 800 million people and caused almost seven million deaths. Obesity was quickly identified as a risk factor for severe COVID-19, ICU admission, acute respiratory distress syndrome, organ support including mechanical ventilation and prolonged length of stay. The relationship among obesity; COVID-19; and respiratory, thrombotic, and renal complications upon admission to the ICU is unclear. RECENT FINDINGS The predominant effect of a hyperinflammatory status or a cytokine storm has been suggested in patients with obesity, but more recent studies have challenged this hypothesis. Numerous studies have also shown increased mortality among critically ill patients with obesity and COVID-19, casting doubt on the obesity paradox, with survival advantages with overweight and mild obesity being reported in other ICU syndromes. Finally, it is now clear that the increase in the global prevalence of overweight and obesity is a major public health issue that must be accompanied by a transformation of our ICUs, both in terms of equipment and human resources. Research must also focus more on these patients to improve their care. In this review, we focused on the central role of obesity in critically ill patients during this pandemic, highlighting its specificities during their stay in the ICU, identifying the lessons we have learned, and identifying areas for future research as well as the future challenges for ICU activity.
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Affiliation(s)
- Alexandra Beurton
- Department of Intensive Care, Hôpital Tenon, APHP, Paris, France.
- UMR_S 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, INSERM, Sorbonne Université, Paris, France.
| | - Emma J Kooistra
- Department of Intensive Care Medicine, Radboud University Medical Center, 6500HB, Nijmegen, The Netherlands
- Radboud Center for Infectious Diseases, Radboud University Medical Center, 6500HB, Nijmegen, The Netherlands
| | - Audrey De Jong
- Anesthesia and Critical Care Department, Saint Eloi Teaching Hospital, University Montpellier 1, Montpellier, France
- Phymed Exp INSERM U1046, CNRS UMR 9214, Montpellier, France
| | - Helmut Schiffl
- Division of Nephrology, Department of Internal Medicine IV, University Hospital LMU Munich, Munich, Germany
| | - Mercedes Jourdain
- CHU Lille, Univ-Lille, INSERM UMR 1190, ICU Department, F-59037, Lille, France
| | - Bruno Garcia
- CHU Lille, Univ-Lille, INSERM UMR 1190, ICU Department, F-59037, Lille, France
| | - Damien Vimpère
- Anesthesia and Critical Care Department, Hôpital Necker, APHP, Paris, France
| | - Samir Jaber
- Anesthesia and Critical Care Department, Saint Eloi Teaching Hospital, University Montpellier 1, Montpellier, France
- Phymed Exp INSERM U1046, CNRS UMR 9214, Montpellier, France
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, 6500HB, Nijmegen, The Netherlands
- Radboud Center for Infectious Diseases, Radboud University Medical Center, 6500HB, Nijmegen, The Netherlands
| | - Laurent Papazian
- Intensive Care Unit, Centre Hospitalier de Bastia, Bastia, Corsica, France
- Aix-Marseille University, Marseille, France
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12
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Lee JE, Kang DH, Kim SY, Kim DK, Lee SI. Clinical Manifestations and Outcomes of Older Patients with COVID-19: A Comprehensive Review. Tuberc Respir Dis (Seoul) 2024; 87:145-154. [PMID: 38368903 PMCID: PMC10990616 DOI: 10.4046/trd.2023.0157] [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: 10/03/2023] [Revised: 11/17/2023] [Accepted: 01/13/2024] [Indexed: 02/20/2024] Open
Abstract
The consequences of coronavirus disease 2019 (COVID-19) are particularly severe in older adults with a disproportionate number of severe and fatal outcomes. Therefore, this integrative review aimed to provide a comprehensive overview of the clinical characteristics, management approaches, and prognosis of older patients diagnosed with COVID-19. Common clinical presentations in older patients include fever, cough, and dyspnea. Additionally, preexisting comorbidities, especially diabetes and pulmonary and cardiovascular diseases, were frequently observed and associated with adverse outcomes. Management strategies varied, however, early diagnosis, vigilant monitoring, and multidisciplinary care were identified as key factors for enhancing patient outcomes. Nonetheless, the prognosis remains guarded for older patients, with increased rates of hospitalization, mechanical ventilation, and mortality. However, timely therapeutic interventions, especially antiviral and supportive treatments, have demonstrated some efficacy in mitigating the severe consequences in this age group. In conclusion, while older adults remain highly susceptible to severe outcomes from COVID-19, early intervention, rigorous monitoring, and comprehensive care can play a pivotal role in improving their clinical outcomes.
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Affiliation(s)
- Jeong Eun Lee
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Republic of Korea
| | - Da Hyun Kang
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Republic of Korea
| | - So-Yun Kim
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Republic of Korea
| | - Duk Ki Kim
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Republic of Korea
| | - Song I Lee
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Republic of Korea
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13
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Choffat D, Rossel JB, Aujesky D, Vollenweider P, Baumgartner C, Méan M. Association of pharmacologic thromboprophylaxis with clinically relevant bleeding and hospital-acquired anemia in medical inpatients: the risk stratification for hospital-acquired venous thromboembolism in medical patients study. J Thromb Haemost 2024; 22:765-774. [PMID: 38072378 DOI: 10.1016/j.jtha.2023.11.021] [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: 04/19/2023] [Revised: 11/17/2023] [Accepted: 11/24/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Pharmacologic thromboprophylaxis (pTPX) might exacerbate the risk of clinically relevant bleeding (CRB) and hospital-acquired anemia (HAA) in older multimorbid inpatients. OBJECTIVES We aimed to evaluate the association of pTPX use with CRB and HAA. METHODS We used data from a prospective cohort study conducted in 3 Swiss university hospitals. Adult patients admitted to internal medicine wards with no therapeutic anticoagulation were included. pTPX use was ascertained during hospitalization. Outcomes were in-hospital CRB and HAA. We calculated incidence rates by status of pTPX. We assessed the association of pTPX with CRB using survival analysis and with HAA using logistic regression, adjusted for infection, length of stay, and the International Medical Prevention Registry on Venous Thromboembolism bleeding risk score. RESULTS Among 1305 patients (mean age, 63.7 years; 44% women, 90% at low risk of bleeding), 809 (62%) received pTPX. The incidence of CRB was 2.4 per 1000 patient-days and was not significantly higher in patients with pTPX than in those without. We found no significant association between pTPX and CRB. HAA was frequent (20.2%) and higher in patients with pTPX than in those without (23.2% vs 15.3%). The incidence of HAA was 21.2 per 1000 patient-days and did not significantly differ between patients with pTPX and those without. We found an association between pTPX and HAA (adjusted odds ratio, 1.4; 95% CI, 1.0-2.1). CONCLUSION Our study confirmed the safety of pTPX in medical inpatients at low risk of bleeding but identified an association between pTPX and HAA. Adherence to guidelines that recommend administering pTPX to medical inpatients at increased venous thromboembolism risk and low bleeding risk is necessary.
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Affiliation(s)
- Damien Choffat
- Division of Internal Medicine, Department of Medicine, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois [CHUV]), Lausanne, Switzerland.
| | - Jean-Benoît Rossel
- Clinical Trial Unit of the Department of Clinical Research (CTU Bern), University of Bern, Bern, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Peter Vollenweider
- Division of Internal Medicine, Department of Medicine, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois [CHUV]), Lausanne, Switzerland
| | - Christine Baumgartner
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marie Méan
- Division of Internal Medicine, Department of Medicine, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois [CHUV]), Lausanne, Switzerland
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14
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Xiao LX, Zhu DL, Chen J, Lv J, Liu MJ, Dai X, Wang DX, Deng W. Exploring the therapeutic role of early heparin administration in ARDS management: a MIMIC-IV database analysis. J Intensive Care 2024; 12:9. [PMID: 38409068 PMCID: PMC10895755 DOI: 10.1186/s40560-024-00723-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 02/18/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) is a severe respiratory condition characterized by a high mortality rate, the management of which relies on supportive care and a profound understanding of its pathophysiology. Heparin, with its anticoagulant and potential anti-inflammatory properties, offers a new therapeutic opportunity for the treatment of ARDS. METHODS In this retrospective cohort study, we examined the MIMIC-IV database for ARDS patients who received prophylactic heparin within the first 72 h of ICU admission. Employing propensity score matching and inverse probability weighting (IPW) analysis, we evaluated the impact of early heparin use on patient outcomes, focusing on mortality rates. RESULTS Patients who received prophylactic heparin had a significantly lower in-hospital mortality rate compared to those who did not (13.55% vs 17.93%, HR = 0.71, 95% CI: 0.54-0.93, P = 0.012). This result remained significant after propensity score matching (12.75% vs 17.93%, HR = 0.65, 95% CI 0.47-0.90, P = 0.010). Analysis using five different statistical models indicated that early use of heparin significantly reduced the in-hospital mortality rate, with HR = 0.669 (95% CI 0.487-0.919, P = 0.013) in the doubly robust model without balanced covariates; HR = 0.705 (95% CI 0.515-0.965, P = 0.029) with all covariates considered; HR = 0.660 (95% CI 0.491-0.888, P = 0.006) in the propensity score (IPW) model; HR = 0.650 (95% CI 0.470-0.900, P = 0.010) in the propensity score matching model; and HR = 0.706 (95% CI 0.536-0.930, P = 0.013) in the multivariate Cox regression model. Secondary outcomes indicated that heparin use was also associated with reduced mortality rates at 60 days, and 90 days. CONCLUSION This research highlights that early prophylactic administration of heparin may substantially lower mortality in ARDS patients. These findings underscore the potential of heparin as a key component in the management of ARDS, offering a new perspective and novel strategies for clinical treatment.
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Affiliation(s)
- Ling-Xi Xiao
- Department of Pulmonary and Critical Care Medicine, Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Yuzhong District, Chongqing, 400010, China
| | - De Liang Zhu
- Department of Gastrointestinal Surgery, China-Japan Union Hospital of Jilin University, No. 126, Xiantai Street, Changchun, 130033, China
| | - Juan Chen
- Department of Pulmonary and Critical Care Medicine, Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Yuzhong District, Chongqing, 400010, China
| | - Jing Lv
- Department of Pulmonary and Critical Care Medicine, Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Yuzhong District, Chongqing, 400010, China
| | - Mei-Jun Liu
- Department of Pulmonary and Critical Care Medicine, Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Yuzhong District, Chongqing, 400010, China
| | - Xue Dai
- Department of Pulmonary and Critical Care Medicine, Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Yuzhong District, Chongqing, 400010, China
| | - Dao-Xin Wang
- Department of Pulmonary and Critical Care Medicine, Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Yuzhong District, Chongqing, 400010, China
| | - Wang Deng
- Department of Pulmonary and Critical Care Medicine, Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Yuzhong District, Chongqing, 400010, China.
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15
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Tufano A, Brenner B. Prevention of Venous Thromboembolism in Medical Patients with Thrombocytopenia or with Platelet Dysfunction: The Last 10 Years. Semin Thromb Hemost 2024; 50:96-103. [PMID: 37201536 DOI: 10.1055/s-0043-1769013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Current guideline recommendations for primary prophylaxis of venous thromboembolism (VTE) are based on randomized clinical trials that usually exclude subjects at a potentially high risk of bleeding complications. For this reason, no specific guideline is available for thromboprophylaxis in hospitalized patients with thrombocytopenia and/or platelet dysfunction. However, except in patients with absolute contraindications to anticoagulant drugs, antithrombotic prophylaxis should always be considered, for example, in hospitalized cancer patients with thrombocytopenia, especially in those with multiple VTE risk factors. Low platelet number, platelet dysfunction, and clotting abnormalities are also very common in patients with liver cirrhosis, but these patients have a high incidence of portal venous thrombosis, implying that cirrhotic coagulopathy does not fully protect against thrombosis. These patients may benefit from antithrombotic prophylaxis during hospitalization. Patients hospitalized for COVID-19 need prophylaxis, but frequently experience thrombocytopenia or coagulopathy. In patients with antiphospholipid antibodies, a high thrombotic risk is usually present, even in the presence of thrombocytopenia. VTE prophylaxis in high-risk conditions is thus suggested in these patients. At variance with severe thrombocytopenia (< 50,000/mm3), mild/moderate thrombocytopenia (≥ 50,000/mm3) should not interfere with VTE prevention decisions. In patients with severe thrombocytopenia, pharmacological prophylaxis should be considered on an individual basis. Aspirin is not as effective as heparins in lowering the risk of VTE. Studies in patients with ischemic stroke demonstrated that thromboprophylaxis with heparins is safe in these patients also during antiplatelet treatment. The use of direct oral anticoagulants in the prophylaxis of VTE in internal medicine patients has been recently evaluated, but no specific recommendation exists for patients with thrombocytopenia. The need for VTE prophylaxis in patients on chronic treatment with antiplatelet agents should be evaluated after assessing the individual risk of bleeding complications. Finally, the selection of patients who require post-discharge pharmacological prophylaxis remains debated. New molecules currently under development (such as the inhibitors of factor XI) may contribute to improve the risk/benefit ratio of VTE primary prevention in this setting of patients.
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Affiliation(s)
- Antonella Tufano
- Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Via Sergio Pansini, Naples, Italy
| | - Benjamin Brenner
- Department of Hematology and Bone Marrow Transplantation, Haifa, Israel
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16
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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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17
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Wang Q, Qin Y, Ma J, Zhou K, Xia G, Li Y, Xie L, Afful RG, Lan Q, Huo X, Zou J, Yang H. An early warning indicator of mortality risk in patients with COVID-19: the neutrophil extracellular traps/neutrophilic segmented granulocyte ratio. Front Immunol 2024; 15:1287132. [PMID: 38348024 PMCID: PMC10859410 DOI: 10.3389/fimmu.2024.1287132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 01/15/2024] [Indexed: 02/15/2024] Open
Abstract
Background Neutrophil extracellular traps (NETs) play a key role in thrombus formation in patients with coronavirus disease 2019 (COVID-19). However, the existing detection and observation methods for NETs are limited in their ability to provide quantitative, convenient, and accurate descriptions of in situ NETs. Therefore, establishing a quantitative description of the relationship between NETs and thrombosis remains a challenge. Objective We employed morphological observations of blood cells and statistical analyses to investigate the correlation between the NETs/neutrophilic segmented granulocyte ratio and mortality risk in patients with COVID-19. Methods Peripheral blood samples were collected from 117 hospitalized patients with COVID-19 between November 2022 and February 2023, and various blood cell parameters were measured. Two types of smudge cells were observed in the blood and counted: lymphatic and neutral smudge cells. Statistical data analysis was used to establish COVID-19 mortality risk assessment indicators. Results Morphological observations of neutrophilic smudge cells revealed swelling, eruption, and NETs formation in the neutrophil nuclei. Subsequently, the NETs/neutrophilic segmented granulocyte ratio (NNSR) was calculated. A high concentration of NETs poses a fatal risk for thrombus formation in patients. Statistical analysis indicated that a high NNSR was more suitable for evaluating the risk of death in patients with COVID-19 compared to elevated fibrinogen (FIB) and D-dimer (DD) levels. Conclusion Observing blood cell morphology is an effective method for the detection of NETs, NNSR are important markers for revealing the mortality risk of patients with COVID-19.
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Affiliation(s)
- Qiong Wang
- The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi People’s Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, China
| | - Yu Qin
- Key Laboratory of Industrial Biotechnology, Ministry of Education, School of Biotechnology, Jiangnan University, Wuxi, China
| | - Jingyun Ma
- The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi People’s Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, China
| | - Kehao Zhou
- Key Laboratory of Industrial Biotechnology, Ministry of Education, School of Biotechnology, Jiangnan University, Wuxi, China
| | - Guiping Xia
- The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi People’s Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, China
| | - Ya Li
- Key Laboratory of Industrial Biotechnology, Ministry of Education, School of Biotechnology, Jiangnan University, Wuxi, China
| | - Li Xie
- School of Internet of Things Engineering, Jiangnan University, Wuxi, China
| | - Richmond Godwin Afful
- Key Laboratory of Industrial Biotechnology, Ministry of Education, School of Biotechnology, Jiangnan University, Wuxi, China
| | - Qian Lan
- School of Internet of Things Engineering, Jiangnan University, Wuxi, China
| | - Xingyu Huo
- Key Laboratory of Industrial Biotechnology, Ministry of Education, School of Biotechnology, Jiangnan University, Wuxi, China
| | - Jian Zou
- The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi People’s Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, China
| | - Hailin Yang
- Key Laboratory of Industrial Biotechnology, Ministry of Education, School of Biotechnology, Jiangnan University, Wuxi, China
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18
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Dibenedetto JR, Cetrone M, Antonacci M, Cannone DP, Antonacci S, Bratta P, Leonetti F, Tricarico D. The Community Pharmacy as a Study Center for the Epidemiological Analysis of the Population Vaccination against SARS-CoV-2: Evaluation of Vaccine Safety and Pharmaceutical Service. PHARMACY 2024; 12:16. [PMID: 38392923 PMCID: PMC10892165 DOI: 10.3390/pharmacy12010016] [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: 11/28/2023] [Revised: 01/12/2024] [Accepted: 01/17/2024] [Indexed: 02/25/2024] Open
Abstract
We conducted a monocentric observational study aimed at evaluating the vaccine safety and the pharmaceutical service provided at a community pharmacy (C.PHARM) in the Puglia Region in the period from 29 December 2021 to 12 March 2022 using data from 550 patients of various ages and sexes and with concomitant diseases. We collected anamnestic data, the number of hospitalizations, and any post-vaccination adverse reactions. Interviews using the integrated EQ5 method were also performed to evaluate the quality of the service offered and any therapy preference. As expected, the vaccines were reactogenic after the first dose in the patients with mild-moderate reactions, with younger age and female gender as risk factors. Immune-allergic reactions of a moderate-severe degree were observed in adult females. In the elderly, the vaccination was well tolerated. Comirnaty® showed a favorable O.R. < 1 vs. other vaccines. No cardiovascular events or hospitalizations were observed up to May 2023. Regional data indicate that all treatments during May 2023 were correlated with the viremia. PaxlovidTM was prescribed in 3% of the patients in our center and in 1.46% in the region, and distributed/dispensed on behalf of third parties in accordance with a novel distribution/dispensation protocol of the C.PHARM that resulted in a safe vaccination center providing appropriate patient inclusion during vaccination.
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Affiliation(s)
- Jacopo Raffaele Dibenedetto
- Management Control Unit, Puglia Regional PHT Office, Pharmaceutical Territorial Area (ASL BA), Via L. Starita, 6, 70132 Bari, Italy; (J.R.D.); (M.C.); (M.A.); (S.A.); (P.B.)
| | - Michela Cetrone
- Management Control Unit, Puglia Regional PHT Office, Pharmaceutical Territorial Area (ASL BA), Via L. Starita, 6, 70132 Bari, Italy; (J.R.D.); (M.C.); (M.A.); (S.A.); (P.B.)
| | - Marina Antonacci
- Management Control Unit, Puglia Regional PHT Office, Pharmaceutical Territorial Area (ASL BA), Via L. Starita, 6, 70132 Bari, Italy; (J.R.D.); (M.C.); (M.A.); (S.A.); (P.B.)
- Department of Pharmacy-Pharmaceutical Science, University of Bari Aldo Moro, Via Orabona 4, 70125 Bari, Italy;
| | | | - Stefania Antonacci
- Management Control Unit, Puglia Regional PHT Office, Pharmaceutical Territorial Area (ASL BA), Via L. Starita, 6, 70132 Bari, Italy; (J.R.D.); (M.C.); (M.A.); (S.A.); (P.B.)
| | - Pasquale Bratta
- Management Control Unit, Puglia Regional PHT Office, Pharmaceutical Territorial Area (ASL BA), Via L. Starita, 6, 70132 Bari, Italy; (J.R.D.); (M.C.); (M.A.); (S.A.); (P.B.)
| | - Francesco Leonetti
- Department of Pharmacy-Pharmaceutical Science, University of Bari Aldo Moro, Via Orabona 4, 70125 Bari, Italy;
| | - Domenico Tricarico
- Department of Pharmacy-Pharmaceutical Science, University of Bari Aldo Moro, Via Orabona 4, 70125 Bari, Italy;
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19
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Wang X, Chen W, Guo J, Qiu X, You C, Ma L. Association between antithrombotic therapy and mortality in patients hospitalized for COVID‑19. Thromb J 2024; 22:5. [PMID: 38178082 PMCID: PMC10768353 DOI: 10.1186/s12959-023-00572-6] [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: 06/27/2023] [Accepted: 12/13/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND The prothrombotic state is a common abnormality in patients with coronavirus disease 2019 (COVID-19). However, there is controversy over the use of anticoagulants, especially oral anticoagulants (OAC) due to limited studies. We sought to evaluate the association between antithrombotic therapy on mortality and clinical outcomes in patients hospitalized for COVID-19 through propensity score matching (PSM) analysis. METHODS A retrospective cohort study was performed to include adult patients with COVID-19 in a university hospital. The primary outcome was in-hospital mortality. Secondary outcomes included intensive care unit (ICU) admission, mechanical ventilation, and acute kidney injury (AKI) during hospitalization. PSM was used as a powerful tool for matching patients' baseline characteristics. Adjusted odds ratios (aOR) with 95% confidence intervals (CI) were calculated from the models. RESULTS Of 4,881 COVID-19 patients during the study period, 690 (14.1%) patients received antithrombotic therapy and 4,191 (85.9%) patients were under no antithrombotic therapy. After adjustment with multivariate regression analysis, patients receiving OAC, compared with those who did not receive any antithrombotic therapy, had significantly lower odds for in-hospital mortality (aOR: 0.46. 95% CI: 0.24 to 0.87; P= 0.017). PSM analysis observed similar results (aOR: 0.35. 95% CI: 0.19 to 0.61; P< 0.001). Moreover, in critically ill patients who received mechanical ventilation, antithrombotic treatment (aOR: 0.54. 95% CI: 0.32 to 0.89; P= 0.022) was associated with reduced risk of mortality. CONCLUSIONS The application OACs was associated with reduced hospital mortality and mechanical ventilation requirement in COVID-19 patients. Besides, antithrombotic treatment was associated with a reduction in in-hospital mortality among critically ill COVID-19 patients who required mechanical ventilation.
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Affiliation(s)
- Xing Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Wuqian Chen
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jiulin Guo
- Information Center, West China Hospital, Sichuan University, Chengdu, China
| | - Xingyu Qiu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lu Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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20
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Iba T, Helms J, Levi M, Levy JH. Thromboinflammation in acute injury: infections, heatstroke, and trauma. J Thromb Haemost 2024; 22:7-22. [PMID: 37541590 DOI: 10.1016/j.jtha.2023.07.020] [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: 06/09/2023] [Revised: 07/13/2023] [Accepted: 07/23/2023] [Indexed: 08/06/2023]
Abstract
Tissue microcirculation is essential for the maintenance of organ homeostasis. Following acute infections, activation of coagulation and inflammation, which are critical interconnected responses, lead to thromboinflammation and microthrombosis, thereby contributing to multiorgan dysfunction. Sepsis is the most common underlying disease and has been extensively studied. However, the COVID-19 pandemic further illustrated the pathomechanisms of diseases in which thromboinflammation plays a critical role. During thromboinflammation, injury to monocytes, neutrophils, platelets, and endothelial cells, along with coagulation and complement activation, was further characterized. Thrombin is pivotal in orchestrating thrombosis and inflammation and has long been considered a potential therapeutic target in sepsis. Although thromboprophylaxis for venous thromboembolism with heparins is part of standard management for COVID-19, it also potentially attenuates organ dysfunction due to thrombotic sequela. In contrast, the effectiveness of anticoagulation with heparin, antithrombin, or thrombomodulin to reduce mortality has not conclusively been proven in sepsis. Nonetheless, thromboinflammation has also been reported as an important pathophysiologic mechanism in other critical illnesses, including heatstroke, trauma, and ischemia/reperfusion injury, and may provide a potential therapeutic target for future clinical studies.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.
| | - Julie Helms
- Strasbourg University (UNISTRA), Strasbourg University Hospital, Medical Intensive Care Unit - NHC; INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France
| | - Marcel Levi
- Department of Vascular Medicine, Amsterdam University Medical Center, The Netherlands; Department of Medicine, University College London Hospitals NHS Foundation Trust (UCLH), Cardio-metabolic Programme-National Institute for Health and Care Research UCLH/UCL Biomedical Research Centres, London, United Kingdom
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina, USA
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21
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Sultan MA, Kong Y, Story C, Caterson H, Dix C, Gad F, Dhaliwal JS, Dunkley S, Jo H, van Hal S, Passam F. Thrombo-inflammatory response in hospitalised patients with COVID-19: a single institution experience. Intern Med J 2024; 54:43-53. [PMID: 37926861 DOI: 10.1111/imj.16285] [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: 05/17/2023] [Accepted: 10/29/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Severe COVID-19 causes acute inflammation, which is complicated by venous thromboembolism events (VTE). However, it is unclear if VTE risk has evolved over time since the COVID-19 outbreak. AIMS To determine markers of thrombo-inflammation and rates of symptomatic VTE in patients hospitalised for COVID-19 in a metropolitan hospital in Sydney, Australia. METHODS A retrospective, single-centre, cohort study was performed by reviewing electronic medical records of consecutive patients admitted to Royal Prince Alfred Hospital between March 2020 and September 2021. This period included three waves of COVID-19 outbreaks in Australia with the ancestral, alpha and delta variants. Standard coagulation assays and inflammatory markers were recorded over 4 weeks. RESULTS A total of 205 patients were consecutively admitted during the study period. Activated partial thromboplastin time, neutrophil count and C-reactive protein (CRP) were significantly increased in patients hospitalised in the intensive care unit (ICU) compared with non-ICU patients. The use of anti-inflammatory medication increased in 2021 compared with 2020. The mortality rate was 7.3% in our cohort. Ninety-four per cent of patients received anticoagulation with 6.3% of patients developing VTE. CONCLUSION We observed lower rates of VTE compared to the internationally reported rate for the same period. We conclude that in the setting of controlled hospital admission rate and standard anticoagulation guidelines, COVID-19 resulted in similar thrombo-inflammatory response and VTE rates over the first 1.5 years of the pandemic.
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Affiliation(s)
- Muhammad Ahmed Sultan
- Department of Haematology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Central Clinical School, Faculty of Medicine Health, University of Sydney, Sydney, New South Wales, Australia
| | - Yvonne Kong
- Department of Haematology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Chloe Story
- Department of Infectious Diseases, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Harriet Caterson
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Caroline Dix
- Department of Haematology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Fady Gad
- Department of Pharmacy, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Jagpreet Singh Dhaliwal
- Department of Haematology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Central Clinical School, Faculty of Medicine Health, University of Sydney, Sydney, New South Wales, Australia
| | - Scott Dunkley
- Department of Haematology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Helen Jo
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Sebastian van Hal
- Department of Infectious Diseases, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Freda Passam
- Department of Haematology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Central Clinical School, Faculty of Medicine Health, University of Sydney, Sydney, New South Wales, Australia
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22
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Wu MA, Del GIovane C, Colombo R, Dolci G, Arquati M, Vicini R, Russo U, Ruggiero D, Coluccio V, Taino A, Franceschini E, Facchinetti P, Mighali P, Trombetta L, Tonelli F, Gabiati C, Cogliati C, D'Amico R, Marietta M. Low-molecular-weight heparin for the prevention of clinical worsening in severe non-critically ill COVID-19 patients: a joint analysis of two randomized controlled trials. Intern Emerg Med 2024; 19:71-79. [PMID: 37794281 DOI: 10.1007/s11739-023-03439-w] [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: 06/22/2023] [Accepted: 09/14/2023] [Indexed: 10/06/2023]
Abstract
Coronavirus disease 2019 (COVID-19) carries a high risk of vascular thrombosis. However, whether a specific anticoagulation intensity strategy may prevent clinical worsening in severe COVID-19 patients is still debated. We conducted a joint analysis of two randomized controlled trials, COVID-19 HD (NCT044082359) and EMOS-COVID (NCT04646655), to assess the efficacy and safety of two anticoagulant regimens in hospitalized severe COVID-19 patients. Subjects with COVID-19-associated respiratory compromise and/or coagulopathy were randomly assigned to low (4000 IU qd) or high (70 IU Kg-1 every 12 h) enoxaparin dose. The primary efficacy endpoint was clinical worsening within 30 days, defined as the occurrence of at least one of the following events, whichever came first: in-hospital death, evidence of arterial or venous thromboembolism, acute myocardial infarction, need for either continuous positive airway pressure (CPAP) or non-invasive ventilation (NIV) in patients receiving standard oxygen therapy or none at randomization, and need for mechanical ventilation in any patient. The safety endpoint was major bleeding. We estimated the relative risk (RR) and its 95% confidence interval (CI) for the outcomes. Among 283 patients included in the study (144 in the low-dose and 139 in the high-dose group), 118 (41.7%) were on NIV or CPAP at randomization. 23/139 (16.5%) patients in the high-dose group reached the primary endpoint compared to 33/144 (22.9%) in the low-dose group (RR 0.72, 95% CI 0.45-1.17). No major bleeding was observed. No significant differences were found in the clinical worsening of hospitalized COVID-19 patients treated with high versus low doses of enoxaparin.
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Affiliation(s)
- Maddalena Alessandra Wu
- Division of Internal Medicine, Department of Biomedical and Clinical Sciences, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy.
| | - Cinzia Del GIovane
- Department of Medical and Surgical Sciences for Children and Adults, University-Hospital of Modena and Reggio Emilia, Modena, Italy
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Unità di Supporto Statistico Metodologico per la Ricerca Clinica Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Riccardo Colombo
- Division of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Giovanni Dolci
- Infectious Diseases Unit, University of Modena and Reggio Emilia, Modena, Italy
| | | | - Roberto Vicini
- Unità di Supporto Statistico Metodologico per la Ricerca Clinica Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Umberto Russo
- Division of Haematology, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Diego Ruggiero
- Division of Cardiology, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Valeria Coluccio
- Hematology Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Alba Taino
- Division of Internal Medicine, Department of Biomedical and Clinical Sciences, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Erica Franceschini
- Infectious Diseases Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Pietro Facchinetti
- Division of Internal Medicine, Department of Biomedical and Clinical Sciences, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Pasquale Mighali
- Servizio Formazione, Ricerca e Innovazione, Azienda Ospedaliero-Universitaria di Modena, Ospedale Policlinico, Modena, Italy
| | - Lucia Trombetta
- Division of Internal Medicine, Department of Biomedical and Clinical Sciences, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Francesca Tonelli
- Division of Internal Medicine, Department of Biomedical and Clinical Sciences, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Claudia Gabiati
- Division of Internal Medicine, Department of Biomedical and Clinical Sciences, ASST Fatebenefratelli Sacco, Fatebenefratelli Hospital, University of Milan, Milan, Italy
| | - Chiara Cogliati
- Division of Internal Medicine, Department of Biomedical and Clinical Sciences, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Roberto D'Amico
- Department of Medical and Surgical Sciences for Children and Adults, University-Hospital of Modena and Reggio Emilia, Modena, Italy
- Unità di Supporto Statistico Metodologico per la Ricerca Clinica Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Marco Marietta
- Hematology Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
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23
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Fusco F, Krasuski RA, Sadeghi S, Rosenbaum MS, Lewis MJ, Carazo MR, Rodriguez FH, Halpern DG, Feinberg JL, Galilea FA, Baraona F, Cedars AM, Ko JM, Porayette P, Maldonado JR, Frogoudaki AA, Nir A, Chaudhry A, John AS, Karbassi A, Ganame J, Hoskoppal A, Frischhertz BP, Hendrickson B, Rodriguez-Monserrate CP, Broda CR, Tobler D, Gregg D, Martinez-Quintana E, Yeung E, Krieger EV, Ruperti-Repilado FJ, Giannakoulas G, Lui GK, Ephrem G, Singh HS, Hasan A, Bartlett HL, Lindsay I, Grewal J, Nicolarsen J, Araujo JJ, Cramer JW, Bouchardy J, Al Najashi K, Ryan K, Alshawabkeh L, Andrade L, Ladouceur M, Schwerzmann M, Greutmann M, Merás P, Ferrero P, Dehghani P, Tung PP, Garcia-Orta R, Tompkins R, Gendi SM, Cohen S, Klewer SE, Hascoet S, Upadhyay S, Fisher SD, Cook S, Cotts TB, Kovacs AH, Aboulhosn JA, Scognamiglio G, Broberg CS, Sarubbi B. COVID-19-Related Thrombotic and Bleeding Events in Adults With Congenital Heart Disease. JACC. ADVANCES 2023; 2:100701. [PMID: 38938489 PMCID: PMC11198511 DOI: 10.1016/j.jacadv.2023.100701] [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: 11/07/2022] [Revised: 08/07/2023] [Accepted: 09/05/2023] [Indexed: 06/29/2024]
Abstract
Background Altered coagulation is a striking feature of COVID-19. Adult patients with congenital heart disease (ACHD) are prone to thromboembolic (TE) and bleeding complications. Objectives The purpose of this study was to investigate the prevalence and risk factors for COVID-19 TE/bleeding complications in ACHD patients. Methods COVID-19-positive ACHD patients were included between May 2020 and November 2021. TE events included ischemic cerebrovascular accident, systemic and pulmonary embolism, deep venous thrombosis, myocardial infarction, and intracardiac thrombosis. Major bleeding included cases with hemoglobin drop >2 g/dl, involvement of critical sites, or fatal bleeding. Severe infection was defined as need for intensive care unit, endotracheal intubation, renal replacement therapy, extracorporeal membrane oxygenation, or death. Patients with TE/bleeding were compared to those without events. Factors associated with TE/bleeding were determined using logistic regression. Results Of 1,988 patients (age 32 [IQR: 25-42] years, 47% male, 59 ACHD centers), 30 (1.5%) had significant TE/bleeding: 12 TE events, 12 major bleeds, and 6 with both TE and bleeding. Patients with TE/bleeding had higher in-hospital mortality compared to the remainder cohort (33% vs 1.7%; P < 0.0001) and were in more advanced physiological stage (P = 0.032) and NYHA functional class (P = 0.01), had lower baseline oxygen saturation (P = 0.0001), and more frequently had a history of atrial arrhythmia (P < 0.0001), previous hospitalization for heart failure (P < 0.0007), and were more likely hospitalized for COVID-19 (P < 0.0001). By multivariable logistic regression, prior anticoagulation (OR: 4.92; 95% CI: 2-11.76; P = 0.0003), cardiac injury (OR: 5.34; 95% CI: 1.98-14.76; P = 0.0009), and severe COVID-19 (OR: 17.39; 95% CI: 6.67-45.32; P < 0.0001) were independently associated with increased risk of TE/bleeding complications. Conclusions ACHD patients with TE/bleeding during COVID-19 infection have a higher in-hospital mortality from the illness. Risk of coagulation disorders is related to severe COVID-19, cardiac injury during infection, and use of anticoagulants.
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Affiliation(s)
- Flavia Fusco
- Adult Congenital Heart Disease Unit, Monaldi Hospital, Naples, Italy
| | - Richard A. Krasuski
- Department of Cardiovascular Medicine, Duke University Health System in Durham, Durham, North Carolina, USA
| | - Soraya Sadeghi
- Ahmanson/UCLA Adult Congenital Heart Center, Los Angeles, California, USA
| | - Marlon S. Rosenbaum
- Division of Cardiology, Columbia University Medical Center, New York, New York, USA
| | - Matthew J. Lewis
- Division of Cardiology, Columbia University Medical Center, New York, New York, USA
| | - Matthew R. Carazo
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Fred H. Rodriguez
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Dan G. Halpern
- Division of Cardiology, New York University Langone Health, New York, New York, USA
| | - Jodi L. Feinberg
- Division of Cardiology, New York University Langone Health, New York, New York, USA
| | - Francisca A. Galilea
- Instituto Nacional del Tórax - Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Fernando Baraona
- Instituto Nacional del Tórax - Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Ari M. Cedars
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jong M. Ko
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Prashob Porayette
- Division of Cardiology, University of Iowa Stead Family Children’s Hospital, Iowa City, Iowa, USA
| | - Jennifer R. Maldonado
- Division of Cardiology, University of Iowa Stead Family Children’s Hospital, Iowa City, Iowa, USA
| | | | - Amiram Nir
- Pediatric Cardiology and Adult Congenital Heart Disease Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Anisa Chaudhry
- Penn State Hershey Heart and Vascular Institute, State College, Pennsylvania, USA
| | - Anitha S. John
- Division of Cardiology, Children’s National Hospital, Washington, District of Columbia, USA
| | | | | | - Arvind Hoskoppal
- UPMC Adult Congenital Heart Disease Program, Pittsburgh, Pennsylvania, USA
| | - Benjamin P. Frischhertz
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Benjamin Hendrickson
- Le Bonheur Heart Institute, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | | | | | - Daniel Tobler
- Division of Cardiology, University Hospital of Basel, Basel, Switzerland
| | - David Gregg
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Efrén Martinez-Quintana
- Cardiology Service, Universitario Insular-Materno Infantil, Las Palmas de Gran Canaria, Spain
| | - Elizabeth Yeung
- Colorado’s Adult and Teen Congenital Heart Program, Colorado University School of Medicine, Aurora, Colorado, USA
| | - Eric V. Krieger
- Division of Cardiology, University of Washington School of Medicine, Seattle, Washington, USA
| | | | | | - George K. Lui
- Division of Cardiovascular Medicine and Pediatric Cardiology, Stanford University School of Medicine, Stanford, California, USA
| | - Georges Ephrem
- Krannert Cardiovascular Research Center, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Harsimran S. Singh
- Department of Medicine & Pediatrics, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Almeneisi Hasan
- The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Heather L. Bartlett
- Department of Pediatrics and Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | - Ian Lindsay
- Division of Pediatric Cardiology, University of Utah, Salt Lake City, Utah, USA
| | - Jasmine Grewal
- St. Paul’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jeremy Nicolarsen
- Department of Pediatric and Adult Cardiology, Providence Adult and Teen Congenital Heart Program, Spokane, Washington, USA
| | - John J. Araujo
- Department of Pediatric and Adult Congenital Heart Disease, Somer Incare Cardiovascular Center, Rionegro, Colombia
| | - Jonathan W. Cramer
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Judith Bouchardy
- Department of Cardiology and Cardiac Surgery, University Hospital Lausanne, Lausanne, Switzerland
| | - Khalid Al Najashi
- Pediatric Cardiology Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Kristi Ryan
- Adult Congenital Heart Program, OSF Healthcare Children’s Hospital of Illinois, Peoria, Illinois, USA
| | - Laith Alshawabkeh
- Department of Cardiovascular Medicine, University of California-San Diego, La Jolla, California, USA
| | - Lauren Andrade
- Division of Cardiology, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Magalie Ladouceur
- Adult Congenital Heart Disease Unit, Hôpital Européen Georges Pompidou, AP-HP, Université de Paris Cité, Paris, France
| | - Markus Schwerzmann
- Center for Congenital Heart Disease, University Hospital Inselspital, Bern, Switzerland
| | | | - Pablo Merás
- Cardiology Department, University Hospital La Paz, Madrid, Spain
| | - Paolo Ferrero
- Cardiovascular Department, ASST Papa Giovanni XXIII, University of Milano, Bergamo, Italy
| | - Payam Dehghani
- Prairie Vascular Research Network, University of Saskatchewan, Regina, Saskatchewan, Canada
| | - Poyee P. Tung
- Division of Adult Congenital Heart Disease, University of Texas at Houston, Houston, Texas, USA
| | - Rocio Garcia-Orta
- Cardiology Department, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Rose Tompkins
- The Geurin Family Congenital Heart Program, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Salwa M. Gendi
- Adult Congenital Heart Disease Program, West Virginia University, Morgantown, West Virginia, USA
| | - Scott Cohen
- Adult Congenital Heart Disease Program, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Scott E. Klewer
- Division of Cardiology, University of Arizona, Tucson, Arizona, USA
| | - Sebastien Hascoet
- Department of Pediatric Cardiology and Congenital Heart Disease, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Shailendra Upadhyay
- Division of Pediatric Cardiology, Connecticut Children’s Medical Center, Hartford, Connecticut, USA
| | - Stacy D. Fisher
- Department of Medicine and Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Stephen Cook
- Adult Congenital Heart Center, Helen DeVos Children’s Hospital, Grand Rapids, Michigan, USA
| | - Timothy B. Cotts
- Department of Medicine and Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Adrienne H. Kovacs
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Jamil A. Aboulhosn
- Ahmanson/UCLA Adult Congenital Heart Center, Los Angeles, California, USA
| | | | - Craig S. Broberg
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Berardo Sarubbi
- Adult Congenital Heart Disease Unit, Monaldi Hospital, Naples, Italy
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24
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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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25
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Artaud-Macari E, Le Bouar G, Maris J, Dantoing E, Vatignez T, Girault C. [Ventilatory management of SARS-CoV-2 acute respiratory failure]. Rev Mal Respir 2023; 40:751-767. [PMID: 37865564 DOI: 10.1016/j.rmr.2023.09.005] [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: 04/16/2023] [Accepted: 09/19/2023] [Indexed: 10/23/2023]
Abstract
COVID-19 pneumonia presents several particularities in its clinical presentation (cytokine storm, silent hypoxemia, thrombo-embolic risk) and may lead to a number of acute respiratory distress syndrome (ARDS) phenotypes. While the optimal oxygenation strategy in cases of hypoxemic acute respiratory failure (ARF) is still under debate, ventilatory management of COVID-19-related ARF has confirmed the efficacy of high-flow oxygen therapy and restored interest in other ventilatory approaches such as continuous positive airway pressure (CPAP) and noninvasive ventilation involving a helmet, which due to patient overflow are sometimes implemented outside of critical care units. However, further studies are still needed to determine which patients should be given which oxygenation technique, and under which conditions they require invasive mechanical ventilation, given that delayed initiation potentially burdens prognosis. During invasive mechanical ventilation, ventral decubitus and extracorporeal membrane oxygenation have become increasingly prevalent. While innovative therapies such as awake prone position or lung transplantation have likewise been developed, their indications, modalities and efficacy remain to be determined.
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Affiliation(s)
- E Artaud-Macari
- Service de pneumologie, oncologie thoracique et soins intensifs respiratoires, CHU de Rouen, 76000 Rouen, France; UNIROUEN, UR-3830, Normandie université, CHU de Rouen, 76000 Rouen, France.
| | - G Le Bouar
- Service de pneumologie, oncologie thoracique et soins intensifs respiratoires, CHU de Rouen, 76000 Rouen, France
| | - J Maris
- Service de pneumologie, oncologie thoracique et soins intensifs respiratoires, CHU de Rouen, 76000 Rouen, France
| | - E Dantoing
- Service de pneumologie, oncologie thoracique et soins intensifs respiratoires, CHU de Rouen, 76000 Rouen, France
| | - T Vatignez
- Service de médecine intensive et réanimation, CHU de Rouen, 76000 Rouen, France
| | - C Girault
- UNIROUEN, UR-3830, Normandie université, CHU de Rouen, 76000 Rouen, France; Service de médecine intensive et réanimation, CHU de Rouen, 76000 Rouen, France
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26
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Giannis D, Goldin M, Rahman H, Sison CP, Lesser ML, Ngu S, Tsang J, Qiu M, Sanghani S, Yeh J, Matsagkas M, Arnaoutoglou E, Spyropoulos AC. Risk Factors for Postdischarge Major Thromboembolism and Mortality in Hospitalized Patients with COVID-19 with Cardiovascular Comorbidities: Insights from the CORE-19 Registry. Thromb Haemost 2023; 123:1089-1099. [PMID: 37146648 DOI: 10.1055/a-2087-3003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) is associated with venous and arterial thromboembolism (VTE and ATE) and all-cause mortality (ACM) in hospitalized patients. High-quality data are needed on postdischarge outcomes in patients with cardiovascular disease. OBJECTIVES To analyze outcomes and identify risk factors for ATE, VTE, and ACM in a high-risk subgroup of hospitalized COVID-19 patients with baseline cardiovascular disease. METHODS We investigated postdischarge rates and associated risk factors of ATE, VTE, and ACM in 608 hospitalized COVID-19 patients with coronary artery disease, carotid artery stenosis (CAS), peripheral arterial disease (PAD), or ischemic stroke. RESULTS Through 90 days postdischarge, outcome rates were: ATE 27.3% (10.2% myocardial infarction, 10.1% ischemic stroke, 13.2% systemic embolism, 12.7% major adverse limb event); VTE 6.9% (4.1% deep vein thrombosis, 3.6% pulmonary embolism); composite of ATE, VTE, or ACM 35.2% (214/608). Multivariate analysis showed significant association between this composite endpoint and age >75 years (odds ratio [OR]: 1.90, 95% confidence interval [CI]: 1.22-2.94, p = 0.004), PAD (OR: 3.23, 95% CI: 1.80-5.81, p ≤ 0.0001), CAS (OR: 1.74, 95% CI: 1.11-2.75, p = 0.017), congestive heart failure (CHF) (OR: 1.84, 95% CI: 1.02-3.35, p = 0.044), previous VTE (OR: 3.08, 95% CI: 1.75-5.42, p < 0.0001), and intensive care unit (ICU) admission (OR: 2.93, 95% CI: 1.81-4.75, p < 0.0001). CONCLUSION COVID-19 inpatients with cardiovascular disease experience high rates of ATE, VTE, or ACM through 90 days postdischarge. Age >75 years, PAD, CAS, CHF, previous VTE, and ICU admission are independent risk factors.
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Affiliation(s)
- Dimitrios Giannis
- Institute of Health Systems Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States
- Department of Vascular Surgery, University of Thessaly, Larissa, Greece
- Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, New York, United States
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - Mark Goldin
- Institute of Health Systems Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States
- Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, New York, United States
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - Husneara Rahman
- Institute of Health Systems Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - Cristina P Sison
- Institute of Health Systems Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - Martin L Lesser
- Institute of Health Systems Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - Sam Ngu
- Institute of Health Systems Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States
- Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, New York, United States
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - James Tsang
- Institute of Health Systems Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - Michael Qiu
- Institute of Health Systems Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - Shreya Sanghani
- Institute of Health Systems Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - Jackson Yeh
- Institute of Health Systems Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - Miltiadis Matsagkas
- Department of Vascular Surgery, University of Thessaly, Larissa, Greece
- Department of Anesthesiology, University of Thessaly, Larissa, Greece
| | - Eleni Arnaoutoglou
- Department of Vascular Surgery, University of Thessaly, Larissa, Greece
- Department of Anesthesiology, University of Thessaly, Larissa, Greece
| | - Alex C Spyropoulos
- Institute of Health Systems Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States
- Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, New York, United States
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
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Ortega-Paz L, Talasaz AH, Sadeghipour P, Potpara TS, Aronow HD, Jara-Palomares L, Sholzberg M, Angiolillo DJ, Lip GYH, Bikdeli B. COVID-19-Associated Pulmonary Embolism: Review of the Pathophysiology, Epidemiology, Prevention, Diagnosis, and Treatment. Semin Thromb Hemost 2023; 49:816-832. [PMID: 36223804 DOI: 10.1055/s-0042-1757634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
COVID-19 is associated with endothelial activation in the setting of a potent inflammatory reaction and a hypercoagulable state. The end result of this thromboinflammatory state is an excess in thrombotic events, in particular venous thromboembolism. Pulmonary embolism (PE) has been of special interest in patients with COVID-19 given its association with respiratory deterioration, increased risk of intensive care unit admission, and prolonged hospital stay. The pathophysiology and clinical characteristics of COVID-19-associated PE may differ from the conventional non-COVID-19-associated PE. In addition to embolic events from deep vein thrombi, in situ pulmonary thrombosis, particularly in smaller vascular beds, may be relevant in patients with COVID-19. Appropriate prevention of thrombotic events in COVID-19 has therefore become of critical interest. Several changes in viral biology, vaccination, and treatment management during the pandemic may have resulted in changes in incidence trends. This review provides an overview of the pathophysiology, epidemiology, clinical characteristics, and risk factors of COVID-19-associated PE. Furthermore, we briefly summarize the results from randomized controlled trials of preventive antithrombotic therapies in COVID-19, focusing on their findings related to PE. We discuss the acute treatment of COVID-19-associated PE, which is substantially similar to the management of conventional non-COVID-19 PE. Ultimately, we comment on the current knowledge gaps in the evidence and the future directions in the treatment and follow-up of COVID-19-associated PE, including long-term management, and its possible association with long-COVID.
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Affiliation(s)
- Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida
| | - Azita H Talasaz
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Parham Sadeghipour
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Clinical Trial Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Tatjana S Potpara
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Intensive Arrhythmia Care, Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia
| | - Herbert D Aronow
- Department of Cardiology, Warren Alpert Medical School of Brown University, Providence, Rhode Island
- Department of Cardiology, Henry Ford Health, Detroit, Michigan
| | - Luis Jara-Palomares
- Respiratory Unit, Hospital Universitario Virgen del Rocio, Sevilla, Spain
- Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias (CIBERES), Carlos III Health Institute, Madrid, Spain
| | - Michelle Sholzberg
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Behnood Bikdeli
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Yale/YNHH Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut
- Cardiovascular Research Foundation (CRF), New York, New York
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Shibahashi E, Jujo K. D-dimer and Beyond: Harnessing the Potential of New Coagulation Indicators in COVID-19 Management. Intern Med 2023; 62:2929-2930. [PMID: 37532543 PMCID: PMC10641190 DOI: 10.2169/internalmedicine.2355-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 06/20/2023] [Indexed: 08/04/2023] Open
Affiliation(s)
- Eiji Shibahashi
- Department of Cardiology, Tokyo Women's Medical University, Japan
| | - Kentaro Jujo
- Department of Cardiology, Tokyo Women's Medical University, Japan
- Department of Cardiology, Saitama Medical University, Saitama Medical Center, Japan
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29
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Masuda E, Fukushima K, Hebisawa Y, Tanaka M, Ohta A, Imamura A. Coronavirus disease 2019-associated thrombotic microangiopathy treated with plasma exchange and antihypertensive therapy in a patient with HIV: A case report with literature review. Medicine (Baltimore) 2023; 102:e35469. [PMID: 37832064 PMCID: PMC10578717 DOI: 10.1097/md.0000000000035469] [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: 07/04/2023] [Accepted: 09/13/2023] [Indexed: 10/15/2023] Open
Abstract
RATIONALE Coronavirus disease 2019 (COVID-19) is an infectious disease that often causes complications in multiple organs and thrombosis due to abnormal blood coagulation. This case report aimed to describe the clinical course of COVID-19-associated thrombotic microangiopathy (TMA) and reviewed the comprehensive information on TMA, thrombotic thrombocytopenic purpura (TTP), and atypical hemolytic uremic syndrome associated with COVID-19 in the past literature. PATIENT CONCERNS A 46-year-old Japanese man was diagnosed with human immunodeficiency virus infection 10 years ago and treated with antiretroviral therapy. The patient presented with fever, malaise, hematuria, and bilateral upper abdominal discomfort for the past 4 days. DIAGNOSES COVID-19-associated TMA was diagnosed based on a positive polymerase chain reaction for severe acute respiratory syndrome coronavirus 2 and laboratory findings such as thrombocytopenia, acute kidney injury, and hemolytic anemia. Malignant hypertension and human immunodeficiency virus infection were also considered as differential diagnoses of TMA. INTERVENTIONS Considering the possibility of TTP, plasma exchange was performed, and glucocorticoids were administered. Hemodialysis was performed for acute kidney injury. Antihypertensive drugs were administered to control the high blood pressure. OUTCOMES Platelet count and renal function improved, and hemodialysis was no longer required. The patient was in good general condition and was discharged from the hospital. LESSONS COVID-19-associated TMA should be considered as a differential diagnosis during the COVID-19 epidemic. Excessive inflammation and severe COVID-19 are not essential for TMA development. Early intervention using conventional TMA treatments, such as plasma exchange and corticosteroids, might be important in improving prognosis while differentiating between TTP and atypical hemolytic uremic syndrome. Antihypertensive therapy may be helpful in the treatment of COVID-19-associated TMA.
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Affiliation(s)
- Eriko Masuda
- Department of Infectious Diseases, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
| | - Kazuaki Fukushima
- Department of Infectious Diseases, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
| | - Yu Hebisawa
- Department of Nephrology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
| | - Masayuki Tanaka
- Department of Nephrology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
| | - Akito Ohta
- Department of Nephrology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
| | - Akifumi Imamura
- Department of Infectious Diseases, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
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Yazdani AN, Abdi A, Velpuri P, Patel P, DeMarco N, Agrawal DK, Rai V. A Review of Hematological Complications and Treatment in COVID-19. Hematol Rep 2023; 15:562-577. [PMID: 37873794 PMCID: PMC10594461 DOI: 10.3390/hematolrep15040059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/30/2023] [Accepted: 10/11/2023] [Indexed: 10/25/2023] Open
Abstract
COVID-19, caused by SARS-CoV-2, and its variants have spread rapidly across the globe in the past few years, resulting in millions of deaths worldwide. Hematological diseases and complications associated with COVID-19 severely impact the mortality and morbidity rates of patients; therefore, there is a need for oversight on what pharmaceutical therapies are prescribed to hematologically at-risk patients. Thrombocytopenia, hemoglobinemia, leukopenia, and leukocytosis are all seen at increased rates in patients infected with COVID-19 and become more prominent in patients with severe COVID-19. Further, COVID-19 therapeutics may be associated with hematological complications, and this became more important in immunocompromised patients with hematological conditions as they are at higher risk of hematological complications after treatment. Thus, it is important to understand and treat COVID-19 patients with underlying hematological conditions with caution. Hematological changes during COVID-19 infection and treatment are important because they may serve as biomarkers as well as to evaluate the treatment response, which will help in changing treatment strategies. In this literature review, we discuss the hematological complications associated with COVID-19, the mechanisms, treatment groups, and adverse effects of commonly used COVID-19 therapies, followed by the hematological adverse events that could arise due to therapeutic agents used in COVID-19.
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Affiliation(s)
- Armand N. Yazdani
- College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA 91766, USA
| | - Arian Abdi
- College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA 91766, USA
| | - Prathosh Velpuri
- College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA 91766, USA
| | - Parth Patel
- College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA 91766, USA
| | - Nathaniel DeMarco
- College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA 91766, USA
| | - Devendra K. Agrawal
- Department of Translational Research, Western University of Health Sciences, Pomona, CA 91766, USA
| | - Vikrant Rai
- Department of Translational Research, Western University of Health Sciences, Pomona, CA 91766, USA
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Spyropoulos AC, Goldin M, Koulas I, Solomon J, Qiu M, Ngu S, Smith K, Leung T, Ochani K, Malik F, Cohen SL, Giannis D, Khan S, McGinn T. Universal EHRs Clinical Decision Support for Thromboprophylaxis in Medical Inpatients: A Cluster Randomized Trial. JACC. ADVANCES 2023; 2:100597. [PMID: 38938337 PMCID: PMC11198051 DOI: 10.1016/j.jacadv.2023.100597] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 05/18/2023] [Accepted: 06/23/2023] [Indexed: 06/29/2024]
Abstract
Background Thromboprophylaxis for medically ill patients during hospitalization and postdischarge remains underutilized. Clinical decision support (CDS) may address this need if embedded within workflow, interchangeable among electronic health records (EHRs), and anchored on a validated model. Objectives The purpose of this study was to assess the clinical impact of a universal EHR-integrated CDS tool based on the International Medical Prevention Registry on Venous Thromboembolism plus D-Dimer venous thromboembolism model. Methods This was a cluster randomized trial of 4 tertiary academic hospitals from December 21, 2020 to January 21, 2022. Inpatients over age 60 with key medical illnesses were eligible. We embedded CDS at admission and discharge. Hospitals were randomized to intervention (CDS; n = 2) vs usual care (n = 2) groups. The primary outcome was rate of appropriate thromboprophylaxis. Secondary outcomes included venous, arterial, and total thromboembolism, major bleeding, and all-cause mortality through 30 days postdischarge. Results After exclusions, 10,699 of 19,823 patients were analyzed. Intervention group tool adoption was 77.8%. Appropriate thromboprophylaxis was increased at intervention hospitals, both inpatient (80.1% vs 72.5%, OR: 1.52, 95% CI: 1.39-1.67) and at discharge (13.6% vs 7.5%, OR: 1.93, 95% CI: 1.60-2.33). There were fewer venous (2.7% vs 3.3%, OR: 0.80, 95% CI: 0.64-1.00), arterial (0.25% vs 0.70%, OR: 0.35, 95% CI: 0.19-0.67), and total thromboembolisms (2.9% vs 4.0%, OR: 0.71, 95% CI: 0.58-0.88) at intervention hospitals. Major bleeding was rare and did not differ between groups. Mortality was higher at intervention hospitals (9.1% vs 7.0%, OR: 1.32, 95% CI: 1.15-1.53). Conclusions EHR-embedded CDS increased appropriate thromboprophylaxis and reduced thromboembolism without increasing major bleeding in medically ill inpatients. Mortality was higher at intervention hospitals.
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Affiliation(s)
- Alex C. Spyropoulos
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Mark Goldin
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Ioannis Koulas
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Jeffrey Solomon
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Michael Qiu
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Sam Ngu
- Department of Hematology/Oncology, Lenox Hill Hospital at Northwell Health, New York, New York, USA
| | - Kolton Smith
- Department of Internal Medicine, Lenox Hill Hospital at Northwell Health, New York, New York, USA
| | - Tungming Leung
- Biostatistics Unit, Office of Academic Affairs, Northwell Health, Hempstead, New York, USA
| | - Kanta Ochani
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Fatima Malik
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Stuart L. Cohen
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
- Department of Radiology, North Shore University Hospital at Northwell Health, Manhasset, New York, USA
| | - Dimitrios Giannis
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Sundas Khan
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas, USA
| | - Thomas McGinn
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- CommonSpirit Health, Chicago, Illinois, USA
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32
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Tanzadehpanah H, Lotfian E, Avan A, Saki S, Nobari S, Mahmoodian R, Sheykhhasan M, Froutagh MHS, Ghotbani F, Jamshidi R, Mahaki H. Role of SARS-COV-2 and ACE2 in the pathophysiology of peripheral vascular diseases. Biomed Pharmacother 2023; 166:115321. [PMID: 37597321 DOI: 10.1016/j.biopha.2023.115321] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 08/08/2023] [Accepted: 08/10/2023] [Indexed: 08/21/2023] Open
Abstract
The occurrence of a novel coronavirus known as severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), created a serious challenge worldwide. SARS-CoV-2 has high infectivity, the ability to be transmitted even during the asymptomatic phase, and relatively low virulence, which has resulted in rapid transmission. SARS-CoV-2 can invade epithelial cells, hence, many patients infected with SARS-CoV-2 have suffered from vascular diseases (VDs) in addition to pulmonary manifestations. Accordingly, SARS-CoV-2 may can worsen the clinical condition of the patients with pre-existing VDs. Endothelial cells express angiotensin-converting enzyme 2 (ACE2). ACE2 is a biological enzyme that converts angiotensin (Ang)- 2 to Ang-(1-7). SARS-CoV-2 uses ACE2 as a cell receptor for viral entry. Thus, the SARS-CoV-2 virus promotes downregulation of ACE2, Ang-(1-7), and anti-inflammatory cytokines, as well as, an increase in Ang-2, resulting in pro-inflammatory cytokines. SARS-CoV-2 infection can cause hypertension, and endothelial damage, which can lead to intravascular thrombosis. In this review, we have concentrated on the effect of SARS-CoV-2 in peripheral vascular diseases (PVDs) and ACE2 as an enzyme in Renin-angiotensin aldosterone system (RAAS). A comprehensive search was performed on PubMed, Google Scholar, Scopus, using related keywords. Articles focusing on ("SARS-CoV-2", OR "COVID-19"), AND ("Vascular disease", OR "Peripheral vascular disease", OR interested disease name) with regard to MeSH terms, were selected. According to the studies, it is supposed that vascular diseases may increase susceptibility to severe SARS-CoV-2 infection due to increased thrombotic burden and endothelial dysfunction. Understanding SARS-CoV-2 infection mechanism and vascular system pathogenesis is crucial for effective management and treatment in pre-existing vascular diseases.
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Affiliation(s)
- Hamid Tanzadehpanah
- Antimicrobial Resistance Research Center, Mashhad University of Medical Sciences; Metabolic Syndrome Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Elham Lotfian
- Vascular and Endovascular Surgery Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amir Avan
- Metabolic Syndrome Research Center, Mashhad University of Medical Sciences; Medical Genetics Research Center, Mashhad University of Medical Sciences; Medical Genetics Research center, Mashhad University of Medical Sciences; Basic Sciences Research Institute, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Sahar Saki
- Molecular Medicine Research Center, Hamadan University of Medical Science, Hamadan Iran
| | - Sima Nobari
- Molecular Medicine Research Center, Hamadan University of Medical Science, Hamadan Iran
| | - Roghaye Mahmoodian
- Molecular Medicine Research Center, Hamadan University of Medical Science, Hamadan Iran
| | - Mohsen Sheykhhasan
- Department of Mesenchymal Stem Cells, Academic Center for Education, Culture and Research, Qom, Iran
| | | | - Farzaneh Ghotbani
- Faculty of Medicine, Mashhad University of Medical Science, Mashhad, Iran
| | - Raoufeh Jamshidi
- Faculty of Medicine, Mashhad University of Medical Science, Mashhad, Iran
| | - Hanie Mahaki
- Vascular and Endovascular Surgery Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
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33
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Visca D, Centis R, Pontali E, Zampogna E, Russell AM, Migliori GB, Andrejak C, Aro M, Bayram H, Berkani K, Bruchfeld J, Chakaya JM, Chorostowska-Wynimko J, Crestani B, Dalcolmo MP, D'Ambrosio L, Dinh-Xuan AT, Duong-Quy S, Fernandes C, García-García JM, de Melo Kawassaki A, Carrozzi L, Martinez-Garcia MA, Martins PC, Mirsaeidi M, Mohammad Y, Naidoo RN, Neuparth N, Sese L, Silva DR, Solovic I, Sooronbaev TM, Spanevello A, Sverzellati N, Tanno L, Tiberi S, Vasankari T, Vasarmidi E, Vitacca M, Annesi-Maesano I. Clinical standards for diagnosis, treatment and prevention of post-COVID-19 lung disease. Int J Tuberc Lung Dis 2023; 27:729-741. [PMID: 37749839 PMCID: PMC10519381 DOI: 10.5588/ijtld.23.0248] [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: 06/06/2023] [Accepted: 06/06/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND: The aim of these clinical standards is to provide guidance on 'best practice' care for the diagnosis, treatment and prevention of post-COVID-19 lung disease.METHODS: A panel of international experts representing scientific societies, associations and groups active in post-COVID-19 lung disease was identified; 45 completed a Delphi process. A 5-point Likert scale indicated level of agreement with the draft standards. The final version was approved by consensus (with 100% agreement).RESULTS: Four clinical standards were agreed for patients with a previous history of COVID-19: Standard 1, Patients with sequelae not explained by an alternative diagnosis should be evaluated for possible post-COVID-19 lung disease; Standard 2, Patients with lung function impairment, reduced exercise tolerance, reduced quality of life (QoL) or other relevant signs or ongoing symptoms ≥4 weeks after the onset of first symptoms should be evaluated for treatment and pulmonary rehabilitation (PR); Standard 3, The PR programme should be based on feasibility, effectiveness and cost-effectiveness criteria, organised according to local health services and tailored to an individual patient's needs; and Standard 4, Each patient undergoing and completing PR should be evaluated to determine its effectiveness and have access to a counselling/health education session.CONCLUSION: This is the first consensus-based set of clinical standards for the diagnosis, treatment and prevention of post-COVID-19 lung disease. Our aim is to improve patient care and QoL by guiding clinicians, programme managers and public health officers in planning and implementing a PR programme to manage post-COVID-19 lung disease.
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Affiliation(s)
- D Visca
- Division of Pulmonary Rehabilitation, Istituti Clinici Scientifici (ICS) Maugeri, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Tradate, Department of Medicine and Surgery, Respiratory Diseases, University of Insubria, Varese
| | - R Centis
- Respiratory Diseases Clinical Epidemiology Unit, Istituti Clinici Scientifici Maugeri, IRCCS, Tradate
| | - E Pontali
- Department of Infectious Diseases, Galliera Hospital, Genoa, Italy
| | - E Zampogna
- Division of Pulmonary Rehabilitation, Istituti Clinici Scientifici (ICS) Maugeri, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Tradate
| | - A-M Russell
- Faculty of Health and Life Sciences, University of Exeter, Exeter, Royal Devon University Hospitals NHS Trust, Exeter, North Bristol NHS Trust, Bristol, UK
| | - G B Migliori
- Respiratory Diseases Clinical Epidemiology Unit, Istituti Clinici Scientifici Maugeri, IRCCS, Tradate
| | - C Andrejak
- Respiratory Department, Centre Hospitalier Universitaire Amiens Picardie, Amiens, Unité de Recherche 4294, Agents Infectieux, Résistance et Chimiothérapie, Picardie Jules Verne University, Amiens, GREPI (Group pour la Recherche et enseignement en pneumo-infectiologie) Work group of French society of respiratory diseases, Paris, France
| | - M Aro
- Finnish Lung Health Association (FILHA), Helsinki, Finland
| | - H Bayram
- Department of Pulmonary Medicine, Koc University Research Center for Translational Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - K Berkani
- Pierre de Soleil Clinic, Respiratory Rehabilitation, Vetraz Monthoux, France
| | - J Bruchfeld
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Division of Infectious Diseases, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - J M Chakaya
- Department of Medicine, Therapeutics and Dermatology, Kenyatta University, Nairobi, Kenya, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - J Chorostowska-Wynimko
- Department of Genetics and Clinical Immunology, National Institute of Tuberculosis and Lung Diseases, Warsaw, Poland
| | - B Crestani
- Université Paris Cité, Physiopathologie et épidémiologie des maladies respiratoires, Institut national de la santé et de la recherche médicale (INSERM), Paris, Assistance Publique des Hôpitaux de Paris (APHP), Hôpital Bichat, Service de Pneumologie A, FHU APOLLO, Paris, France
| | - M P Dalcolmo
- Hélio Fraga Reference Center, Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro, RJ, Brazil
| | - L D'Ambrosio
- Public Health Consulting Group, Lugano, Switzerland
| | - A-T Dinh-Xuan
- Service de Physiologie-Explorations Fonctionnelles, APHP, Hôpital Cochin, Université Paris Cité, Paris, France
| | - S Duong-Quy
- Respiratory Department, Lam Dong Medical College, Dalat, Vietnam
| | - C Fernandes
- Heart Institute, Cardio-pulmonology Department, University of Sao Paulo, Sao Paulo, SP, Brazil
| | - J-M García-García
- Tuberculosis Research Programme (PII-TB), Sociedad Española de Neumología y Cirugía Torácica, Barcelona, Spain
| | - A de Melo Kawassaki
- Serviço de Pneumologia, Instituto do Câncer do Estado de São Paulo (ICESP) e do ambulatÓrio de Doenças Pulmonares Intersticiais, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brazil
| | - L Carrozzi
- Department of Surgical, Medical, and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Pulmonary Unit, Cardiothoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy
| | - M A Martinez-Garcia
- Respiratory Department, University and Polytechnic La Fe Hospital, Valencia, Centro de InvestigaciÓn Biomédica en Red, Respiratory Disorders, Madrid, Spain
| | - P Carreiro Martins
- Allergy and Clinical Immunology Department, Dona Estefânia Hospital, Centro Hospitalar Universitário de Lisboa Central, Lisbon, NOVA Medical School-Comprehensive Health Research Center, Lisbon, Portugal
| | - M Mirsaeidi
- Division of Pulmonary and Critical Care, University of Florida, Jacksonville, FL, USA
| | - Y Mohammad
- Al Sham private University, Faculty of Medicine and Pharmacy, Damascus and Latakia, Centre for Research on Chronic Respiratory Diseases, Tishreen University, Lattakia, Syria
| | - R N Naidoo
- Discipline of Occupational and Environmental Health, University of KwaZulu-Natal, Durban, South Africa
| | - N Neuparth
- Allergy and Clinical Immunology Department, Dona Estefânia Hospital, Centro Hospitalar Universitário de Lisboa Central, Lisbon, NOVA Medical School-Comprehensive Health Research Center, Lisbon, Portugal
| | - L Sese
- Department of Physiology and Functional Explorations, Hôpital Avicenne, INSERM, Unité mixte de recherche 1272 Hypoxia and the Lung, Université Sorbonne Paris Nord, Bobigny, Department of Pneumology, Centre Constitutif de référence des maladies pulmonaires rares, Hôpital Avicenne, Bobigny, France
| | - D R Silva
- Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - I Solovic
- National Institute for TB, Lund Diseases and Thoracic Surgery, Vysne Hagy, Catholic University, Ruzomberok, Slovakia
| | - T M Sooronbaev
- Department of Respiratory Medicine, National Center for Cardiology and Internal Medicine, Bishkek, Kyrgyzstan
| | - A Spanevello
- Division of Pulmonary Rehabilitation, Istituti Clinici Scientifici (ICS) Maugeri, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Tradate, Department of Medicine and Surgery, Respiratory Diseases, University of Insubria, Varese
| | - N Sverzellati
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - L Tanno
- Institut Desbrest of Epidemiology and Santé Publique, INSERM & Montpellier University, Montpellier and Department of Allergic and Respiratory Diseases, Montpellier University Hospital, Montpellier, France
| | - S Tiberi
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - T Vasankari
- FILHA, Helsinki, University of Turku, Department of Pulmonary Diseases and Clinical Allergology, Turku, Finland
| | - E Vasarmidi
- Department of Respiratory Medicine and Laboratory of Molecular and Cellular Pneumonology, School of Medicine, University of Crete, Heraklion, Greece
| | - M Vitacca
- ICS Maugeri IRCCS, Respiratory Rehabilitation of the Institute of Lumezzane, Brescia, Italy
| | - I Annesi-Maesano
- Institut Desbrest of Epidemiology and Santé Publique, INSERM & Montpellier University, Montpellier and Department of Allergic and Respiratory Diseases, Montpellier University Hospital, Montpellier, France
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Mardani M, Mohammadshahi J, Teimourpour R. Outcomes of COVID-19 in immunocompromised patients: a single center experience. Virusdisease 2023; 34:373-382. [PMID: 37780900 PMCID: PMC10533436 DOI: 10.1007/s13337-023-00832-z] [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: 04/04/2023] [Accepted: 07/18/2023] [Indexed: 10/03/2023] Open
Abstract
Malignancy, bone marrow and organ transplantation are associated with deficient and defective immune systems. Immunocompromised patients are at risk for severe and chronic complication of COVID-19 infection. However, the pathogenesis, diagnosis and management of this comorbidity remain to be elucidated. The purpose of the present study was to describe key aspects of COVID-19 infection in immunocompromised patients. In this retrospective, cross-sectional study, lab findings and outcomes of 418 COVID-19 patients with secondary immunodeficiency disorders admitted to Taleghani Hospital in Tehran, from March 2020 to September 2022 were investigated. Of the 418 immunocompromised patients with COVID-19, 236 (56.5%) were male and the median age of all studied patients was 56.6 ± 16.4 with range of 14 to 92 years. Totally, 198 (47.4%) of the patients died during hospitalization. Remdesivir was used for treatment of all patients. Mortality rate among patients admitted to ICU ward (86.8%) was significantly higher than non ICU admission (p < 0.001). The death rate in patients with CKD was substantially higher than other underlying disease (p < 0.001). In terms of laboratory finding, there was a significant relationship between ICU admission and worse outcome with WBC count (HR = 1.94, 95% CI = 1. 46-2.59, p < 0.001), PMN count (HR = 1.93, 95% CI = 1.452.56, p < 0.001), Hb (HR = 1.49, 95% CI = 1.042.13, p = 0.028), AST (HR = 2.55, 95% CI = 1.913.41, p < 0.001), BUN (HR = 2.56, 95% CI = 2.063.69, p < 0.001), Cr (HR = 2.63, 95% CI = 1.89-3.64, p < 0.001), Comorbidities index (HR = 1.71, 95% CI = 1.29-2.27, p < 0.001) and aging (HR = 1.91, 95% CI = 1.4-2.54, p < 0.001). Immunocompromised status increased the risk of mortality or worse outcome in patients diagnosed with COVID-19. Our finding showed outcome predicting markers in whom the waned immune system encounter new emerging disease and improved our understanding of COVID-19 virus behavior in immunocompromised individuals.
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Affiliation(s)
- Masoud Mardani
- Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical, Tehran, Iran
| | - Jafar Mohammadshahi
- Ardabil University of medical science, Ardabil, Iran
- Department of Infectious Diseases, School of Medicine, Ardabil University of Medical Science, Ardabil, Iran
| | - Roghayeh Teimourpour
- Ardabil University of medical science, Ardabil, Iran
- Department of Microbiology, School of Medicine, Ardabil University of Medical Science, Ardabil, Iran
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Chew MS, Olkkola KT, Kalliomäki ML, Rehn M, Sigurðsson MI, Møller MH. ISTH guidelines for antithrombotic treatment in COVID-19: Endorsement by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine. Acta Anaesthesiol Scand 2023; 67:1118-1120. [PMID: 37318942 DOI: 10.1111/aas.14259] [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: 04/13/2023] [Accepted: 04/15/2023] [Indexed: 06/17/2023]
Abstract
The Clinical Practice Committee of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine endorses the ISTH guidelines for antithrombotic treatment in COVID-19. This evidence-based guideline serves as a useful decision aid for Nordic anaesthesiologists caring for patients with COVID-19.
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Affiliation(s)
- Michelle S Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Klaus T Olkkola
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | - Marius Rehn
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Martin Ingi Sigurðsson
- Division of Anesthesia and Intensive Care Medicine, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Gigante B, Levy JH, van Gorp E, Bartoloni A, Bochaton-Piallat ML, Bäck M, Ten Cate H, Christersson C, Ferreiro JL, Geisler T, Lutgens E, Schulman S, Storey RF, Thachil J, Vilahur G, Liaw PC, Rocca B. Management of patients on antithrombotic therapy with severe infections: a joint clinical consensus statement of the ESC Working Group on Thrombosis, the ESC Working Group on Atherosclerosis and Vascular Biology, and the International Society on Thrombosis and Haemostasis. Eur Heart J 2023; 44:3040-3058. [PMID: 37439553 DOI: 10.1093/eurheartj/ehad388] [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: 10/06/2022] [Revised: 05/01/2023] [Accepted: 05/29/2023] [Indexed: 07/14/2023] Open
Abstract
Patients with severe infections and a pre-existing indication for antithrombotic therapy, i.e. antiplatelet agents, anticoagulant drugs, or their combinations, require integrated clinical counselling among coagulation, infectious disease, and cardiology specialists, due to sepsis-induced coagulopathy that frequently occurs. Bacterial and viral pathogens constitute an increasing threat to global public health, especially for patients with ongoing antithrombotic treatment who have a high risk of thrombotic recurrences and high susceptibility to severe infections with increased morbidity and mortality. Similarly, sepsis survivors are at increased risk for major vascular events. Coagulopathy, which often complicates severe infections, is associated with a high mortality and obligates clinicians to adjust antithrombotic drug type and dosing to avoid bleeding while preventing thrombotic complications. This clinical consensus statement reviews the best available evidence to provide expert opinion and statements on the management of patients hospitalized for severe bacterial or viral infections with a pre-existing indication for antithrombotic therapy (single or combined), in whom sepsis-induced coagulopathy is often observed. Balancing the risk of thrombosis and bleeding in these patients and preventing infections with vaccines, if available, are crucial to prevent events or improve outcomes and prognosis.
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Affiliation(s)
- Bruna Gigante
- Division of Cardiovascular Medicine, Department of Medicine, Karolinska Institutet, Solnavägen 30. 17164 and Department of Cardiology, Danderyds Hospital, Entrévägen 2, 182 88, Stockholm, Sweden
| | - Jerrold H Levy
- Departments of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, United States; 2301 Erwin Road, Durham, NC 27710, USA
| | - Eric van Gorp
- Department of Viroscience, Erasmus MC, Rotterdam, PO box 2040 [Room Ee1726], 3000 CA Rotterdam, The Netherlands
| | - Alessandro Bartoloni
- Department of Experimental and Clinical Medicine, Infectious Diseases Unit, University of Florence, Largo Brambilla 3, 50100 Florence, Italy
| | - Marie-Luce Bochaton-Piallat
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, 1 rue Michel-Servet 1, CH-1211 Genève, Switzerland
| | - Magnus Bäck
- Department of Translational Cardiology, Karolinska Institutet and Karolinska University Hospital, CMM L8:01, 171 76 Stockholm, Sweden
- INSERM U1116, University of Lorraine, Nancy University Hospital, 2 rue Jean Lamour, 54505 Vandoeuvre les Nancy Cedex, France
| | - Hugo Ten Cate
- Department of Internal medicine, Thrombosis Expertise Center, Maastricht University Medical Center and CARIM school for cardiovascular diseases, Universiteitsingel 50, PO Box 616, 6200 MD Maastricht, The Netherlands
- Center for Thrombosis and Haemostasis, Gutenberg University Medical Center, Langenbeckstr. 1, Bldg. 403, 55131 Mainz, Germany
| | - Christina Christersson
- Department of Medical Sciences, Cardiology, Uppsala University, Akademiska Sjukhuset, 75185, Uppsala, Sweden
| | - José Luis Ferreiro
- Department of Cardiology and Bio-Heart Cardiovascular Diseases Research Group; Bellvitge University Hospital - Bellvitge Biomedical Research Institute (IDIBELL); CIBERCV; L'Hospitalet de Llobregat, Hospital Duran i Reynals - Edifici Terapèutic - 2a planta Gran Via de l'Hospitalet, 199, 08908 Hospitalet de Llobregat Barcelona -Spain
| | - Tobias Geisler
- Department of Cardiology and Angiology, University Hospital Tübingen, Otfried-Müller-Straße 10, 72076 Tübingen, Germany
| | - Esther Lutgens
- Cardiovascular Medicine, Experimental CardioVascular Immunology Laboratory, Mayo Clinic, 200 First St SW, 55905, Rochester, MN, USA
- Institute for Cardiovascular Prevention (IPEK), Ludwig-Maximilians Universität, München, Germany & German Center for Cardiovascular Research (DZHK), partner site Munich Heart Alliance, Pettenkoferstrasse 9, 80336, Munich, Germany
| | - Sam Schulman
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada HHS - General Hospital 237, Barton Street East, Hamilton, ON, L8L 2X2, Canada
- Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Bol'shaya Pirogovskaya Ulitsa, 2, стр. 4, Moscow 119435, Russia
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Pegasus House, 463a Glossop Road, Sheffield, S10 2QD, UK
| | - Jecko Thachil
- Department of Haematology, Manchester University Hospitals, Oxford road, Manchester, M13 9WL, UK
| | - Gemma Vilahur
- Institut de Recerca Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, CIBERCV, Avda. Sant Antoni Maria Claret 167, 08025 Barcelona, Spain
| | - Patricia C Liaw
- Department of Medicine, Thrombosis & Atherosclerosis Research Institute (TaARI), McMaster University, 237 Barton Street East Hamilton, Ontario L8L 2X2, Canada
| | - Bianca Rocca
- Department of Safety and Bioethics, Section on Pharmacology, Catholic University School of Medicine, Largo F. Vito 1, 00168 Rome, Italy
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Amani-Beni R, Kermani-Alghoraishi M, Darouei B, Reid CM. A systematic review on post-discharge venous thromboembolism prophylaxis in patients with COVID-19. Egypt Heart J 2023; 75:72. [PMID: 37596465 PMCID: PMC10439090 DOI: 10.1186/s43044-023-00400-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 08/12/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND Coronavirus disease of 2019 (COVID-19) is associated with venous thromboembolism (VTE), not only during hospitalization but also after discharge, raising concerns about anticoagulant (AC) use for post-discharge COVID-19 patients. We aimed to systematically review the current literature on the possible benefits or risks regarding extended thromboprophylaxis. MAIN BODY We searched related databases from December 1, 2019, to October 6, 2022, including studies on the necessity, duration, and selection of the ideal AC regarding extended thromboprophylaxis for post-discharge COVID-19 patients. The screening of the selected databases led to 18 studies and 19 reviews and guidelines. Studies included 52,927 hospitalized COVID-19 patients, with 19.25% receiving extended thromboprophylaxis. VTE events ranging from 0 to 8.19% (median of 0.7%) occurred in a median follow-up of 49.5 days. All included studies and guidelines, except four studies, recommended post-discharge prophylaxis after an individual risk assessment indicating high thrombotic and low bleeding risk. Studies used risk assessment models (RAMs), clinical evaluation, and laboratory data to identify COVID-19 patients with a high risk of VTE. IMPROVE-DD was the most recommended RAM. Direct oral anticoagulants (DOACs) and low molecular weight heparins (LMWHs) were the most used AC classes. CONCLUSIONS Post-discharge prophylaxis for COVID-19 patients is recommended after an individual assessment. The IMPROVE-DD model can help predict VTE risk. After distinguishing patients who need post-discharge AC therapy, DOACs for 30-35 days and LMWHs for 40-45 days can be the drug of choice. Further studies, particularly the results of the ongoing randomized controlled trials (RCTs), are required. Also, to properly handle such patients, every physician should consider lifestyle modification in addition to pharmacological treatment for post-discharge VTE prophylaxis.
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Affiliation(s)
- Reza Amani-Beni
- Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Kermani-Alghoraishi
- Interventional Cardiology Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Bahar Darouei
- Hypertension Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Christopher M Reid
- Centre of Clinical Research and Education, Curtin University, Perth, WA, Australia
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Santos BC, Flumignan RL, Civile VT, Atallah ÁN, Nakano LC. Prophylactic anticoagulants for non-hospitalised people with COVID-19. Cochrane Database Syst Rev 2023; 8:CD015102. [PMID: 37591523 PMCID: PMC10428666 DOI: 10.1002/14651858.cd015102.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic has impacted healthcare systems worldwide. Multiple reports on thromboembolic complications related to COVID-19 have been published, and researchers have described that people with COVID-19 are at high risk for developing venous thromboembolism (VTE). Anticoagulants have been used as pharmacological interventions to prevent arterial and venous thrombosis, and their use in the outpatient setting could potentially reduce the prevalence of vascular thrombosis and associated mortality in people with COVID-19. However, even lower doses used for a prophylactic purpose may result in adverse events such as bleeding. It is important to consider the evidence for anticoagulant use in non-hospitalised people with COVID-19. OBJECTIVES To evaluate the benefits and harms of prophylactic anticoagulants versus active comparators, placebo or no intervention, or non-pharmacological interventions in non-hospitalised people with COVID-19. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 18 April 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing prophylactic anticoagulants with placebo or no treatment, another active comparator, or non-pharmacological interventions in non-hospitalised people with COVID-19. We included studies that compared anticoagulants with a different dose of the same anticoagulant. We excluded studies with a duration of under two weeks. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. Our primary outcomes were all-cause mortality, VTE (deep vein thrombosis (DVT) or pulmonary embolism (PE)), and major bleeding. Our secondary outcomes were DVT, PE, need for hospitalisation, minor bleeding, adverse events, and quality of life. We used GRADE to assess the certainty of the evidence. MAIN RESULTS We included five RCTs with up to 90 days of follow-up (short term). Data were available for meta-analysis from 1777 participants. Anticoagulant compared to placebo or no treatment Five studies compared anticoagulants with placebo or no treatment and provided data for three of our outcomes of interest (all-cause mortality, major bleeding, and adverse events). The evidence suggests that prophylactic anticoagulants may lead to little or no difference in all-cause mortality (risk ratio (RR) 0.36, 95% confidence interval (CI) 0.04 to 3.61; 5 studies; 1777 participants; low-certainty evidence) and probably reduce VTE from 3% in the placebo group to 1% in the anticoagulant group (RR 0.36, 95% CI 0.16 to 0.85; 4 studies; 1259 participants; number needed to treat for an additional beneficial outcome (NNTB) = 50; moderate-certainty evidence). There may be little to no difference in major bleeding (RR 0.36, 95% CI 0.01 to 8.78; 5 studies; 1777 participants; low-certainty evidence). Anticoagulants probably result in little or no difference in DVT (RR 1.02, 95% CI 0.30 to 3.46; 3 studies; 1009 participants; moderate-certainty evidence), but probably reduce the risk of PE from 2.7% in the placebo group to 0.7% in the anticoagulant group (RR 0.25, 95% CI 0.08 to 0.79; 3 studies; 1009 participants; NNTB 50; moderate-certainty evidence). Anticoagulants probably lead to little or no difference in reducing hospitalisation (RR 1.01, 95% CI 0.59 to 1.75; 4 studies; 1459 participants; moderate-certainty evidence) and may lead to little or no difference in adverse events (minor bleeding, RR 2.46, 95% CI 0.90 to 6.72; 5 studies, 1777 participants; low-certainty evidence). Anticoagulant compared to a different dose of the same anticoagulant One study compared anticoagulant (higher-dose apixaban) with a different (standard) dose of the same anticoagulant and reported five relevant outcomes. No cases of all-cause mortality, VTE, or major bleeding occurred in either group during the 45-day follow-up (moderate-certainty evidence). Higher-dose apixaban compared to standard-dose apixaban may lead to little or no difference in reducing the need for hospitalisation (RR 1.89, 95% CI 0.17 to 20.58; 1 study; 278 participants; low-certainty evidence) or in the number of adverse events (minor bleeding, RR 0.47, 95% CI 0.09 to 2.54; 1 study; 278 participants; low-certainty evidence). Anticoagulant compared to antiplatelet agent One study compared anticoagulant (apixaban) with antiplatelet agent (aspirin) and reported five relevant outcomes. No cases of all-cause mortality or major bleeding occurred during the 45-day follow-up (moderate-certainty evidence). Apixaban may lead to little or no difference in VTE (RR 0.36, 95% CI 0.01 to 8.65; 1 study; 279 participants; low-certainty evidence), need for hospitalisation (RR 3.20, 95% CI 0.13 to 77.85; 1 study; 279 participants; low-certainty evidence), or adverse events (minor bleeding, RR 2.13, 95% CI 0.40 to 11.46; 1 study; 279 participants; low-certainty evidence). No included studies reported on quality of life or investigated anticoagulants compared to a different anticoagulant, or anticoagulants compared to non-pharmacological interventions. AUTHORS' CONCLUSIONS We found low- to moderate-certainty evidence from five RCTs that prophylactic anticoagulants result in little or no difference in major bleeding, DVT, need for hospitalisation, or adverse events when compared with placebo or no treatment in non-hospitalised people with COVID-19. Low-certainty evidence indicates that prophylactic anticoagulants may result in little or no difference in all-cause mortality when compared with placebo or no treatment, but moderate-certainty evidence indicates that prophylactic anticoagulants probably reduce the incidence of VTE and PE. Low-certainty evidence suggests that comparing different doses of the same prophylactic anticoagulant may result in little or no difference in need for hospitalisation or adverse events. Prophylactic anticoagulants may result in little or no difference in risk of VTE, hospitalisation, or adverse events when compared with antiplatelet agents (low-certainty evidence). Given that there were only short-term data from one study, these results should be interpreted with caution. Additional trials of sufficient duration are needed to clearly determine any effect on clinical outcomes.
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Affiliation(s)
- Brena C Santos
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Ronald Lg Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
- Cochrane Brazil, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Vinicius T Civile
- Cochrane Brazil, Universidade Federal de São Paulo, São Paulo, Brazil
- Department of Physiotherapy, Universidade Paulista, São Paulo, Brazil
| | - Álvaro N Atallah
- Cochrane Brazil, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Luis Cu Nakano
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
- Cochrane Brazil, Universidade Federal de São Paulo, São Paulo, Brazil
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Wang D, Leo C, Liu L, Huang L, Huang L, Lu Y. Antithrombotic therapy in patients with COVID-19: indications, pharmacotherapy and controversy. Stroke Vasc Neurol 2023; 8:263-265. [PMID: 36797011 PMCID: PMC10512043 DOI: 10.1136/svn-2023-002321] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 01/15/2023] [Indexed: 02/18/2023] Open
Affiliation(s)
- David Wang
- Department of Neurology, Petznick Stroke Center, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Christopher Leo
- Department of Medicine/Division of General Internal Medicine/Hospital Medicine, Duke University, Durham, North Carolina, USA
| | - Liping Liu
- Neurosurgical Intensive Care Unit (NICU), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Li Huang
- Doctors Medical Center, Modesto, California, USA
| | - Lisa Huang
- Chesapeake Regional Medical Center, Chesapeake, Virginia, USA
| | - Yun Lu
- Hennepin Healthcare System and the University of Minnesota, Minneapolis, Minnesota, USA
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40
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Honkanen M, Sirkeoja S, Viskari H, Kailankangas V, Sinisalo M, Syrjänen J. Risk of venous thromboembolism in COVID-19 infection. Intern Med J 2023; 53:1478-1480. [PMID: 37449583 DOI: 10.1111/imj.16145] [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: 02/24/2023] [Accepted: 05/25/2023] [Indexed: 07/18/2023]
Abstract
The incidence of venous thromboembolism (VTE) for non-hospitalised patients with coronavirus disease-2019 infection has not been very widely studied. 13 019 persons with a positive SARS-CoV-2 nucleic acid amplification test were identified. In total, 447 (0.2%) VTEs were identified in the study population, 293 (66%) of these were pulmonary embolisms. A positive SARS-CoV-2 test did not increase the risk for VTE in the univariate analysis (odds ratio (OR): 1.0, 95% confidence interval (CI): 0.69-1.4) or multivariable analysis (OR: 1.36, 95% CI: 0.93-1.97).
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Affiliation(s)
- Meeri Honkanen
- Department of Internal Medicine, Tampere University Hospital and Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland
| | - Simo Sirkeoja
- Department of Internal Medicine, Tampere University Hospital and Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland
| | - Hanna Viskari
- Department of Internal Medicine, Tampere University Hospital and Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland
| | - Ville Kailankangas
- Department of Internal Medicine, Tampere University Hospital and Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland
| | - Marjatta Sinisalo
- Department of Internal Medicine, Tampere University Hospital and Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland
| | - Jaana Syrjänen
- Department of Internal Medicine, Tampere University Hospital and Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland
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41
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Iba T, Levy JH. A commentary on "Thromboinflammation in long COVID - the elusive key to post-infection sequelae?". J Thromb Haemost 2023; 21:2061-2063. [PMID: 37468178 DOI: 10.1016/j.jtha.2023.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 05/22/2023] [Indexed: 07/21/2023]
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
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Arachchillage DJ, Rajakaruna I, Odho Z, Makris M, Laffan M. Impact of thromboprophylaxis on hospital acquired thrombosis following discharge in patients admitted with COVID-19: Multicentre observational study in the UK. Br J Haematol 2023; 202:485-497. [PMID: 37202865 PMCID: PMC10952807 DOI: 10.1111/bjh.18874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/07/2023] [Accepted: 05/10/2023] [Indexed: 05/20/2023]
Abstract
Post-discharge thromboprophylaxis in patients admitted with COVID-19 remains controversial. We aimed to determine the impact of thromboprophylaxis on hospital acquired thrombosis (HAT) in patients (≥18 years) discharged following admission for COVID-19 in an observational study across 26 NHS Trusts in the UK (01.04.2020-31.12.2021). Overall, 8895 patients were included to the study: 971 patients were discharged with thromboprophylaxis and propensity score matched (PSM) with a desired ratio of 1:1, from patients discharged without thromboprophylaxis. Patients with heparin induced thrombocytopenia, major bleeding during admission and pregnant women were excluded. As expected from 1:1 PSM, no difference was observed in parameters between the two groups, including duration of hospital stay, except the thromboprophylaxis group had a significantly higher proportion who had received therapeutic dose anticoagulation during admission. There were no differences in the laboratory parameters especially D-dimers between the two groups at admission or discharge. Median duration of thromboprophylaxis following discharge from hospital was 4 weeks (1-8 weeks). No difference was found in HAT in patients discharged with TP versus no TP (1.3% vs. 0.92%, p = 0.52). Increasing age and smoking significantly increased the risk of HAT. Many patients in both cohorts had raised D-dimer at discharge but D-dimer was not associated with increased risk of HAT.
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Affiliation(s)
- Deepa J. Arachchillage
- Centre for HaematologyDepartment of Immunology and Inflammation, Imperial College LondonLondonUK
- Department of HaematologyImperial College Healthcare NHS TrustLondonUK
| | - Indika Rajakaruna
- Department of Computer ScienceUniversity of East London, University WayLondonUK
| | - Zain Odho
- Department of BiochemistryRoyal Brompton HospitalLondonUK
| | - Mike Makris
- Department of Infection, Immunity and Cardiovascular DiseaseUniversity of SheffieldSheffieldUK
| | - Mike Laffan
- Centre for HaematologyDepartment of Immunology and Inflammation, Imperial College LondonLondonUK
- Department of HaematologyImperial College Healthcare NHS TrustLondonUK
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Cameron SJ, Carman TL. Thromboprophylaxis for COVID-19: Time to ask for an extension? Vasc Med 2023; 28:340-341. [PMID: 37259519 PMCID: PMC10235914 DOI: 10.1177/1358863x231175183] [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] [Indexed: 06/02/2023]
Affiliation(s)
- Scott J Cameron
- Department of Cardiovascular Medicine,
Section of Vascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic
Foundation, Cleveland, OH, USA
- Department of Hematology, Taussig Cancer
Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Teresa L Carman
- Harrington Heart & Vascular Institute,
University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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Rodrigues A, Dias Domingues T, Nobre Jesus G, Garção A, Rodrigues AR, Jacinto Correia C, Leal Pereira C, Correia D, Beleza Á, Ribeiro JM. COVID-19-associated Coagulopathy Characterization using Rotational Thromboelastometry in a Prospective, Observational Cohort Study: The HemoCoV Study. ACTA MEDICA PORT 2023; 36:496-505. [PMID: 37429589 DOI: 10.20344/amp.19475] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 03/31/2023] [Indexed: 07/12/2023]
Abstract
INTRODUCTION COVID-19-associated coagulopathy includes systemic and endothelial inflammation with coagulation dysregulation related to immunothrombosis. The aim of this study was to characterize this complication of SARS-CoV-2 infection in patients with moderate to severe COVID-19. METHODS An open-label, prospective observational study conducted in patients with COVID-19 moderate to severe acute respiratory failure admitted to an intensive care unit (ICU). Coagulation testing, including thromboelastometry, biochemical analysis and clinical variables, were collected at prespecified time points during the 30 days of ICU stay. RESULTS The study included 145 patients, 73.8% male, with a median age of 68 years (interquartile range - IQR 55 - 74). The most prevalent comorbidities were arterial hypertension (63.4%), obesity (44.1%) and diabetes (22.1%). Simplified acute physiology score II (SAPS II) was on average 43.5 (11 - 105) and sequential organ failure assessment (SOFA) at admission was 7.5 (0 - 14). During ICU stay, 66.9% of patients underwent invasive mechanical ventilation and 18.4% extracorporeal membrane oxygenation support; thrombotic and hemorrhagic events occurred in 22.1% and 15.1% of the patients respectively; anticoagulation with heparin was present in 99.2% of patients since early ICU stay. Death occurred in 35% of patients. Longitudinal studies revealed changes in almost all coagulation tests during the ICU stay. SOFA score, lymphocyte counts, some biochemical, inflammatory and coagulation parameters, including hypercoagulability and hypofibrinolysis seen in thromboelastometry, differed significantly (p < 0.05), between ICU admission and discharge. Hypercoagulability and hypofibrinolysis persisted throughout ICU hospitalization, showing higher incidence and severity in non-survivors. CONCLUSION COVID-19-associated coagulopathy is characterized by hypercoagulability and hypofibrinolysis from ICU admission, and persisted throughout the clinical course in severe COVID-19. These changes were more pronounced in patients with higher disease burden and in non-survivors.
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Affiliation(s)
- Anabela Rodrigues
- Transfusion Medicine Department. Hospital Santa Maria. Centro Hospitalar Universitário Lisboa Norte. Lisbon. Portugal
| | - Tiago Dias Domingues
- Centro de Estatística e Aplicações - CEAUL. Faculdade de Ciências. Universidade de Lisboa. Lisbon. Portugal
| | - Gustavo Nobre Jesus
- Intensive Medicine Department. Clínica Universitária de Medicina Intensiva. Hospital Santa Maria. Centro Hospitalar Universitário Lisboa Norte. Lisbon; Clínica Universitária de Medicina Intensiva. Faculdade de Medicina. Universidade de Lisboa. Lisbon. Portugal
| | - Ana Garção
- Transfusion Medicine Department. Hospital Santa Maria. Centro Hospitalar Universitário Lisboa Norte. Lisbon. Portugal
| | - Ana Rita Rodrigues
- Intensive Medicine Department. Clínica Universitária de Medicina Intensiva. Hospital Santa Maria. Centro Hospitalar Universitário Lisboa Norte. Lisbon. Portugal
| | - Catarina Jacinto Correia
- Transfusion Medicine Department. Hospital Santa Maria. Centro Hospitalar Universitário Lisboa Norte. Lisbon. Portugal
| | - Carla Leal Pereira
- Transfusion Medicine Department. Hospital Santa Maria. Centro Hospitalar Universitário Lisboa Norte. Lisbon. Portugal
| | - Dulce Correia
- Intensive Medicine Department. Clínica Universitária de Medicina Intensiva. Hospital Santa Maria. Centro Hospitalar Universitário Lisboa Norte. Lisbon. Portugal
| | - Álvaro Beleza
- Transfusion Medicine Department. Hospital Santa Maria. Centro Hospitalar Universitário Lisboa Norte. Lisbon. Portugal
| | - João Miguel Ribeiro
- Intensive Medicine Department. Clínica Universitária de Medicina Intensiva. Hospital Santa Maria. Centro Hospitalar Universitário Lisboa Norte. Lisbon. Portugal
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Kneffel M, Kemmling A, Timmermann L, Simon OJ. [Thromboembolism - A common cause of stroke]. Dtsch Med Wochenschr 2023; 148:899-907. [PMID: 37493951 DOI: 10.1055/a-1848-6834] [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: 07/27/2023]
Abstract
In the field of neurology, thromboembolic events are responsible for approximately 40% of ischemic strokes 1. The embolisms are differentiated according to their origin: One group includes emboli that occur in the heart, e.g. due to atrial fibrillation (cardioembolic stroke). Another group includes emboli, which are caused by arteriosclerotic plaques, e.g. in the area of the carotid bifurcation in the large vessels supplying the brain. After the acute therapy of the ischemic stroke, further diagnostics are essential to determine the exact cause of the ischemic stroke. Targeted therapy to prevent further strokes can only be initiated if the cause is known (secondary prevention). In the following - in addition to the current diagnostics and therapy of thromboembolic strokes - new guideline recommendations and COVID-19 will be discussed.
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Griffee MJ, Bozza PT, Reyes LF, Eddington DP, Rosenberger D, Merson L, Citarella BW, Fanning JP, Alexander PM, Fraser J, Dalton H, Cho SM. Thrombotic and hemorrhagic complications of COVID-19 in adults hospitalized in high-income countries compared with those in adults hospitalized in low- and middle-income countries in an international registry. Res Pract Thromb Haemost 2023; 7:102142. [PMID: 37601011 PMCID: PMC10439444 DOI: 10.1016/j.rpth.2023.102142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 05/29/2023] [Accepted: 06/08/2023] [Indexed: 08/22/2023] Open
Abstract
Background COVID-19 has been associated with a broad range of thromboembolic, ischemic, and hemorrhagic complications (coagulopathy complications). Most studies have focused on patients with severe disease from high-income countries (HICs). Objectives The main aims were to compare the frequency of coagulopathy complications in developing countries (low- and middle-income countries [LMICs]) with those in HICs, delineate the frequency across a range of treatment levels, and determine associations with in-hospital mortality. Methods Adult patients enrolled in an observational, multinational registry, the International Severe Acute Respiratory and Emerging Infections COVID-19 study, between January 1, 2020, and September 15, 2021, met inclusion criteria, including admission to a hospital for laboratory-confirmed, acute COVID-19 and data on complications and survival. The advanced-treatment cohort received care, such as admission to the intensive care unit, mechanical ventilation, or inotropes or vasopressors; the basic-treatment cohort did not receive any of these interventions. Results The study population included 495,682 patients from 52 countries, with 63% from LMICs and 85% in the basic treatment cohort. The frequency of coagulopathy complications was higher in HICs (0.76%-3.4%) than in LMICs (0.09%-1.22%). Complications were more frequent in the advanced-treatment cohort than in the basic-treatment cohort. Coagulopathy complications were associated with increased in-hospital mortality (odds ratio, 1.58; 95% CI, 1.52-1.64). The increased mortality associated with these complications was higher in LMICs (58.5%) than in HICs (35.4%). After controlling for coagulopathy complications, treatment intensity, and multiple other factors, the mortality was higher among patients in LMICs than among patients in HICs (odds ratio, 1.45; 95% CI, 1.39-1.51). Conclusion In a large, international registry of patients hospitalized for COVID-19, coagulopathy complications were more frequent in HICs than in LMICs (developing countries). Increased mortality associated with coagulopathy complications was of a greater magnitude among patients in LMICs. Additional research is needed regarding timely diagnosis of and intervention for coagulation derangements associated with COVID-19, particularly for limited-resource settings.
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Affiliation(s)
- Matthew J. Griffee
- Department of Anesthesiology, University of Utah, Salt Lake City, Utah, USA
- ISARIC, Pandemic Sciences Institute, University of Oxford, Oxford, United Kingdom
| | - Patricia T. Bozza
- Laboratory of Immunopharmacology, Institutio Oswaldo Cruz, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Luis Felipe Reyes
- Unisabana Center for Translational Science, School of Medicine, Universidad de La Sabana, Chia, Colombia
| | - Devin P. Eddington
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | | | - Laura Merson
- ISARIC, Pandemic Sciences Institute, University of Oxford, Oxford, United Kingdom
| | | | | | - Peta M.A. Alexander
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - John Fraser
- Critical Care Research Group, The Prince Charles Hospital, University of Queensland, Brisbane, Australia
| | - Heidi Dalton
- Pediatric Critical Care Medicine, Heart and Vascular Institute, Inova Fairfax Hospital, Annandale, Virginia, USA
| | - Sung-Min Cho
- Divisions of Neuroscience Critical Care and Cardiac Surgery, Departments of Neurology, Surgery, Anesthesia and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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Boccatonda A, Campello E, Simion C, Simioni P. Long-term hypercoagulability, endotheliopathy and inflammation following acute SARS-CoV-2 infection. Expert Rev Hematol 2023; 16:1035-1048. [PMID: 38018136 DOI: 10.1080/17474086.2023.2288154] [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: 07/06/2023] [Accepted: 11/22/2023] [Indexed: 11/30/2023]
Abstract
INTRODUCTION both symptomatic and asymptomatic SARS-CoV-2 infections - coined Coronavirus disease 2019 (COVID-19) - have been linked to a higher risk of cardiovascular events after recovery. AREAS COVERED our review aims to summarize the latest evidence on the increased thrombotic and cardiovascular risk in recovered COVID-19 patients and to examine the pathophysiological mechanisms underlying the interplay among endothelial dysfunction, inflammatory response and coagulation in long-COVID. We performed a systematic search of studies on hypercoagulability, endothelial dysfunction and inflammation after SARS-CoV-2 infection. EXPERT OPINION endothelial dysfunction is a major pathophysiological mechanism responsible for most clinical manifestations in COVID-19. The pathological activation of endothelial cells by a virus infection results in a pro-adhesive and chemokine-secreting phenotype, which in turn promotes the recruitment of circulating leukocytes. Cardiovascular events after COVID-19 appear to be related to persistent immune dysregulation. Patients with long-lasting symptoms display higher amounts of proinflammatory molecules such as tumor necrosis factor-α, interferon γ and interleukins 2 and 6. Immune dysregulation can trigger the activation of the coagulation pathway. The formation of extensive microclots in vivo, both during acute COVID-19 and in long-COVID-19, appears to be a relevant mechanism responsible for persistent symptoms and cardiovascular events.
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Affiliation(s)
- Andrea Boccatonda
- Internal Medicine, Bentivoglio Hospital, AUSL Bologna, Bentivoglio, Italy
| | - Elena Campello
- General Medicine and Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, University Hospital of Padova, Padova, Italy
| | - Chiara Simion
- General Medicine and Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, University Hospital of Padova, Padova, Italy
| | - Paolo Simioni
- General Medicine and Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, University Hospital of Padova, Padova, Italy
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Zhang Z, Yan T, Ren D, Zhou J, Liu L, Li J, Fu S, Ni T, Xu W, Yang Y, Chen T, He Y, Zhao Y, Liu J. Low-molecular-weight heparin therapy reduces 28-day mortality in patients with sepsis-3 by improving inflammation and coagulopathy. Front Med (Lausanne) 2023; 10:1157775. [PMID: 37359014 PMCID: PMC10289000 DOI: 10.3389/fmed.2023.1157775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 05/02/2023] [Indexed: 06/28/2023] Open
Abstract
Background and aim Sepsis is a syndromic response to infection and is associated with high mortality, thus imposing a significant global burden of disease. Although low-molecular-weight heparin (LMWH) has been recommended to prevent venous thromboembolism, its anticoagulant and anti-inflammatory effects in sepsis remain controversial. Owing to the modification of the Sepsis-3 definition and diagnostic criteria, further evaluation of the efficacy and benefit population of LMWH is required. Methods We performed a retrospective cohort study to assess whether LMWH improved the inflammation, coagulopathy, and clinical outcomes against Sepsis-3 and to identify the target patients. All patients diagnosed with sepsis at the First Affiliated Hospital of Xi'an Jiaotong University (the largest general hospital in northwest China) from January 2016 to December 2020 were recruited and re-evaluated using Sepsis-3 criteria. Results After 1:1 propensity score matching, 88 pairs of patients were categorized into the treatment and control groups based on subcutaneous LMWH administration. Compared with the control group, a significantly lower 28-day mortality was observed in the LMWH group (26.1 vs. 42.0%, p = 0.026) with a comparable incidence of major bleeding events (6.8 vs. 8.0%, p = 0.773). Cox regression analysis showed that LMWH administration was the independent protective factor for septic patients (aHR, 0.48; 95% CI, 0.29-0.81; p = 0.006). Correspondingly, the LMWH treatment group showed a significant improvement in inflammation and coagulopathy. Further subgroup analysis showed that LMWH therapy was associated with favorable outcomes in patients younger than 60 years and diagnosed with sepsis-induced coagulopathy (SIC), ISTH overt DIC, non-septic shock, or non-diabetics and in patients included in the moderate-risk group (APACHE II score 20-35 or SOFA score 8-12). Conclusion Our study results showed that LMWH improves 28-day mortality by improving inflammatory response and coagulopathy in patients meeting Sepsis-3 criteria. The SIC and ISTH overt DIC scoring systems can better identify septic patients who are likely to benefit more from LMWH administration.
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Affiliation(s)
- Ze Zhang
- The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
- Shaanxi Clinical Medical Research Center of Infectious Diseases, Xi'an, China
| | - Taotao Yan
- The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
- Shaanxi Clinical Medical Research Center of Infectious Diseases, Xi'an, China
| | - Danfeng Ren
- The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
- Shaanxi Clinical Medical Research Center of Infectious Diseases, Xi'an, China
| | - Jingwen Zhou
- The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
- Shaanxi Clinical Medical Research Center of Infectious Diseases, Xi'an, China
| | - Liangru Liu
- Shaanxi Clinical Medical Research Center of Infectious Diseases, Xi'an, China
| | - Juan Li
- The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
- Shaanxi Clinical Medical Research Center of Infectious Diseases, Xi'an, China
| | - Shan Fu
- Shaanxi Clinical Medical Research Center of Infectious Diseases, Xi'an, China
| | - Tianzhi Ni
- Shaanxi Clinical Medical Research Center of Infectious Diseases, Xi'an, China
| | - Weicheng Xu
- Shaanxi Clinical Medical Research Center of Infectious Diseases, Xi'an, China
| | - Yuan Yang
- The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
- Institution of Hepatology, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Tianyan Chen
- The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
- Institution of Hepatology, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Yingli He
- The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
- Institution of Hepatology, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Yingren Zhao
- Shaanxi Clinical Medical Research Center of Infectious Diseases, Xi'an, China
- Institution of Hepatology, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Jinfeng Liu
- The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
- Shaanxi Clinical Medical Research Center of Infectious Diseases, Xi'an, China
- Institution of Hepatology, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
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Rahi MS, Parekh J, Pednekar P, Mudgal M, Jindal V, Gunasekaran K. Role of Therapeutic Anticoagulation in COVID-19: The Current Situation. Hematol Rep 2023; 15:358-369. [PMID: 37367086 DOI: 10.3390/hematolrep15020037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 05/30/2023] [Accepted: 06/01/2023] [Indexed: 06/28/2023] Open
Abstract
Thrombotic complications from COVID-19 are now well known and contribute to significant morbidity and mortality. Different variants confer varying risks of thrombotic complications. Heparin has anti-inflammatory and antiviral effects. Due to its non-anticoagulant effects, escalated-dose anticoagulation, especially therapeutic-dose heparin, has been studied for thromboprophylaxis in hospitalized patients with COVID-19. Few randomized, controlled trials have examined the role of therapeutic anticoagulation in moderately to severely ill patients with COVID-19. Most of these patients had elevated D-dimers and low bleeding risks. Some trials used an innovative adaptive multiplatform with Bayesian analysis to answer this critical question promptly. All the trials were open-label and had several limitations. Most trials showed improvements in the meaningful clinical outcomes of organ-support-free days and reductions in thrombotic events, mainly in non-critically-ill COVID-19 patients. However, the mortality benefit needed to be more consistent. A recent meta-analysis confirmed the results. Multiple centers initially adopted intermediate-dose thromboprophylaxis, but the studies failed to show meaningful benefits. Given the new evidence, significant societies have suggested therapeutic anticoagulation in carefully selected patients who are moderately ill and do not require an intensive-care-unit level of care. There are multiple ongoing trials globally to further our understanding of therapeutic-dose thromboprophylaxis in hospitalized patients with COVID-19. In this review, we aim to summarize the current evidence regarding the use of anticoagulation in patients with COVID-19 infection.
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Affiliation(s)
- Mandeep Singh Rahi
- Division of Pulmonary Diseases and Critical Care Medicine, Yale-New Haven Health Lawrence and Memorial Hospital, New London, CT 06320, USA
| | - Jay Parekh
- Department of Internal Medicine, Yale-New Haven Health Bridgeport Hospital, Bridgeport, CT 06610, USA
| | - Prachi Pednekar
- Department of Internal Medicine, Yale-New Haven Hospital, New Haven, CT 06510, USA
| | - Mayuri Mudgal
- Department of Medicine, Camden Clark Medical Center, Parkersburg, WV 26101, USA
| | - Vishal Jindal
- Department of Hematology and Oncology, Sinai Hospital, Baltimore, MD 21215, USA
| | - Kulothungan Gunasekaran
- Department of Pulmonary and Critical Care, Yuma Regional Medical Center, Yuma, AZ 85364, USA
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Szekely Y, Gilead R, Réa ABBAC, Lawler PR. An Evolving Understanding of the Basis and Management of Vascular Complications of COVID-19: Where Do We Go From Here? Can J Cardiol 2023; 39:865-874. [PMID: 36966983 PMCID: PMC10036296 DOI: 10.1016/j.cjca.2023.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 03/21/2023] [Accepted: 03/21/2023] [Indexed: 03/26/2023] Open
Abstract
The COVID-19 pandemic led to millions of deaths worldwide after its emergence in 2020. The SARS-CoV-2 virus primarily affects respiratory function, but immune dysregulation leading to systemic inflammation, endothelial dysfunction, and coagulopathy can predispose to systemic complications including hematologic and vascular complications. Treatment strategies for patients with COVID-19 have rapidly evolved and the effectiveness and safety of antithrombotic agents have been evaluated in multiple clinical trials. The findings have spurred interest in the prevention and treatment of the hematologic and vascular complications of non-COVID-19 respiratory infections. This review is focused on hematological and vascular complications of COVID-19, including their pathophysiology, clinical manifestations, and management. Because of the perpetually changing nature of the disease, the review places previous data in temporal contexts and outlines potential next steps for future research in COVID-19 and other severe respiratory infections.
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Affiliation(s)
- Yishay Szekely
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Department of Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv University School of Medicine, Tel Aviv, Israel.
| | - Rami Gilead
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | | | - Patrick R Lawler
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Ted Rogers Centre for Heart Research, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.
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