The Impact of Anticoagulation on COVID-19 (SARS CoV-2) Patient Outcomes: A Systematic Review

Effect of combination of prophylactic or therapeutic anticoagulation with aspirin on the outcomes of hospitalized COVID-19 patients: An observational retrospective study

Regimens for managing thromboembolic complications of COVID-19 are still not very well established. The present study compares the clinical characteristics and outcomes of patients hospitalized with COVID-19 receiving different anticoagulation regimens with and without aspirin. This is a retrospective observational study of 491 patients hospitalized for COVID-19 from August 2020 to April 2021. Data regarding clinical characteristics, laboratory findings, and outcomes of patients receiving different anticoagulation with and without aspirin regimens was collected, according to which 5 patient groups were defined: received no anticoagulation (NAA), prophylactic anticoagulation with (PA) or without aspirin (PAA) and therapeutic anticoagulation with (TA) or without aspirin (TAA). The average age was highest in the TAA group. Desaturation was highest in the TA and TAA groups. Diabetes, hypertension, dyslipidemia and coronary artery disease were the most prevalent in aspirin groups (PAA and TAA) as was heart failure in the TA and TAA groups and cancer in the TA and PAA groups. Elevated troponin was observed in the PAA and TAA groups. TA and TAA patients received oxygen therapy, needed ICU admission overall, and required invasive ventilation and vasopressors the most. Prophylactic anticoagulation groups (PA and PAA) had the highest patient survival rates. Patients with severe COVID-19 infections were more likely to receive higher, therapeutic, anticoagulation doses. Aspirin was given to patients with preexisting comorbidities, but it had no statistically significant impact on the outcomes of the different groups. Groups receiving prophylactic anticoagulation had the best survival outcomes.

Immunothrombosis and COVID-19 ‒ a nested post-hoc analysis from a 3186 patient cohort in a Latin American public reference hospital

OBJECTIVE

COVID-19 is associated with an elevated risk of thromboembolism and excess mortality. Difficulties with best anticoagulation practices and their implementation motivated the current analysis of COVID-19 patients who developed Venous Thromboembolism (VTE).

METHOD

This is a post-hoc analysis of a COVID-19 cohort, described in an economic study already published. The authors analyzed a subset of patients with confirmed VTE. We described the characteristics of the cohort, such as demographics, clinical status, and laboratory results. We tested differences amid two subgroups of patients, those with VTE or not, with the competitive risk Fine and Gray model.

RESULTS

Out of 3186 adult patients with COVID-19, 245 (7.7%) were diagnosed with VTE, 174 (5.4%) of them during admission to the hospital. Four (2.3% of these 174) did not receive prophylactic anticoagulation and 19 (11%) discontinued anticoagulation for at least 3 days, resulting in 170 analyzed. During the first week of hospitalization, the laboratory most altered results were C-reactive protein and D-dimer. Patients with VTE were more critical, had a higher mortality rate, worse SOFA score, and, on average, 50% longer hospital stay.

CONCLUSION

Proven VTE incidence in this severe COVID-19 cohort was 7.7%, despite 87% of them complying completely with VTE prophylaxis. The clinician must be aware of the diagnosis of VTE in COVID-19, even in patients receiving proper prophylaxis.

Rate of COVID-19 infection and 30 day mortality between blue and green (dedicated COVID-19 safe) pathways: Results from phase 1 and 2 of the UK foot and ankle COVID-19 national (UK-FAlCoN) audit

OBJECTIVES

The primary aim was to determine the differences in COVID-19 infection rate and 30-day mortality in patients undergoing foot and ankle surgery between different treatment pathways over the two phases of the UK-FALCON audit, spanning the first and second UK national lockdowns.

SETTING

This was an ambispective (retrospective Phase 1 and prospective Phase 2) national audit of foot and ankle procedures in the UK in 2020 completed between 13th January 2020 and 30th November 2020.

PARTICIPANTS

All adult patients undergoing foot and ankle surgery in an operating theatre during the study period were included from 46 participating centres in England, Scotland, Wales and Northern Ireland. Patients were categorised as either a green pathway (designated COVID-19 free) or blue pathway (no protocols to prevent COVID-19 infection).

RESULTS

10,846 patients were included, 6644 from phase 1 and 4202 from phase 2. Over the 2 phases the infection rate on a blue pathway was 1.07% (69/6470) and 0.21% on a green pathway (9/4280). In phase 1, there was no significant difference in the COVID-19 perioperative infection rate between the blue and green pathways in any element of the first phase (pre-lockdown (p = .109), lockdown (p = .923) or post-lockdown (p = .577)). However, in phase 2 there was a significant reduction in perioperative infection rate when using the green pathway in both the pre-lockdown (p < .001) and lockdown periods (Odd's Ratio 0.077, p < .001). There was no significant difference in COVID-19 related mortality between pathways.

CONCLUSIONS

There was a five-fold reduction in the perioperative COVID-19 infection rate when using designated COVID-19 green pathways over the whole study period; however the success of the pathways only became significant in phase 2 of the study, where there was a 13-fold reduction in infection rate. The study shows a developing success to using green pathways in reducing the risk to patients undergoing foot and ankle surgery.

Structural characteristics of Heparan sulfate required for the binding with the virus processing Enzyme Furin

Furin is one of the nine-member proprotein convertase family. Furin cleaves proteins with polybasic residues, which includes many viral glycoproteins such as SARS-Cov-2 spike protein. The cleavage is required for the activation of the proteins. Currently, the mechanisms that regulate Furin activity remain largely unknown. Here we demonstrated that Furin is a novel heparin/heparan sulfate binding protein by the use of biochemical and genetic assays. The KD is 9.78 nM based on the biolayer interferometry assay. Moreover, we found that sulfation degree, site-specific sulfation (N-sulfation and 3-O-sulfation), and iduronic acid are the major structural determinants for the binding. Furthermore, we found that heparin inhibits the enzymatic activity of Furin when pre-mixes heparin with either Furin or Furin substrate. We also found that the Furin binds with cells of different origin and the binding with the cells of lung origin is the strongest one. These data could advance our understanding of the working mechanism of Furin and will benefit the Furin based drug discovery such as inhibitors targeting the interaction between heparan sulfate and Furin for inhibition of viral infection.

The Incidence and Mortality Impact of Gastrointestinal Bleeding in Hospitalized COVID-19 Patients

Background

Patients requiring hospitalization to critical care units are at a higher risk for gastrointestinal (GI) bleeding. Although severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) infection is predominantly a pulmonary disease, other serious manifestations including thromboembolic phenomenon are reported. Acute respiratory distress syndrome (ARDS) requiring mechanical ventilation, use of steroids and anticoagulation are all known to increase the risk of GI bleeding significantly.

Aim

To study the incidence of GI bleeding and its impact on mortality in patients admitted with SARS-CoV-2.

Methods

We retrospectively reviewed all patients admitted with SARS-CoV-2 from February 1, 2020 to April 15, 2020. We collected data including demographics, comorbid conditions, laboratory parameters, steroid and anticoagulant use. Coffee ground emesis, hematemesis, melena and hematochezia were defined as GI bleeding. All-cause mortality was reviewed for all patients included in the study. The relationship between GI bleeding and mortality was studied using logistic regression.

Results

We had a total of 1206 patients hospitalized with SARS-CoV-2 infection with an all-cause mortality of 34% (n = 411). The overall incidence of GI bleeding was 3.1% (n = 37) with no significant difference between the patients who survived versus died during hospitalization (1.3% vs 1.5%, p = 0.77). Logistic regression analysis did not identify GI bleeding as an independent predictor of mortality. Therapeutic doses of anticoagulation were administered in 13.3% (n = 161) of patients, of which 6.8% (n = 11) developed GI bleeding. Patients were more likely to develop GI bleeding with use of therapeutic doses of anticoagulation (29.7% vs 12.8%, p = 0.003), steroids (37.8% vs 18.5%, p = 0.003) and mechanical ventilation (48.6% vs 30.4%, p = 0.018).

Conclusion

Patients hospitalized with SARS-CoV-2 infection are at risk of gastrointestinal bleeding. Therapeutic doses of anticoagulation, mechanical ventilation and steroid use are significant risk factors for GI bleeding. However, GI bleeding did not significantly alter the mortality rates in SARS-CoV-2-infected patients.