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Landsteiner I, Pinheiro JA, Felix N, Gewehr DM, Cardoso R. Chronic Anticoagulation in Patients with Atrial Fibrillation and COVID-19: A Systematic Review and Meta-Analysis. Arq Bras Cardiol 2024; 121:e20230470. [PMID: 38695466 PMCID: PMC11081175 DOI: 10.36660/abc.20230470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 10/29/2023] [Accepted: 11/14/2023] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) is associated with hypercoagulability. It remains uncertain whether ongoing anticoagulation for atrial fibrillation (AF) in patients who later contract COVID-19 improves clinical outcomes. OBJECTIVES To compare chronic oral anticoagulation with no previous anticoagulation in patients with AF who contracted a COVID-19 infection concerning the outcomes of all-cause mortality, COVID-19 mortality, intensive care unit (ICU) admission, and hospitalization. METHODS We systematically searched PubMed, Embase, and Cochrane Library for eligible studies from inception to December 2022. We included studies comparing COVID-19 outcomes in patients with versus without prior chronic anticoagulation for AF. Risk ratios (RR) with 95% confidence intervals (CI) were pooled with a random-effects model. The level of significance was set at p < 0.05. Quality assessment and risk of bias were performed according to Cochrane recommendations. RESULTS Ten studies comprising 1,177,858 patients with COVID-19 and AF were identified, of whom 893,772 (75.9%) were on prior chronic anticoagulation for AF. In patients with COVID-19, being on chronic anticoagulation for AF significantly reduced all-cause mortality (RR 0.75; 95% CI 0.57 to 0.99; p = 0.048; I2 = 89%) and COVID-19-related mortality (RR 0.76; 95% CI 0.72 to 0.79; p < 0.001; I2 = 0%) when compared with no prior anticoagulation. In contrast, there was no difference between groups regarding hospitalization (RR 1.08; 95% CI 0.82 to 1.41; p = 0.587; I2 = 95%) or ICU admission (RR 0.86; 95% CI 0.68 to 1.09; p = 0.216; I2 = 69%). CONCLUSIONS In this meta-analysis, chronic anticoagulation for patients with AF who contracted COVID-19 was associated with significantly lower rates of all-cause mortality and COVID-19-related mortality as compared with no previous anticoagulation.
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Affiliation(s)
- Isabela Landsteiner
- Massachusetts General HospitalBostonMassachusettsEUAMassachusetts General Hospital, Boston, Massachusetts – EUA
| | - Jonathan A. Pinheiro
- Universidade de FortalezaFortalezaCEBrasilUniversidade de Fortaleza, Fortaleza, CE – Brasil
| | - Nicole Felix
- Universidade Federal de Campina GrandeCampina GrandePBBrasilUniversidade Federal de Campina Grande, Campina Grande, PB – Brasil
| | - Douglas Mesadri Gewehr
- Instituto do Coração de CuritibaCuritibaPRBrasilInstituto do Coração de Curitiba, Curitiba, PR, Brasil
| | - Rhanderson Cardoso
- Brigham and Women's Hospital and Harvard Medical School BostonBostonMassachusettsEUABrigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts – EUA
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2
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Chen X, Zhang S, Liu H, Zhang Q, Chen J, Zheng Q, Guo N, Cai Y, Luo Q, Xu Q, Yang S, Chen X. Effect of anticoagulation on the incidence of venous thromboembolism, major bleeding, and mortality among hospitalized COVID-19 patients: an updated meta-analysis. Front Cardiovasc Med 2024; 11:1381408. [PMID: 38646150 PMCID: PMC11026614 DOI: 10.3389/fcvm.2024.1381408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 03/26/2024] [Indexed: 04/23/2024] Open
Abstract
Objective Anticoagulation is crucial for patients hospitalized with coronavirus disease 2019 (COVID-19) due to the high risk of venous thromboembolism (VTE). However, the optimal anticoagulation regimen needs further exploration. Therefore, we evaluated the efficacy and safety of diverse anticoagulation dosage dosages for COVID-19. Methods An updated meta-analysis was performed to assess the effect of thromboprophylaxis (standard, intermediate, and therapeutic dose) on the incidence of VTE, mortality and major bleeding among COVID-19 patients. Literature was searched via PubMed, EMBASE, Web of Science, and China National Knowledge Infrastructure (CNKI) database. The odds ratio (OR) and 95% confidence interval (CI) were calculated for effect estimates. Results Nineteen studies involving 25,289 participants without VTE history were included. The mean age of patients was 59.3 years old. About 50.96% were admitted to the intensive care unit. In the pooled analysis, both therapeutic-dose and intermediate-dose anticoagulation did not have a significant advantage in reducing VTE risk over standard dosage (OR = 1.09, 95% CI: 0.58-2.02, and OR = 0.89, 95% CI: 0.70-1.12, respectively). Similarly, all-cause mortality was not further decreased in either therapeutic-dose group (OR = 1.12, 95% CI: 0.75-1.67) or intermediate-dose group (OR = 1.34, 95% CI: 0.83-2.17). While the major bleeding risk was significantly elevated in the therapeutic-dose group (OR = 2.59, 95%CI: 1.87-3.57) as compared with the standard-dose regimen. Compared with intermediate dosage, therapeutic anticoagulation did not reduce consequent VTE risk (OR = 0.85, 95% CI: 0.52-1.38) and all-cause mortality (OR = 0.84, 95% CI: 0.60-1.17), but significantly increased major bleeding rate (OR = 2.42, 95% CI: 1.58-3.70). In subgroup analysis of patients older than 65 years, therapeutic anticoagulation significantly lowered the incidence of VTE in comparation comparison with standard thromboprophylaxis, however, at the cost of elevated risk of major bleeding. Conclusion Our results indicated that for most hospitalized patients with COVID-19, standard-dose prophylactic anticoagulation might be the optimal choice. For elderly patients at low risk of bleeding, therapeutic-dose anticoagulation could further reduce VTE risk and should be considered especially when there were other strong risk factors of VTE during hospital stay. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO, identifier, CRD42023388429.
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Affiliation(s)
- Xinwang Chen
- Department of Pulmonary and Critical Care Medicine, Fujian Medical University Union Hospital, Fuzhou, China
| | - Suyun Zhang
- Department of Internal Medicine, Fujian Medical University Union Hospital, Fuzhou, China
| | - Haiyu Liu
- Department of Pulmonary and Critical Care Medicine, Fujian Medical University Union Hospital, Fuzhou, China
| | - Qianyuan Zhang
- Department of General Medicine, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jinghan Chen
- Department of Oncology Medicine, Fujian Medical University Union Hospital, Fuzhou, China
| | - Qixian Zheng
- Department of Pulmonary and Critical Care Medicine, Fujian Medical University Union Hospital, Fuzhou, China
| | - Ningjing Guo
- Department of Oncology Medicine, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yuanyuan Cai
- Department of General Medicine, Fujian Medical University Union Hospital, Fuzhou, China
| | - Qiong Luo
- Department of Oncology Medicine, Fujian Medical University Union Hospital, Fuzhou, China
| | - Qian Xu
- Department of Oncology Medicine, Fujian Medical University Union Hospital, Fuzhou, China
| | - Sheng Yang
- Department of Oncology Medicine, Fujian Medical University Union Hospital, Fuzhou, China
- Fujian Key Laboratory of Translational Research in Cancer and Neurodegenerative Diseases, Fuzhou, China
| | - Xiangqi Chen
- Department of Pulmonary and Critical Care Medicine, Fujian Medical University Union Hospital, Fuzhou, China
- Fujian Key Laboratory of Translational Research in Cancer and Neurodegenerative Diseases, Fuzhou, China
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3
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Velásquez PA, Hernandez JC, Galeano E, Hincapié-García J, Rugeles MT, Zapata-Builes W. Effectiveness of Drug Repurposing and Natural Products Against SARS-CoV-2: A Comprehensive Review. Clin Pharmacol 2024; 16:1-25. [PMID: 38197085 PMCID: PMC10773251 DOI: 10.2147/cpaa.s429064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 11/14/2023] [Indexed: 01/11/2024] Open
Abstract
The Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is a betacoronavirus responsible for the COVID-19 pandemic, causing respiratory disorders, and even death in some individuals, if not appropriately treated in time. To face the pandemic, preventive measures have been taken against contagions and the application of vaccines to prevent severe disease and death cases. For the COVID-19 treatment, antiviral, antiparasitic, anticoagulant and other drugs have been reused due to limited specific medicaments for the disease. Drug repurposing is an emerging strategy with therapies that have already tested safe in humans. One promising alternative for systematic experimental screening of a vast pool of compounds is computational drug repurposing (in silico assay). Using these tools, new uses for approved drugs such as chloroquine, hydroxychloroquine, ivermectin, zidovudine, ribavirin, lamivudine, remdesivir, lopinavir and tenofovir/emtricitabine have been conducted, showing effectiveness in vitro and in silico against SARS-CoV-2 and some of these, also in clinical trials. Additionally, therapeutic options have been sought in natural products (terpenoids, alkaloids, saponins and phenolics) with promising in vitro and in silico results for use in COVID-19 disease. Among these, the most studied are resveratrol, quercetin, hesperidin, curcumin, myricetin and betulinic acid, which were proposed as SARS-CoV-2 inhibitors. Among the drugs reused to control the SARS-CoV2, better results have been observed for remdesivir in hospitalized patients and outpatients. Regarding natural products, resveratrol, curcumin, and quercetin have demonstrated in vitro antiviral activity against SARS-CoV-2 and in vivo, a nebulized formulation has demonstrated to alleviate the respiratory symptoms of COVID-19. This review shows the evidence of drug repurposing efficacy and the potential use of natural products as a treatment for COVID-19. For this, a search was carried out in PubMed, SciELO and ScienceDirect databases for articles about drugs approved or under study and natural compounds recognized for their antiviral activity against SARS-CoV-2.
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Affiliation(s)
- Paula Andrea Velásquez
- Grupo Infettare, Facultad de Medicina, Universidad Cooperativa de Colombia, Medellín, Colombia
- Grupo Inmunovirología, Facultad de Medicina, Universidad de Antioquia UdeA, Medellín, Colombia
| | - Juan C Hernandez
- Grupo Infettare, Facultad de Medicina, Universidad Cooperativa de Colombia, Medellín, Colombia
- Grupo Inmunovirología, Facultad de Medicina, Universidad de Antioquia UdeA, Medellín, Colombia
| | - Elkin Galeano
- Grupo Productos Naturales Marinos, Departamento de Farmacia, Facultad de Ciencias Farmacéuticas y Alimentarias, Universidad de Antioquia UdeA, Medellín, Colombia
| | - Jaime Hincapié-García
- Grupo de investigación, Promoción y prevención farmacéutica, Facultad de Ciencias Farmacéuticas y Alimentarias, Universidad de Antioquia UdeA, Medellín, Colombia
| | - María Teresa Rugeles
- Grupo Inmunovirología, Facultad de Medicina, Universidad de Antioquia UdeA, Medellín, Colombia
| | - Wildeman Zapata-Builes
- Grupo Infettare, Facultad de Medicina, Universidad Cooperativa de Colombia, Medellín, Colombia
- Grupo Inmunovirología, Facultad de Medicina, Universidad de Antioquia UdeA, Medellín, Colombia
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Kafan S, Fattahi MR, Akhbari Shojaei M, Hossein Nezhad A, Imankhan M, Jahansouz D, Montazeri M, Hadadi A, Fattahi S, Iranmehr A, Pazoki M, Rahimzadeh H. Comparing Therapeutic versus Prophylactic Enoxaparin Therapy in Severe COVID-19 Patients: A Randomized Clinical Trial. Med J Islam Repub Iran 2023; 37:129. [PMID: 38318404 PMCID: PMC10843207 DOI: 10.47176/mjiri.37.129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Indexed: 02/07/2024] Open
Abstract
Background Coronavirus disease 2019 (COVID-19) has been associated with a hypercoagulopathy state; however, the efficacy of different anticoagulant regimens in preventing thrombotic events is not clear. We aimed to compare therapeutic versus prophylactic enoxaparin therapy in severe COVID-19 patients. Methods In this single-center, open-label, randomized controlled trial, adult patients with severe COVID-19 presentations and an increased D-dimer level of more than 4 times the normal upper limit were randomly assigned to receive either prophylactic or therapeutic dose of enoxaparin. All patients were observed for at least 4 months regarding the overall survival as the primary outcome. Hospitalization duration, the need for intensive care unit (ICU) admission, the need for mechanical ventilation, and major adverse events (MAEs) were also analyzed as the secondary outcomes. Survival analysis was done via Kaplan-Meier curves and the Log-rank test. Cox regression was used, adjusting for baseline variables. Results Overall, 237 patients (152 men and 85 women) were randomized to either arm (121 to prophylactic and 116 to therapeutic groups). The mortality rate was 27 (22.3%) and 52 (44.8%) in prophylactic and therapeutic arms, respectively. Prophylactic enoxaparin was associated with better survival in the log-rank test (P < 0.001; HR, 0.42). Additionally, a significantly lower rate of ICU admission, a lower rate of MAEs, and shorter hospitalization were observed in the prophylactic arm (P < 0.001, P = 0.009, and P = 0.028, respectively). Conclusion The results of the current study were in favor of anticoagulant treatment with prophylactic doses of enoxaparin. Still, due to the limitations of this paper, we suggest that these findings be treated cautiously.
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Affiliation(s)
- Samira Kafan
- Department of Internal Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Fattahi
- Department of Internal Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Student Research Committee, School of Advanced Technologies in Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahsa Akhbari Shojaei
- Department of Internal Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Aida Hossein Nezhad
- School of Medicine, Islamic Azad University, Tonekabon Medical Branch, Tonekabon, Iran
| | - Mahshid Imankhan
- School of Medicine, Islamic Azad University, Tehran Medical Branch, Tehran, Iran
| | - Davoud Jahansouz
- Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Mahnaz Montazeri
- Department of Infectious Disease, Tehran University of Medical Sciences, Tehran, Iran
| | - Azar Hadadi
- Department of Internal Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Department of Infectious Disease, Tehran University of Medical Sciences, Tehran, Iran
| | - Sara Fattahi
- Department of Clinical Psychology, Tehran University of Medical Sciences, Tehran, Iran
| | - Arad Iranmehr
- Neurosurgery Department, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Marzieh Pazoki
- Department of Internal Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Hormat Rahimzadeh
- Department of Nephrology Disease, Tehran University of Medical Sciences, Tehran, Iran
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5
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Tang H, Yan Y. A case report of spontaneous pectoral hematoma in a male with background antiplatelet therapy after severe COVID-19 infection. Thromb J 2023; 21:93. [PMID: 37679755 PMCID: PMC10485993 DOI: 10.1186/s12959-023-00539-7] [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: 06/26/2023] [Accepted: 09/04/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND Spontaneous muscle hematoma is a rare complication in hospitalized patients with COVID-19. We present a case of spontaneous pectoral hematoma occurring after COVID-19 infection and anticoagulation therapy. CASE PRESENTATION A 69-year-old male presented to the hospital with a two-week history of shortness of breath and a one-week history of high fever. Despite testing positive for COVID-19, the patient's symptoms did not improve with two doses of ritonavir-boosted nirmatrelvir (Paxlovid). A chest CT scan revealed pulmonary infection and SpO2 tested between 80% and 85% at rest in local hospital. The patient transferred to our intensive care unit, then received multiple treatments, including high flow nasal oxygen (HFNO), antibiotics, methylprednisolone, IL-6 receptor antagonist monoclonal antibody (tocilizumab), and an increased D-Dimer level leaded to intermediate dose of anticoagulation therapy. However, on the 10th day of hospitalization, the patient developed a hematoma in the left pectoralis major muscle. This was accompanied by hemorrhagic shock, necessitating the administration of norepinephrine, fluid resuscitation, and a blood transfusion. Arterial embolization was performed to manage the bleeding, resulting in stabilization of the patient's condition. Following discharge, the patient experienced an uneventful recovery over a period of six months. CONCLUSIONS Severe COVID-19 patients undergoing routine therapeutic anticoagulation may experience fatal bleeding complications. The ideal dosage of anticoagulants for these patients remains uncertain, especially in the patient with a background of anticoagulation or dual antiplatelet therapy. We present a case of spontaneous muscle hematoma accompanied by hemorrhagic shock. The notable reduction in hemoglobin levels indicated significant bleeding, which was confirmed through contrast angiography and cured by arterial embolization. This case underscores the importance of additional research to determine the appropriate utilization of therapeutic anticoagulation in severe COVID-19 patients already undergoing antithrombotic therapy.
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Affiliation(s)
- Hao Tang
- Center for Coronary Artery Disease, Division of Cardiology, Beijing Anzhen Hospital, Capital Medical University, 2 Anzhen Road, Chaoyang District, 100029, Beijing, China
- National Clinical Research Center of Cardiovascular Diseases, Beijing, China
- Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China
| | - Yan Yan
- Center for Coronary Artery Disease, Division of Cardiology, Beijing Anzhen Hospital, Capital Medical University, 2 Anzhen Road, Chaoyang District, 100029, Beijing, China.
- National Clinical Research Center of Cardiovascular Diseases, Beijing, China.
- Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China.
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6
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Ram MD, Umer M, Trada IJ, Khan SJ, Imran L, Rehan T, Hassan W, Zafar F, Razak S, Laeeq T, Aijaz P, Majid Z. The Role of Anticoagulants and Antiplatelets in Reducing Mortality in COVID-19 Patients: A Systematic Review and Meta-Analysis of Studies Reporting Adjusted Data. Cureus 2023; 15:e45749. [PMID: 37872904 PMCID: PMC10590480 DOI: 10.7759/cureus.45749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2023] [Indexed: 10/25/2023] Open
Abstract
The coronavirus disease 2019 (COVID-19) is associated with prolonged prothrombin time (PT), active partial thromboplastin time (aPTT), and increased D-dimer levels. Therefore, we aim to investigate if anticoagulants (AC) and antiplatelet (AP) therapy play a role in mitigating COVID-19 and its associated thrombosis along with its effect on the mortality rate, the need for mechanical ventilation, and the risk of hospital admission. Electronic databases were searched from their inception to July 19, 2022. The studies were divided into two groups: Group A (any dose of AC/AP versus no AC/AP) and Group B (therapeutic dose of AC (tAC)/AP versus prophylactic dose of AC (pAC)/AP). Review Manager (RevMan) version 5.4.1 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark) was used for all statistical analyses. Adjusted data ratios were extracted from all included studies and pooled using the random effects model. A total of 33 studies were taken for the analysis of two groups (Group A: 285,065 COVID-19-positive patients, Group B: 2,421 COVID-19-positive patients). Overall analysis in Group A showed that the AC/AP group had a low risk of mortality in COVID-19 patients compared to the control group (risk ratio (RR): 0.77, 95% confidence interval (CI): 0.69-0.86). There was no significant difference in the need for mechanical ventilation (RR: 0.80, 95% CI: 0.60-1.08) and hospital admission (RR: 1.12, 95% CI: 0.78-1.59) between the AC/AP and no AC/AP group. Alongside, in Group B, tAC/AP did not demonstrate a significant decrease in mortality as compared to pAC/AP (RR: 0.62, 95% CI: 0.37-1.06). Treatment with AC and AP drugs can significantly decrease the mortality rate in COVID-19-infected patients, while AC also significantly reduces the need for mechanical ventilation.
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Affiliation(s)
| | - Muhammed Umer
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | | | | | - Laiba Imran
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Tayyaba Rehan
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Warda Hassan
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Faiqa Zafar
- General Surgery, New York Institute of Osteopathic Medicine, New York, USA
| | - Sufyan Razak
- Oncology, Johns Hopkins University School of Medicine, Baltimore, USA
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Tooba Laeeq
- Internal Medicine, Kirk Kerkorian School of Medicine at University of Nevada, Las Vegas (UNLV), Las Vegas, USA
| | - Parisa Aijaz
- Internal Medicine, Charleston Area Medical Center, Charleston, USA
| | - Zainab Majid
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
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7
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Bagheri B, Alipour A, Yousefi M, Jalalian R, Moghimi M, Mohammadi M, Hassanpour N, Iranian M. Prevalence of Thromboembolic Events, Including Venous Thromboembolism and Arterial Thrombosis, in Patients with COVID-19: A Systematic Review with Meta-Analysis. J Tehran Heart Cent 2023; 18:154-169. [PMID: 38146412 PMCID: PMC10748660 DOI: 10.18502/jthc.v18i3.14110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 06/23/2023] [Indexed: 12/27/2023] Open
Abstract
Background Many studies have evaluated thromboembolic events in COVID-19 patients, and most of them have reported a high estimation of the prevalence of such events. The present study sought to evaluate the prevalence of thromboembolic events in patients with COVID-19. Methods This study is a systematic review with meta-analysis that investigated thromboembolic events in patients with COVID-19 from the start of the pandemic to August 31, 2021. The 4 main databases for collecting articles were Medline, Scopus, Google Scholar, and Web of Science. Deep vein thrombosis, pulmonary embolism, arterial thrombosis, and the overall rate of thromboembolic events were considered primary outcomes. Results In a total of 63 studies (104 920 patients with COVID-19), the overall thrombosis rate was 21% (95% CI, 18% to 25%), the rate of deep vein thrombosis was 20% (95% Cl, 16% to 25%), the rate of pulmonary embolism was 8% (95% Cl, 6% to 10%), and the rate of arterial thrombosis was 5% (95% Cl, 3% to 7%). The prevalence of all primary outcomes in critically ill patients admitted to the intensive care unit (ICU) was significantly higher (P<0.05). In older patients, the prevalence of overall thrombosis, pulmonary embolism, or deep vein thrombosis was significantly higher (P<0.05). Conclusion This study showed that COVID-19 increases the risk of thromboembolic events, especially in elderly and critically ill patients admitted to the ICU. Therefore, more strategies are needed to prevent thromboembolic events in patients with COVID-19, especially in ICU-admitted and elderly patients.
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Affiliation(s)
- Babak Bagheri
- Department of Cardiology, Faculty of Medicine, Cardiovascular Research Center, Mazandaran University of Medical Sciences, Sari, Iran
| | - Abbas Alipour
- Community Medicine Department, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mojtaba Yousefi
- Department of Cardiology, Faculty of Medicine, Cardiovascular Research Center, Mazandaran University of Medical Sciences, Sari, Iran
| | - Rozita Jalalian
- Department of Cardiology, Faculty of Medicine, Cardiovascular Research Center, Mazandaran University of Medical Sciences, Sari, Iran
| | - Minoo Moghimi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mahsa Mohammadi
- Rajaie Cardiovascular Medical and Research Center, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Negar Hassanpour
- Rajaie Cardiovascular Medical and Research Center, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Iranian
- Rajaie Cardiovascular Medical and Research Center, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
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8
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Rama-Maceiras P, Sanduende Y, Taboada M, Casero M, Leal S, Pita-Romero R, Fernández R, López E, López JA, Pita E, Tubío A, Rodríguez A, Varela M, Campaña D, Delgado C, Lombardía M, Villar E, Blanco P, Martínez A, Sarmiento A, Díaz P, Ojea M, Rodríguez Á, Mouriz L, Cid M, Ramos L, Seoane-Pillado T. Critical patients COVID-19 has changed the management and outcomes in the ICU after 1 year of the pandemic? A multicenter, prospective, observational study. ENFERMEDADES INFECCIOSAS Y MICROBIOLOGIA CLINICA (ENGLISH ED.) 2023; 41:70-78. [PMID: 35907774 PMCID: PMC9903149 DOI: 10.1016/j.eimce.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/20/2021] [Accepted: 06/27/2021] [Indexed: 04/14/2023]
Abstract
OBJECTIVE To compare the clinical characteristics, treatments, and evolution of critical patients with COVID-19 pneumonia treated in Intensive Care Units (ICU) after one year of pandemic. METHODOLOGY Multicenter, prospective study, which included critical COVID-19 patients in 9 ICUs in northwestern Spain. The clinical characteristics, treatments, and evolution of patients admitted to the ICU during the months of March-April 2020 (period 1) were compared with patients admitted in January-February 2021 (period 2). RESULTS 337 patients were included (98 in period 1 and 239 in period 2). In period 2, fewer patients required invasive mechanical ventilation (IMV) (65% vs 84%, p < 0.001), using high-flow nasal cannulas (CNAF) more frequently (70% vs 7%, p < 0.001), ventilation non-invasive mechanical (NIMV) (40% vs 14%, p < 0.001), corticosteroids (100% vs 96%, p = 0.007) and prone position in both awake (42% vs 28%, p = 0.012), and intubated patients (67% vs 54%, p = 0.034). The days of IMV, ICU stay and hospital stay were lower in period 2. Mortality was similar in the two periods studied (16% vs 17%). CONCLUSIONS After 1 year of pandemic, we observed that in patients admitted to the ICU, CNAF, NIMV, use of the prone position, and corticosteroids have been used more frequently, reducing the number of patients in IMV, and the length of stay in the ICU and hospital stay. Mortality was similar in the two study periods.
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Affiliation(s)
- Pablo Rama-Maceiras
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de A Coruña (CHUAC), A Coruña, Spain
| | - Yolanda Sanduende
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Pontevedra (CHUP), Pontevedra, Spain
| | - Manuel Taboada
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Santiago, Instituto de Investigación Sanitaria de Santiago (IDIS), Santiago de Compostela, A Coruña, Spain.
| | - María Casero
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Ferrol (CHUF), Ferrol, A Coruña, Spain
| | - Sonsoles Leal
- Servicio de Anestesiología y Reanimación, Hospital POVISA, Vigo, Pontevedra, Spain
| | - Rafael Pita-Romero
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Vigo (CHUVI), Vigo, Pontevedra, Spain
| | - Ricardo Fernández
- Servicio de Anestesiología y Reanimación, Hospital Universitario Lucus Augusti (HULA), Lugo, Spain
| | - Eva López
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Ourense (CHUO), Ourense, Spain
| | - José Antonio López
- Servicio de Anestesiología y Reanimación, Hospital da Mariña, Burela, Lugo, Spain
| | - Elvira Pita
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de A Coruña (CHUAC), A Coruña, Spain
| | - Ana Tubío
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Santiago, Instituto de Investigación Sanitaria de Santiago (IDIS), Santiago de Compostela, A Coruña, Spain
| | - Arancha Rodríguez
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Ferrol (CHUF), Ferrol, A Coruña, Spain
| | - Marina Varela
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Pontevedra (CHUP), Pontevedra, Spain
| | - Daniel Campaña
- Servicio de Anestesiología y Reanimación, Hospital POVISA, Vigo, Pontevedra, Spain
| | - Carla Delgado
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Vigo (CHUVI), Vigo, Pontevedra, Spain
| | - Mónica Lombardía
- Servicio de Anestesiología y Reanimación, Hospital Universitario Lucus Augusti (HULA), Lugo, Spain
| | - Eva Villar
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Ourense (CHUO), Ourense, Spain
| | - Pilar Blanco
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de A Coruña (CHUAC), A Coruña, Spain
| | - Adrián Martínez
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Santiago, Instituto de Investigación Sanitaria de Santiago (IDIS), Santiago de Compostela, A Coruña, Spain
| | - Ana Sarmiento
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Ferrol (CHUF), Ferrol, A Coruña, Spain
| | - Pilar Díaz
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Pontevedra (CHUP), Pontevedra, Spain
| | - María Ojea
- Servicio de Anestesiología y Reanimación, Hospital POVISA, Vigo, Pontevedra, Spain
| | - Ángel Rodríguez
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Vigo (CHUVI), Vigo, Pontevedra, Spain
| | - Lorena Mouriz
- Servicio de Anestesiología y Reanimación, Hospital Universitario Lucus Augusti (HULA), Lugo, Spain
| | - Milagros Cid
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Ourense (CHUO), Ourense, Spain
| | - Lorena Ramos
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de A Coruña (CHUAC), A Coruña, Spain
| | - Teresa Seoane-Pillado
- The Preventive Medicine and Public Health Sciences, University of A Coruña, A Coruña, Spain
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9
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Rama-Maceiras P, Sanduende Y, Taboada M, Casero M, Leal S, Pita-Romero R, Fernández R, López E, López JA, Pita E, Tubío A, Rodríguez A, Varela M, Campaña D, Delgado C, Lombardía M, Villar E, Blanco P, Martínez A, Sarmiento A, Díaz P, Ojea M, Rodríguez Á, Mouriz L, Cid M, Ramos L, Seoane-Pillado T. [Critical patients COVID-19 has changed the management and outcomes in the ICU after 1 year of the pandemic? A multicenter, prospective, observational study]. Enferm Infecc Microbiol Clin 2023; 41:70-78. [PMID: 34305229 PMCID: PMC8286862 DOI: 10.1016/j.eimc.2021.06.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 06/27/2021] [Indexed: 02/07/2023]
Abstract
Objective To compare the clinical characteristics, treatments, and evolution of critical patients with COVID-19 pneumonia treated in intensive care units (ICU) after one year of pandemic. Methodology Multicenter, prospective study, which included critical COVID-19 patients in 9 ICUs in northwestern Spain. The clinical characteristics, treatments, and evolution of patients admitted to the ICU during the months of March-April 2020 (period 1) were compared with patients admitted in January-February 2021 (period 2). Results 337 patients were included (98 in period 1 and 239 in period 2). In period 2, fewer patients required invasive mechanical ventilation (IMV) (65% vs. 84%, P < .001), using high-flow nasal cannulas (CNAF) more frequently (70% vs. 7%, P < .001), ventilation non-invasive mechanical (NIMV) (40% vs. 14%, P < .001), corticosteroids (100% vs. 96%, P = .007) and prone position in both awake (42% vs. 28%, P = .012), and intubated patients (67% vs. 54%, P = .034). The days of IMV, ICU stay and hospital stay were lower in period 2. Mortality was similar in the two periods studied (16% vs. 17%). Conclusions After one year of pandemic, we observed that in patients admitted to the ICU, CNAF, NIMV, use of the prone position, and corticosteroids have been used more frequently, reducing the number of patients in IMV, and the length of stay in the ICU and hospital stay. Mortality was similar in the two study periods.
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Affiliation(s)
- Pablo Rama-Maceiras
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de A Coruña (CHUAC), A Coruña, España
| | - Yolanda Sanduende
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Pontevedra (CHUP), Pontevedra, España
| | - Manuel Taboada
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Santiago, Instituto de Investigación Sanitaria de Santiago (IDIS), Santiago de Compostela, A Coruña, España
| | - María Casero
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Ferrol (CHUF), Ferrol, A Coruña, España
| | - Sonsoles Leal
- Servicio de Anestesiología y Reanimación, Hospital POVISA, Vigo, Pontevedra, España
| | - Rafael Pita-Romero
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Vigo (CHUVI), Vigo, Pontevedra, España
| | - Ricardo Fernández
- Servicio de Anestesiología y Reanimación, Hospital Universitario Lucus Augusti (HULA), Lugo, España
| | - Eva López
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Ourense (CHUO), Ourense, España
| | - José Antonio López
- Servicio de Anestesiología y Reanimación, Hospital da Mariña, Burela, Lugo, España
| | - Elvira Pita
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de A Coruña (CHUAC), A Coruña, España
| | - Ana Tubío
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Santiago, Instituto de Investigación Sanitaria de Santiago (IDIS), Santiago de Compostela, A Coruña, España
| | - Arancha Rodríguez
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Ferrol (CHUF), Ferrol, A Coruña, España
| | - Marina Varela
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Pontevedra (CHUP), Pontevedra, España
| | - Daniel Campaña
- Servicio de Anestesiología y Reanimación, Hospital POVISA, Vigo, Pontevedra, España
| | - Carla Delgado
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Vigo (CHUVI), Vigo, Pontevedra, España
| | - Mónica Lombardía
- Servicio de Anestesiología y Reanimación, Hospital Universitario Lucus Augusti (HULA), Lugo, España
| | - Eva Villar
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Ourense (CHUO), Ourense, España
| | - Pilar Blanco
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de A Coruña (CHUAC), A Coruña, España
| | - Adrián Martínez
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Santiago, Instituto de Investigación Sanitaria de Santiago (IDIS), Santiago de Compostela, A Coruña, España
| | - Ana Sarmiento
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Ferrol (CHUF), Ferrol, A Coruña, España
| | - Pilar Díaz
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Pontevedra (CHUP), Pontevedra, España
| | - María Ojea
- Servicio de Anestesiología y Reanimación, Hospital POVISA, Vigo, Pontevedra, España
| | - Ángel Rodríguez
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Vigo (CHUVI), Vigo, Pontevedra, España
| | - Lorena Mouriz
- Servicio de Anestesiología y Reanimación, Hospital Universitario Lucus Augusti (HULA), Lugo, España
| | - Milagros Cid
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Ourense (CHUO), Ourense, España
| | - Lorena Ramos
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de A Coruña (CHUAC), A Coruña, España
| | - Teresa Seoane-Pillado
- The Preventive Medicine and Public Health Sciences, University of A Coruña, A Coruña, España
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10
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Gabara C, Solarat B, Castro P, Fernández S, Badia JR, Toapanta D, Schulman S, Reverter JC, Soriano A, Moisés J, Aibar J. Anticoagulation strategies and risk of bleeding events in critically ill COVID-19 patients. Med Intensiva 2023; 47:1-8. [PMID: 34345092 PMCID: PMC8321771 DOI: 10.1016/j.medin.2021.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/30/2021] [Accepted: 07/13/2021] [Indexed: 01/04/2023]
Abstract
Objective To evaluate the rate of thrombosis, bleeding and mortality comparing anticoagulant doses in critically ill COVID-19 patients. Design Retrospective observational and analytical cohort study. Setting COVID-19 patients admitted to the intensive care unit of a tertiary hospital between March and April 2020. Patients 201 critically ill COVID-19 patients were included. Patients were categorized into three groups according to the highest anticoagulant dose received during hospitalization: prophylactic, intermediate and therapeutic. Interventions The incidence of venous thromboembolism (VTE), bleeding and mortality was compared between groups. We performed two logistic multivariable regressions to test the association between VTE and bleeding and the anticoagulant regimen. Main variables of interest VTE, bleeding and mortality. Results 78 patients received prophylactic, 94 intermediate and 29 therapeutic doses. No differences in VTE and mortality were found, while bleeding events were more frequent in the therapeutic (31%) and intermediate (15%) dose group than in the prophylactic group (5%) (p < 0.001 and p < 0.05 respectively). The anticoagulant dose was the strongest determinant for bleeding (odds ratio 2.4, 95% confidence interval 1.26-4.58, p = 0.008) but had no impact on VTE. Conclusions Intermediate and therapeutic doses appear to have a higher risk of bleeding without a decrease of VTE events and mortality in critically ill COVID-19 patients.
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Affiliation(s)
- C Gabara
- Internal Medicine Department, Hospital Clínic, IDIBAPS - University of Barcelona, Spain
| | - B Solarat
- Pneumology Department, Hospital Clínic, IDIBAPS - University of Barcelona, Spain
| | - P Castro
- Internal Medicine Department, Hospital Clínic, IDIBAPS - University of Barcelona, Spain
- Medical Intensive Care Unit, Hospital Clínic, IDIBAPS - University of Barcelona, Spain
| | - S Fernández
- Internal Medicine Department, Hospital Clínic, IDIBAPS - University of Barcelona, Spain
- Medical Intensive Care Unit, Hospital Clínic, IDIBAPS - University of Barcelona, Spain
| | - J R Badia
- Pneumology Department, Hospital Clínic, IDIBAPS - University of Barcelona, Spain
| | - D Toapanta
- Liver ICU, Hospital Clínic, IDIBAPS - University of Barcelona, Spain
| | - S Schulman
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
- Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - J C Reverter
- Hematology Department, Hospital Clínic, IDIBAPS - University of Barcelona, Spain
| | - A Soriano
- Infectious Disease Department, Hospital Clínic, IDIBAPS - University of Barcelona, Spain
| | - J Moisés
- Pneumology Department, Hospital Clínic, IDIBAPS - University of Barcelona, Spain
| | - J Aibar
- Internal Medicine Department, Hospital Clínic, IDIBAPS - University of Barcelona, Spain
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11
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Vedovati MC, Graziani M, Agnelli G, Becattini C. Efficacy and safety of two heparin regimens for prevention of venous thromboembolism in hospitalized patients with COVID-19: a meta-analysis. Intern Emerg Med 2022; 18:863-877. [PMID: 36580269 PMCID: PMC9798367 DOI: 10.1007/s11739-022-03159-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 11/20/2022] [Indexed: 12/30/2022]
Abstract
Venous thromboembolism (VTE) is common in patients with coronavirus disease-2019 (COVID-19). The optimal heparin regimen remains unknown and should balance thromboembolic and bleeding risks. The aim of this study was to evaluate the efficacy and safety of standard or higher heparin regimens for the prevention of VTE in patients hospitalized due to COVID-19. We performed a systematic literature search; studies reporting on hospitalized patients with COVID-19 who received standard heparin prophylaxis vs. high (intermediate or therapeutic) heparin regimens were included if outcome events were reported by treatment group and more than 10 patients were included. Primary study outcome was in-hospital VTE. Secondary study outcomes were major bleeding (MB), all-cause death, fatal bleeding and fatal pulmonary embolism. Overall, 33 studies (11,387 patients) were included. Venous thromboembolic events occurred in 5.2% and in 8.2% of patients who received heparin prophylaxis with at high-dose or standard-dose, respectively (RR 0.71, 95% CI 0.55-0.90, I2 48.8%). MB was significantly higher in patients who received high- compared to the standard-dose (4.2% vs 2.2%, RR 1.94, 95% CI 1.47-2.56, I2 18.1%). Sub-analyses showed a slight benefit associated with high-dose heparin in patients admitted to non-intensive care unit (ICU) but not in those to ICU. No significant differences were observed for mortality outcomes. Heparin prophylaxis at high-dose reduces the risk of VTE, but increased the risk of MB compared to the standard-dose. No clinical benefit for heparin high-dose was observed for ICU setting, but its role in the non-ICU deserves further evaluation. PROSPERO registration number: CRD42021252550.
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Affiliation(s)
- Maria Cristina Vedovati
- grid.9027.c0000 0004 1757 3630Internal, Vascular and Emergency Medicine–Stroke Unit, University of Perugia, Via G. Dottori, Perugia, Italy
| | - Mara Graziani
- grid.9027.c0000 0004 1757 3630Internal, Vascular and Emergency Medicine–Stroke Unit, University of Perugia, Via G. Dottori, Perugia, Italy
| | - Giancarlo Agnelli
- grid.9027.c0000 0004 1757 3630Internal, Vascular and Emergency Medicine–Stroke Unit, University of Perugia, Via G. Dottori, Perugia, Italy
| | - Cecilia Becattini
- grid.9027.c0000 0004 1757 3630Internal, Vascular and Emergency Medicine–Stroke Unit, University of Perugia, Via G. Dottori, Perugia, Italy
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12
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Vio R, Giordani AS, Stefil M, Alturki A, Russo V, China P, Gasperetti A, Schiavone M, Čulić V, Biondi-Zoccai G, Themistoclakis S, Lip GY, Proietti R. Therapeutic vs. prophylactic anticoagulation in COVID-19 patients: a systematic review and meta-analysis of real-world studies. Minerva Cardiol Angiol 2022; 70:652-662. [PMID: 36305780 DOI: 10.23736/s2724-5683.22.06230-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Coagulopathy, in the form of either venous or arterial thromboembolism, is one of the most severe sequelae of coronavirus disease (COVID-19) and has been associated with poorer outcomes. However, the role of therapeutic anticoagulation (tAC) or prophylactic anticoagulation (pAC) in COVID-19 patients has not been definitely established. Therefore, the aim of this systematic review and meta-analysis was to gather all the available real-world data in the field and to provide a reliable effect size of the effect on mortality of tAC compared to pAC in COVID-19 patients. EVIDENCE ACQUISITION Real-world studies (RWS) were identified by searching electronic databases from inception to 31st October, 2021. Randomized controlled trials were excluded. Mortality and bleedings were considered as primary and secondary outcomes, respectively. EVIDENCE SYNTHESIS 10 RWS and 5541 patients were included in the analysis. Overall, tAC was associated with lower mortality (HR=0.62, 95% CI: 0.54-0.71). There was asymmetry at the funnel plot suggesting publication bias, that was not confirmed at the Egger test (P=0.07). For the secondary endpoint, there was a non-statistically significant tendency for more bleedings in patients treated with tAC compared to pAC (RR=1.75, 95% CI: 0.81-3.81). CONCLUSIONS Our meta-analysis, based on RWS and adjusted estimates of risk, suggests a survival benefit of tAC over pAC in COVID-19 patients in the real world.
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Affiliation(s)
- Riccardo Vio
- Department of Cardiothoracic, Vascular Medicine and Intensive Care, Dell'Angelo Hospital, Mestre, Venice, Italy -
| | - Andrea S Giordani
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Maria Stefil
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Ahmed Alturki
- Division of Cardiology, McGill University Health Center, Montreal, Canada
| | - Vincenzo Russo
- Department of Medical Translational Sciences, Monaldi Hospital, Luigi Vanvitelli University of Campania, Naples, Italy
| | - Paolo China
- Department of Cardiothoracic, Vascular Medicine and Intensive Care, Dell'Angelo Hospital, Mestre, Venice, Italy
| | - Alessio Gasperetti
- Unit of Cardiology, ASST Fatebenefratelli Sacco-Luigi Sacco University Hospital, Milan, Italy
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Marco Schiavone
- Unit of Cardiology, ASST Fatebenefratelli Sacco-Luigi Sacco University Hospital, Milan, Italy
| | - Viktor Čulić
- School of Medicine, University of Split, Split, Croatia
- Department of Cardiology and Angiology, University Hospital Centre Split, Split, Croatia
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy
- Mediterranea Cardiocentro, Naples, Italy
| | - Sakis Themistoclakis
- Department of Cardiothoracic, Vascular Medicine and Intensive Care, Dell'Angelo Hospital, Mestre, Venice, Italy
| | - Gregory Y Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Riccardo Proietti
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK
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13
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Neb H, Talbot SR, Ruskowski K, Brkic D, Sonntagbauer M, Adam EH, von Knethen A, Zacharowski K, Heinicke U. HIGH HEPARANASE LEVEL IN SURVIVORS OF COVID-19 - INDICATOR OF VASCULAR AND PULMONARY RECOVERY? Shock 2022; 58:514-523. [PMID: 36548643 DOI: 10.1097/shk.0000000000002021] [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: 12/24/2022]
Abstract
ABSTRACT Background: Severe progression of coronavirus disease 2019 (COVID-19) causes respiratory failure and critical illness. Recently, COVID-19 has been associated with heparanase (HPSE)-induced endothelial barrier dysfunction and inflammation, so called endothelitis, and therapeutic treatment with heparin or low-molecular-weight heparin (LMWH) targeting HPSE has been postulated. Because, up to this date, clinicians are unable to measure the severity of endothelitis, which can lead to multiorgan failure and concomitant death, we investigated plasma levels of HPSE and heparin-binding protein (HBP) in COVID-19 intensive care patients to render a possible link between endothelitis and these plasma parameters. Therefore, a prospective prolonged cohort study was conducted, including 47 COVID-19 patients from the intensive care unit. Plasma levels of HPSE, and HBP were measured daily by enzyme-linked immunosorbent assay in survivors (n = 35) and nonsurvivors (n = 12) of COVID-19 from admission until discharge or death. All patients were either treated with heparin or LMWH, aiming for an activated partial thromboplastin time of ≥60 seconds or an anti-Xa level of >0.8 IU/mL using enoxaparin, depending on the clinical status of the patient (patients with extracorporeal membrane oxygenation or >0.1 μg/kg/min noradrenaline received heparin, all others enoxaparin). Results: We found significantly higher plasma levels of HPSE and HBP in survivors and nonsurvivors of COVID-19, compared with healthy controls. Still, interestingly, plasma HPSE levels were significantly higher ( P < 0.001) in survivors compared with nonsurvivors of COVID-19. In contrast, plasma HBP levels were significantly reduced ( P < 0.001) in survivors compared with nonsurvivors of COVID-19. Furthermore, when patients received heparin, they had significantly lower HPSE ( P = 2.22 e - 16) and significantly higher HBP ( P = 0.00013) plasma levels as when they received LMWH. Conclusion: Our results demonstrated that patients, who recover from COVID-19-induced vascular and pulmonary damage and were discharged from the intensive care unit, have significantly higher plasma HPSE level than patients who succumb to COVID-19. Therefore, HPSE is not suitable as marker for disease severity in COVID-19 but maybe as marker for patient's recovery. In addition, patients receiving therapeutic heparin treatment displayed significantly lower heparanse plasma level than upon therapeutic treatment with LMWH.
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Affiliation(s)
- Holger Neb
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Steven R Talbot
- Institute for Laboratory Animal Science, Hannover Medical School, Hannover, Germany
| | - Katharina Ruskowski
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Djurdjina Brkic
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Michael Sonntagbauer
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Elisabeth H Adam
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | | | - Kai Zacharowski
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Ulrike Heinicke
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
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14
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Anticoagulation strategies and risk of bleeding events in critically ill COVID-19 patients. Med Intensiva 2022. [PMCID: PMC9617640 DOI: 10.1016/j.medine.2021.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Objective To evaluate the rate of thrombosis, bleeding and mortality comparing anticoagulant doses in critically ill COVID-19 patients. Design Retrospective observational and analytical cohort study. Setting COVID-19 patients admitted to the intensive care unit of a tertiary hospital between March and April 2020. Patients 201 critically ill COVID-19 patients were included. Patients were categorized into three groups according to the highest anticoagulant dose received during hospitalization: prophylactic, intermediate and therapeutic. Interventions The incidence of venous thromboembolism (VTE), bleeding and mortality was compared between groups. We performed two logistic multivariable regressions to test the association between VTE and bleeding and the anticoagulant regimen. Main variables of interest VTE, bleeding and mortality. Results 78 patients received prophylactic, 94 intermediate and 29 therapeutic doses. No differences in VTE and mortality were found, while bleeding events were more frequent in the therapeutic (31%) and intermediate (15%) dose group than in the prophylactic group (5%) (p < 0.001 and p < 0.05 respectively). The anticoagulant dose was the strongest determinant for bleeding (odds ratio 2.4, 95% confidence interval 1.26–4.58, p = 0.008) but had no impact on VTE. Conclusions Intermediate and therapeutic doses appear to have a higher risk of bleeding without a decrease of VTE events and mortality in critically ill COVID-19 patients.
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15
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Hong PY, Huang MH, Hu AK, Lai YT, Zeng HQ, Zhang XB. Use of low molecular weight heparin and hemoglobin fall in COVID-19 patients: A STROBE-compliant study. Medicine (Baltimore) 2022; 101:e30367. [PMID: 36123921 PMCID: PMC9477703 DOI: 10.1097/md.0000000000030367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
In patients with coronavirus disease 2019 (COVID-19), anticoagulation was suggested as a mitigating strategy. However, little research has been conducted on the adverse consequences of anticoagulant medication. This study aimed to investigate the adverse effect of low molecular weight heparin (LMWH) on hemoglobin fall in COVID-19 treatment. The electronic medical records of COVID-19 patients with pneumonia were collected (including clinical characteristics, vaccination status, complete blood count, coagulation profile, inflammatory cytokines, serum biochemical indicators, and computerized tomography imaging score). Whether they received LMWH, patients were divided into the LMWH group and the control group. Count data were represented as frequency distribution, and a 2-tailed test was used to compare the 2 groups. Spearman rank correlation was used to evaluate the interrelation between changes in hemoglobin and LMWH. The confounding factors were excluded by logistic regression analysis. A total of 179 COVID-19 pneumonia patients were enrolled (81 in the LMWH group and 98 in the control group). The change in hemoglobin was -6.0g/L (IQR -10.8 to 1.0) in the LMWH group and -2.0g/L (IQR -7.0 to 4.0) in the control group (P < .001, between-group difference, -5.0 g/L; 95% confidence interval, -7.0 to -3.0, calculated with the use of the Mann-Whitney U test and the Hodges-Lehmann estimate of confidence intervals for pseudo-medians). The results of multivariate regression analysis showed that after adjusting for confounding factors, LMWH use was not associated with a decrease in hemoglobin (P > .05). In nonsevere COVID-19 patients with pneumonia, the preventive use of LMWH did not lower hemoglobin.
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Affiliation(s)
- Ping-Yang Hong
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital of Xiamen University, School of Medicine, Xiamen University; the Third Clinical College of Fujian Medical University, Fujian, China
| | - Mao-Hong Huang
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital of Xiamen University, School of Medicine, Xiamen University; the Third Clinical College of Fujian Medical University, Fujian, China
| | - An-Ke Hu
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital of Xiamen University, School of Medicine, Xiamen University; the Third Clinical College of Fujian Medical University, Fujian, China
| | - Yan-Ting Lai
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital of Xiamen University, School of Medicine, Xiamen University; the Third Clinical College of Fujian Medical University, Fujian, China
| | - Hui-Qing Zeng
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital of Xiamen University, School of Medicine, Xiamen University; the Third Clinical College of Fujian Medical University, Fujian, China
| | - Xiao-Bin Zhang
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital of Xiamen University, School of Medicine, Xiamen University; the Third Clinical College of Fujian Medical University, Fujian, China
- *Correspondence: Xiao-Bin Zhang, No. 201, Hubin Nan Road, Siming District, Xiamen, Fujian Province, China (e-mail: )
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The optimal anticoagulation strategy for COVID-19, prophylactic or therapeutic?: a meta-analysis, trial sequential analysis, and meta-regression of more than 27,000 participants. EMERGENCY AND CRITICAL CARE MEDICINE 2022. [PMID: 37521812 PMCID: PMC9555559 DOI: 10.1097/ec9.0000000000000059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background Anticoagulants are promising regimens for treating coronavirus disease 2019 (COVID-19). However, whether prophylactic or intermediate-to-therapeutic dosage is optimal remains under active discussion. Methods We comprehensively searched PubMed, Embase, Scopus, Web of Science, Cochrane Library, ClinicalTrials, and MedRxiv databases on April 26, 2022. Two independent researchers conducted literature selection and data extraction separately according to predetermined criteria. Notably, this is the first meta-analysis on COVID-19, taking serious consideration regarding the dosage overlap between the 2 comparison groups of prophylactic anticoagulation (PA) and intermediate-to-therapeutic anticoagulation (I-TA). Results We included 11 randomized controlled trials (RCTs) and 36 cohort studies with 27,051 COVID-19 patients. By analyzing all the RCTs, there was no significant difference in mortality between the PA and I-TA groups, which was further confirmed by trial sequential analysis (TSA) (odds ratio [OR]: 0.93; 95% confidence interval [CI]: 0.71–1.22; P = 0.61; TSA adjusted CI: 0.71–1.26). The rate of major bleeding was remarkably higher in the I-TA group than in the PA group, despite adjusting for TSA (OR: 1.73; 95% CI: 1.15–2.60; P = 0.009; TSA adjusted CI: 1.09–2.58). RCTs have supported the beneficial effect of I-TA in reducing thrombotic events. After including all studies, mortality in the I-TA group was significantly higher than in the PA group (OR: 1.38; 95% CI: 1.15–1.66; P = 0.0005). The rate of major bleeding was similar to the analysis from RCTs (OR: 2.24; 95% CI: 1.86–2.69; P < 0.00001). There was no distinct difference in the rate of thrombotic events between the 2 regimen groups. In addition, in both critical and noncritical subgroups, I-TA failed to reduce mortality but increased major bleeding rate compared with PA, as shown in meta-analysis of all studies, as well as RCTs only. Meta-regression of all studies suggested that there was no relationship between the treatment effect and the overall risk of mortality or major bleeding (P = 0.14, P = 0.09, respectively). Conclusion I-TA is not superior to PA for treating COVID-19 because it fails to lower the mortality rate but increases the major bleeding rate in both critical and noncritical patients.
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17
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Duo H, Li Y, Sun Y, Wei L, Wang Z, Fang F, Zhong Y, Huang J, Luo L, Peng Z, Pan H. Effect of therapeutic versus prophylactic anticoagulation therapy on clinical outcomes in COVID-19 patients: a systematic review with an updated meta-analysis. Thromb J 2022; 20:47. [PMID: 35999599 PMCID: PMC9395810 DOI: 10.1186/s12959-022-00408-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 08/14/2022] [Indexed: 12/15/2022] Open
Abstract
Background Previous studies demonstrate a reduced risk of thrombosis and mortality with anticoagulant treatment in patients with COVID-19 than in those without anticoagulation treatment. However, an open question regarding the efficacy and safety of therapeutic anticoagulation (T-AC) versus a lower dose, prophylaxis anticoagulation (P-AC) in COVID-19 patients is still controversial. Methods We systematically reviewed currently available randomized clinical trials (RCTs) and observational studies (OBs) from January 8, 2019, to January 8, 2022, and compared prophylactic and therapeutic anticoagulant treatment in COVID-19 patients. The primary outcomes were risk of mortality, major bleeding, and the secondary outcomes included venous and arterial thromboembolism. Subgroup analysis was also performed between critically ill and non-critically ill patients with COVID-19 and between patients with higher and lower levels of D-dimer. Sensitivity analysis was performed to decrease the bias and the impact of population heterogeneity. Results We identified 11 RCTs and 17 OBs fulfilling our inclusion criteria. In the RCTs analyses, there was no statistically significant difference in the relative risk of mortality between COVID-19 patients with T-AC treatment and those treated with P-AC (RR 0.95, 95% CI, 0.78–1.15, P = 0.60). Similar results were also found in the OBs analyses (RR 1.21, 95% CI, 0.98–1.49, P = 0.08). The pooling meta-analysis using a random-effects model combined with effect sizes showed that in the RCTs and OBs analyses, patients with COVID-19 who received T-AC treatment had a significantly higher relative risk of the major bleeding event than those with P-AC treatment in COVID-19 patients (RCTs: RR 1.76, 95% CI, 1.19–2.62, P = 0.005; OBs: RR 2.39, 95% CI, 1.56–3.68, P < 0.0001). Compared with P-AC treatment in COVID-19 patients, patients with T-AC treatment significantly reduced the incidence of venous thromboembolism (RR 0.51, 95% CI, 0.39–0.67, P<0.00001), but it is not associated with arterial thrombosis events (RR 0.97, 95% CI, 0.66–1.42, P = 0.87). The subgroup analysis of OBs shows that the mortality risk significantly reduces in critically ill COVID-19 patients treated with T-AC compared with those with P-AC treatment (RR 0.58, 95% CI, 0.39–0.86, P = 0.007), while the mortality risk significantly increases in non-critically ill COVID-19 patients treated with T-AC (RR 1.56, 95% CI, 1.34–1.80, P < 0.00001). In addition, T-AC treatment does not reduce the risk of mortality in COVID-19 patients with high d-dimer levels in RCTs. Finally, the overall sensitivity analysis after excluding two RCTs studies remains consistent with the previous results. Conclusions In our integrated analysis of included RCTs and OBs, there is no significant difference between the mortality of T-AC and P-AC treatment in unselected patients with COVID-19. T-AC treatment in COVID-19 patients significantly reduced the incidence of venous thromboembolism but showed a higher risk of bleeding than those with P-AC treatment. In addition, P-AC treatment was superior to T-AC treatment in non-critically ill COVID-19 patients, the evidence supporting the necessity for T-AC treatment in critically ill COVID-19 patients came only from OBs. Trial registration Protocol registration: The protocol was registered at PROSPERO (CRD42021293294). Graphical abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1186/s12959-022-00408-9.
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Affiliation(s)
- Hong Duo
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, 169 Eastlake Rd., Wuchang, Wuhan, 430071, Hubei province, China.,The Second Clinical College of Wuhan University, Wuhan, 430071, China
| | - Yahui Li
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, 169 Eastlake Rd., Wuchang, Wuhan, 430071, Hubei province, China.,The Second Clinical College of Wuhan University, Wuhan, 430071, China
| | - Yujie Sun
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, 169 Eastlake Rd., Wuchang, Wuhan, 430071, Hubei province, China.,The Second Clinical College of Wuhan University, Wuhan, 430071, China
| | - Liang Wei
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, 169 Eastlake Rd., Wuchang, Wuhan, 430071, Hubei province, China.,The Second Clinical College of Wuhan University, Wuhan, 430071, China
| | - Ziqing Wang
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, 169 Eastlake Rd., Wuchang, Wuhan, 430071, Hubei province, China.,The Second Clinical College of Wuhan University, Wuhan, 430071, China
| | - Fang Fang
- Department of Laboratory Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Yuxin Zhong
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, 169 Eastlake Rd., Wuchang, Wuhan, 430071, Hubei province, China.,Clinical Research Center for Critical Care Medicine of Hubei Province, Wuhan, 430071, China
| | - Jiao Huang
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Linjie Luo
- Department of Experimental Radiation Oncology & Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, 77030, USA.
| | - Zhiyong Peng
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, 169 Eastlake Rd., Wuchang, Wuhan, 430071, Hubei province, China. .,Clinical Research Center for Critical Care Medicine of Hubei Province, Wuhan, 430071, China.
| | - Huaqin Pan
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, 169 Eastlake Rd., Wuchang, Wuhan, 430071, Hubei province, China. .,Clinical Research Center for Critical Care Medicine of Hubei Province, Wuhan, 430071, China.
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18
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Alrashed A, Cahusac P, Mohzari YA, Bamogaddam RF, Alfaifi M, Mathew M, Alrumayyan BF, Alqahtani BF, Alshammari A, AlNekhilan K, Binrokan A, Alamri K, Alshahrani A, Alshahrani S, Alanazi AS, Alhassan BM, Alsaeed A, Almutairi W, Albujaidy A, AlJuaid L, Almalki ZS, Ahmed N, Alajami HN, Aljishi HM, Alsheef M, Alajlan SA, Almutairi F, Alsirhani A, Alotaibi M, Aljaber MA, Bahammam HA, Aldandan H, Almulhim AS, Abraham I, Alamer A. A comparison of three thromboprophylaxis regimens in critically ill COVID-19 patients: An analysis of real-world data. Front Cardiovasc Med 2022; 9:978420. [PMID: 36051287 PMCID: PMC9424612 DOI: 10.3389/fcvm.2022.978420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 07/18/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Thrombotic complications of coronavirus disease 2019 (COVID-19) have received considerable attention. Although numerous conflicting findings have compared escalated thromboprophylaxis doses with a standard dose to prevent thrombosis, there is a paucity of literature comparing clinical outcomes in three different anticoagulation dosing regimens. Thus, we investigated the effectiveness and safety profiles of standard, intermediate, and high-anti-coagulation dosing strategies in COVID-19 critically ill patients. Methodology This retrospective multicenter cohort study of intensive care unit (ICU) patients from the period of April 2020 to August 2021 in four Saudi Arabian centers. Inclusion criteria were age ≥ 18 years, diagnosis with severe or critical COVID-19 infection, and receiving prophylactic anticoagulant dose within 24-48 h of ICU admission. The primary endpoint was a composite of thrombotic events, with mortality rate and minor or major bleeding serving as secondary endpoints. We applied survival analyses with a matching weights procedure to control for confounding variables in the three arms. Results A total of 811 patient records were reviewed, with 551 (standard-dose = 192, intermediate-dose = 180, and high-dose = 179) included in the analysis. After using weights matching, we found that the standard-dose group was not associated with an increase in the composite thrombotic events endpoint when compared to the intermediate-dose group {19.8 vs. 25%; adjusted hazard ratio (aHR) =1.46, [95% confidence of interval (CI), 0.94-2.26]} or when compared to high-dose group [19.8 vs. 24%; aHR = 1.22 (95% CI, 0.88-1.72)]. Also, there were no statistically significant differences in overall in-hospital mortality between the standard-dose and the intermediate-dose group [51 vs. 53.4%; aHR = 1.4 (95% CI, 0.88-2.33)] or standard-dose and high-dose group [51 vs. 61.1%; aHR = 1.3 (95% CI, 0.83-2.20)]. Moreover, the risk of major bleeding was comparable in all three groups [standard vs. intermediate: 4.8 vs. 2.8%; aHR = 0.8 (95% CI, 0.23-2.74); standard vs. high: 4.8 vs. 9%; aHR = 2.1 (95% CI, 0.79-5.80)]. However, intermediate-dose and high-dose were both associated with an increase in minor bleeding incidence with aHR = 2.9 (95% CI, 1.26-6.80) and aHR = 3.9 (95% CI, 1.73-8.76), respectively. Conclusion Among COVID-19 patients admitted to the ICU, the three dosing regimens did not significantly affect the composite of thrombotic events and mortality. Compared with the standard-dose regimen, intermediate and high-dosing thromboprophylaxis were associated with a higher risk of minor but not major bleeding. Thus, these data recommend a standard dose as the preferred regimen.
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Affiliation(s)
- Ahmed Alrashed
- Administration of Pharmaceutical Services, Main Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Peter Cahusac
- Pharmacology and Biostatistics/Comparative Medicine, Alfaisal University College of Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Yahya A. Mohzari
- Clinical Pharmacy Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Reem F. Bamogaddam
- Clinical Pharmacy Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Mashael Alfaifi
- Clinical Pharmacy Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Maya Mathew
- Clinical Pharmacy Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Bashayer F. Alrumayyan
- Administration of Pharmaceutical Services, Main Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Basmah F. Alqahtani
- Administration of Pharmaceutical Services, Main Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Amjad Alshammari
- Administration of Pharmaceutical Services, Main Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Kholud AlNekhilan
- Administration of Pharmaceutical Services, Main Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Aljawharah Binrokan
- Administration of Pharmaceutical Services, Main Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Khalil Alamri
- Administration of Pharmaceutical Services, Main Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Abdullah Alshahrani
- Administration of Pharmaceutical Services, Main Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Safar Alshahrani
- Administration of Pharmaceutical Services, Main Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Ahmad S. Alanazi
- Administration of Pharmaceutical Services, Main Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Batool M. Alhassan
- Department of Clinical Pharmacy, Almoosa Specialist Hospital, Al-Ahasa, Saudi Arabia
| | - Ali Alsaeed
- Department of Neurology, King Fahad Medical City, Riyadh, Saudi Arabia
| | | | - Asma Albujaidy
- Department of Clinical Pharmacy Service, Prince Mohammed Bin Abdulaziz Hospital, Riyadh, Saudi Arabia
| | - Lama AlJuaid
- Pharmacy College, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Ziyad S. Almalki
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
| | - Nehad Ahmed
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
| | - Hamdan N. Alajami
- Clinical Pharmacy Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Hala M. Aljishi
- Research Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Mohammed Alsheef
- Medicine Department, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Saleh A. Alajlan
- Department of Pediatric Dentistry, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Faisal Almutairi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Atheer Alsirhani
- Department of Pharmacy Service, Prince Mutib Bin Abdulaziz Hospital, Sakaka, Saudi Arabia
| | - Manayer Alotaibi
- Department of Pharmacy Service, Prince Mutib Bin Abdulaziz Hospital, Sakaka, Saudi Arabia
| | - Melaf A. Aljaber
- Department of Pharmacy Service, Prince Mutib Bin Abdulaziz Hospital, Sakaka, Saudi Arabia
| | - Hammam A. Bahammam
- Department of Pediatric Dentistry, College of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia
| | | | - Abdulaziz S. Almulhim
- Department of Pharmacy Practice, College of Clinical Pharmacy, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Ivo Abraham
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tuscon, AZ, United States
| | - Ahmad Alamer
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tuscon, AZ, United States
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19
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Amerali M, Politou M. Tinzaparin—a review of its molecular profile, pharmacology, special properties, and clinical uses. Eur J Clin Pharmacol 2022; 78:1555-1565. [PMID: 35871241 PMCID: PMC9308487 DOI: 10.1007/s00228-022-03365-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 07/16/2022] [Indexed: 11/05/2022]
Abstract
Purpose Low molecular weight heparins (LMWHs) are a group of heterogenous moieties, long used in the prevention and treatment of thrombosis. They derive from heparin and since they are prepared by different methods of depolymerization, they differ in pharmacokinetic properties and anticoagulant profiles, and thus are not clinically interchangeable. Methods In this review we provide an overview of tinzaparin's main characteristics and uses. Results Tinzaparin which is produced by the enzymatic depolymerization of unfractionated heparin (UFH) can be used for the treatment and prevention of deep venous thrombosis (DVT) and pulmonary embolism (PE); it has been also used in special populations such as elders, obese, pregnant women, and patients with renal impairment and/or cancer with favorable outcomes in both safety and efficacy, with a once daily dose regimen. Furthermore, LMWHs are extensively used in clinical practice for both thromboprophylaxis and thrombosis treatment of COVID-19 patients. Conclusion Tinzaparin features support the hypothesis for having a role in immunothrombosis treatment (i.e. in the context of cancer ,COVID-19), interfering not only with coagulation cascade but also exhibiting anti-inflammatory potency.
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20
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Eman A, Balaban O, Süner KÖ, Cırdı Y, Şahin F, Demir G, Pekşen Ö, Musmul A, Erdem AF. The effect of low-dose and high-dose low-molecular-weight-heparin and aspirin thromboprophylaxis on clinical outcome and mortality in critical ill patients with COVID-19: A retrospective cohort study. Saudi Med J 2022; 43:715-722. [PMID: 35830988 PMCID: PMC9749692 DOI: 10.15537/smj.2022.43.7.20220038] [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: 02/03/2022] [Accepted: 05/28/2022] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES To assess the effect of different thromboprophylaxis regimens on clinical outcomes and mortality of critical ill patients with coronavirus disease -19 (COVID-19). METHODS We investigated the medical records of patients with positive COVID-19 (using polymerase chain reaction test) who were admitted to the intensive care unit (ICU) at Sakarya University Hospital, Sakarya, Turkey, from March 2020 to January 2021. We included patients under anticoagulant therapy in the clinical course. The patients were allocated to 3 groups: Group A - low-dose (prophylactic) low-molecular-weight-heparin (LMWH) therapy, Group B - high-dose (therapeutic) LMWH therapy, and patients that received aspirin additional to the high-dose (therapeutic) LMWH as Group C. Primary outcomes were overall mortality rates and length of stay (LOS) in ICU. Secondary outcomes were rates of major hemorrhagic and thrombotic events. RESULTS Records of 475 patients were reviewed and 164 patients were included. No significant difference was detected in mortality rates between groups (p=0.135). Intensive care unit stay was 13 (9-24.5) days in Group A, 11 (8.75-23) days in Group B, and 13 (9-17) days in Group C without a significant difference (p=0.547). No significant difference was detected between groups in terms of thrombotic (p=0.565) and hemorrhagic events (p=0.615). CONCLUSION A high-dose anticoagulation therapy and addition of aspirin to LMWH therapy did not decrease the mortality rates and LOS in ICU in critical ill COVİD-19 patients. In addition, it did not increase the incidence of major hemorrhage and major thrombotic events.
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Affiliation(s)
- Ali Eman
- From the Department of Anesthesiology and Reanimation (Eman, Balaban, Şahin, Demir, Pekşen, Erdem); from the Department of Intensive Care (Süner), Sakarya Training and Research Hospital; from the Department of Intensive Care (Cırdı), faculty of Medicine, Sakarya University, Sakarya; and from the Department of Medical Services and Techniques (Musmul), Eskisehir Osmangazi University Vocational School of Health Services, Eskisehir, Turkey
| | - Onur Balaban
- From the Department of Anesthesiology and Reanimation (Eman, Balaban, Şahin, Demir, Pekşen, Erdem); from the Department of Intensive Care (Süner), Sakarya Training and Research Hospital; from the Department of Intensive Care (Cırdı), faculty of Medicine, Sakarya University, Sakarya; and from the Department of Medical Services and Techniques (Musmul), Eskisehir Osmangazi University Vocational School of Health Services, Eskisehir, Turkey
| | - Kezban Ö. Süner
- From the Department of Anesthesiology and Reanimation (Eman, Balaban, Şahin, Demir, Pekşen, Erdem); from the Department of Intensive Care (Süner), Sakarya Training and Research Hospital; from the Department of Intensive Care (Cırdı), faculty of Medicine, Sakarya University, Sakarya; and from the Department of Medical Services and Techniques (Musmul), Eskisehir Osmangazi University Vocational School of Health Services, Eskisehir, Turkey
| | - Yaşar Cırdı
- From the Department of Anesthesiology and Reanimation (Eman, Balaban, Şahin, Demir, Pekşen, Erdem); from the Department of Intensive Care (Süner), Sakarya Training and Research Hospital; from the Department of Intensive Care (Cırdı), faculty of Medicine, Sakarya University, Sakarya; and from the Department of Medical Services and Techniques (Musmul), Eskisehir Osmangazi University Vocational School of Health Services, Eskisehir, Turkey
| | - Fatih Şahin
- From the Department of Anesthesiology and Reanimation (Eman, Balaban, Şahin, Demir, Pekşen, Erdem); from the Department of Intensive Care (Süner), Sakarya Training and Research Hospital; from the Department of Intensive Care (Cırdı), faculty of Medicine, Sakarya University, Sakarya; and from the Department of Medical Services and Techniques (Musmul), Eskisehir Osmangazi University Vocational School of Health Services, Eskisehir, Turkey
- Address correspondence and reprint request to: Dr. Fatih Şahin, Department of Anesthesiology and Reanimation, Sakarya University Training and Research Hospital, Sakarya, Turkey. E-mail: ORCID ID: https://orcid.org/0000-0002-8501-0675
| | - Gürkan Demir
- From the Department of Anesthesiology and Reanimation (Eman, Balaban, Şahin, Demir, Pekşen, Erdem); from the Department of Intensive Care (Süner), Sakarya Training and Research Hospital; from the Department of Intensive Care (Cırdı), faculty of Medicine, Sakarya University, Sakarya; and from the Department of Medical Services and Techniques (Musmul), Eskisehir Osmangazi University Vocational School of Health Services, Eskisehir, Turkey
| | - Özge Pekşen
- From the Department of Anesthesiology and Reanimation (Eman, Balaban, Şahin, Demir, Pekşen, Erdem); from the Department of Intensive Care (Süner), Sakarya Training and Research Hospital; from the Department of Intensive Care (Cırdı), faculty of Medicine, Sakarya University, Sakarya; and from the Department of Medical Services and Techniques (Musmul), Eskisehir Osmangazi University Vocational School of Health Services, Eskisehir, Turkey
| | - Ahmet Musmul
- From the Department of Anesthesiology and Reanimation (Eman, Balaban, Şahin, Demir, Pekşen, Erdem); from the Department of Intensive Care (Süner), Sakarya Training and Research Hospital; from the Department of Intensive Care (Cırdı), faculty of Medicine, Sakarya University, Sakarya; and from the Department of Medical Services and Techniques (Musmul), Eskisehir Osmangazi University Vocational School of Health Services, Eskisehir, Turkey
| | - Ali F. Erdem
- From the Department of Anesthesiology and Reanimation (Eman, Balaban, Şahin, Demir, Pekşen, Erdem); from the Department of Intensive Care (Süner), Sakarya Training and Research Hospital; from the Department of Intensive Care (Cırdı), faculty of Medicine, Sakarya University, Sakarya; and from the Department of Medical Services and Techniques (Musmul), Eskisehir Osmangazi University Vocational School of Health Services, Eskisehir, Turkey
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21
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Volteas P, Drakos P, Alkadaa LN, Cleri NA, Asencio AA, Oganov A, Giannopoulos S, Saadon JR, Mikell CB, Rubano JA, Labropoulos N, Tassiopoulos AK, Mofakham S, Bannazadeh M. Low-Molecular-Weight Heparin Compared to Unfractionated Heparin in Critically Ill COVID-19 Patients. J Vasc Surg Venous Lymphat Disord 2022; 10:1128-1136. [PMID: 35716998 PMCID: PMC9212478 DOI: 10.1016/j.jvsv.2022.04.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 04/05/2022] [Accepted: 04/26/2022] [Indexed: 11/30/2022]
Abstract
Background Thrombosis in COVID-19 worsens mortality. In our study, we sought to investigate how the dose and type of anticoagulation (AC) can influence patient outcomes. Methods This is a single-center retrospective analysis of critically ill intubated patients with COVID-19, comparing low-molecular-weight heparin (LMWH) and unfractionated heparin (UFH) at therapeutic and prophylactic doses. Of 218 patients, 135 received LMWH (70 prophylactic, 65 therapeutic) and 83 UFH (11 prophylactic, 72 therapeutic). The primary outcome was mortality. Secondary outcomes were thromboembolic complications confirmed on imaging and major bleeding complications. Cox proportional-hazards regression models were used to determine whether the type and dose of AC were independent predictors of survival. We performed Kaplan-Meier survival analysis to compare the cumulative survivals. Results Overall, therapeutic AC, with either LMWH (65% vs 79%, P = .09) or UFH (32% vs 46%, P = .73), conveyed no survival benefit over prophylactic AC. UFH was associated with a higher mortality rate than LMWH (66% vs 28%, P = .001), which was also evident in the multivariable analysis (LMWH vs UFH mortality, hazard ratio: 0.47, P = .001) and in the Kaplan-Meier survival analysis. Thrombotic and bleeding complications did not depend on the AC type (prophylactic LMWH vs UFH: thrombosis P = .49, bleeding P = .075; therapeutic LMWH vs UFH: thrombosis P = .5, bleeding P = .17). When comparing prophylactic with therapeutic AC, the rate of both thrombotic and bleeding complications was higher with the use of LMWH compared with UFH. In addition, transfusion requirements were significantly higher with both therapeutic LMWH and UFH. Conclusions Among intubated critically ill COVID-19 intensive care unit patients, therapeutic AC, with either LMWH or UFH, conveyed no survival benefit over prophylactic AC. AC with LMWH was associated with higher cumulative survival compared with AC with UFH.
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Affiliation(s)
- Panagiotis Volteas
- Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, USA
| | - Panagiotis Drakos
- Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, USA
| | - Leor N Alkadaa
- Department of Neurosurgery, Renaissance School of Medicine, Stony Brook, NY, USA
| | - Nathaniel A Cleri
- Department of Neurosurgery, Renaissance School of Medicine, Stony Brook, NY, USA
| | - Anthony A Asencio
- Department of Neurosurgery, Renaissance School of Medicine, Stony Brook, NY, USA
| | - Anthony Oganov
- Department of Neurosurgery, Renaissance School of Medicine, Stony Brook, NY, USA
| | - Stefanos Giannopoulos
- Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, USA; Division of Vascular Surgery, Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, USA
| | - Jordan R Saadon
- Department of Neurosurgery, Renaissance School of Medicine, Stony Brook, NY, USA
| | - Charles B Mikell
- Department of Neurosurgery, Renaissance School of Medicine, Stony Brook, NY, USA
| | - Jerry A Rubano
- Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, USA
| | - Nicos Labropoulos
- Division of Vascular Surgery, Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, USA
| | - Apostolos K Tassiopoulos
- Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, USA; Division of Vascular Surgery, Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, USA
| | - Sima Mofakham
- Department of Neurosurgery, Renaissance School of Medicine, Stony Brook, NY, USA.
| | - Mohsen Bannazadeh
- Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, USA; Division of Vascular Surgery, Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, USA.
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22
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Fragkou PC, Palaiodimou L, Stefanou MI, Katsanos AH, Lambadiari V, Paraskevis D, Andreadou E, Dimopoulou D, Zompola C, Ferentinos P, Vassilakopoulos TI, Kotanidou A, Sfikakis PP, Tsiodras S, Tsivgoulis G. Effects of low molecular weight heparin and fondaparinux on mortality, hemorrhagic and thrombotic complications in COVID-19 patients. Ther Adv Neurol Disord 2022; 15:17562864221099472. [PMID: 35646159 PMCID: PMC9136435 DOI: 10.1177/17562864221099472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 04/20/2022] [Indexed: 12/15/2022] Open
Abstract
Background: Coronavirus disease 2019 (COVID-19) is associated with increased thrombosis prevalence. However, there are insufficient data supporting the appropriate anticoagulation dose in COVID-19. Objective: We aim to systematically assess the currently available data regarding the effects of different dosing regimens of low molecular weight heparin and/or fondaparinux (LMWH/F) on mortality risk as well as the risk of arterial/venous thrombotic events and hemorrhagic complications in confirmed COVID-19 cases. Design: We conducted a living systematic review and meta-analysis on the effects of different LMWH/F doses on mortality, thrombotic and hemorrhagic events in COVID-19 patients. Data Sources and Methods: MEDLINE, Scopus, Embase, Cochrane Library, Cochrane COVID-19 study register, European Union Drug Regulating Authorities Clinical Trials Database, and ClinicalTrials.gov were searched to detect observational cohort studies and randomized-controlled clinical trials (RCTs) comparing difference doses of LMWH/F among confirmed COVID-19 cases. Results: Thirty-one eligible studies (6 RCTs and 25 cohort studies) with 11,430 hospitalized patients were included. No association was found between LMWH/F and mortality during the following comparisons: (1) no LMWH/F versus any LMWH/F; (2) prophylactic versus higher than prophylactic LMWH/F; (3) prophylactic versus therapeutic LMWH/F; (4) intermediate versus therapeutic LMWH/F; and (5) lower than therapeutic versus therapeutic LMWH/F. Mortality was higher in patients receiving prophylactic versus intermediate LMWH/F (OR = 2.01; 95% CI: 1.19–3.39). However, this effect was mostly driven by observational data. No associations were detected between the intensity of LMWH/F and the risk of thrombotic and hemorrhagic events, except the lower risk for hemorrhage in patients on prophylactic compared to higher LMWH/F doses. Conclusion: The risk for all-cause mortality was higher in patients receiving prophylactic LMWH/F compared to those on an intermediate dose of LMWH/F, based on observational data. These results should be interpreted in light of the moderate quality and heterogeneity of the included studies. Registration: The study protocol has been registered in the International Prospective Register of Ongoing Systematic Reviews PROSPERO (Registration number: CRD42021229771).
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Affiliation(s)
- Paraskevi C. Fragkou
- First Department of Critical Care Medicine and Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece
| | - Lina Palaiodimou
- Second Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, ‘Attikon’ University Hospital, Athens, Greece
| | - Maria Ioanna Stefanou
- Second Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, ‘Attikon’ University Hospital, Athens, Greece
| | - Aristeidis H. Katsanos
- Division of Neurology, Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Vaia Lambadiari
- Second Department of Internal Medicine Research Unit and Diabetes Center, School of Medicine, National and Kapodistrian University of Athens, ‘Attikon’ University Hospital, Athens, Greece
| | - Dimitrios Paraskevis
- Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Elisabeth Andreadou
- First Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, Eginition Hospital, Athens, Greece
| | - Dimitra Dimopoulou
- Second Department of Pediatrics, School of Medicine, National and Kapodistrian University of Athens, ‘Panagiotis and Aglaia Kyriakou’ Children’s Hospital, Athens, Greece
| | - Christina Zompola
- Second Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, ‘Attikon’ University Hospital, Athens, Greece
| | - Panagiotis Ferentinos
- Second Department of Psychiatry, School of Medicine, National and Kapodistrian University of Athens, ‘Attikon’ University Hospital, Athens, Greece
| | - Theodoros I. Vassilakopoulos
- Third Department of Critical Care Medicine, School of Medicine, National and Kapodistrian University of Athens, Evgenideio Hospital, Athens, Greece
| | - Anastasia Kotanidou
- First Department of Critical Care Medicine and Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece
| | - Petros P. Sfikakis
- First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Sotirios Tsiodras
- Fourth Department of Internal Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Attikon’ University Hospital, Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, ‘Attikon’ University Hospital, Rimini 1, Chaidari, Athens 12462, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
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23
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Boknäs N, Laine C, Hillarp A, Macwan AS, Gustafsson KM, Lindahl TL, Holmström M. Associations between hemostatic markers and mortality in COVID-19 – Compounding effects of D-dimer, antithrombin and PAP complex. Thromb Res 2022; 213:97-104. [PMID: 35316719 PMCID: PMC8930184 DOI: 10.1016/j.thromres.2022.03.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 03/05/2022] [Accepted: 03/14/2022] [Indexed: 02/08/2023]
Abstract
In this single-center cohort study, we applied a panel of laboratory markers to characterize hemostatic function in 217 consecutive patients that underwent testing for COVID-19 as they were admitted to Linköping University Hospital between April and June 2020. In the 96 patients that tested positive for SARS-CoV-2 (COVID-19+), the cumulative incidences of death and venous thromboembolism were 24.0% and 19.8% as compared to 12.4% (p = 0.031) and 11.6% (p = 0.13) in the 121 patients that tested negative (COVID-19−). In COVID-19+ patients, we found pronounced increases in plasma levels of von Willebrand factor (vWF) and fibrinogen. Excess mortality was observed in COVID-19+ patients with the following aberrations in hemostatic markers: high D-dimer, low antithrombin or low plasmin-antiplasmin complex (PAP) formation, with Odds Ratios (OR) for death of 4.7 (95% confidence interval (CI95) 1.7–12.9; p = 0.003) for D-dimer >0.5 mg/L, 5.9 (CI95 1.8–19.7; p = 0.004) for antithrombin (AT) ˂0.85 kIU/l and 4.9 (CI95 1.3–18.3; p = 0.019) for PAP < 1000 μg/L. Compounding increases in mortality was observed in COVID-19+ patients with combined defects in markers of fibrinolysis and coagulation, with ORs for death of 15.7 (CI95 4.3–57; p < 0.001) for patients with PAP <1000 μg/L and D-dimer >0.5 mg/L and 15.5 (CI95 2.8–87, p = 0.002) for patients with PAP <1000 μg/L and AT ˂0.85 kIU/L. We observed an elevated fraction of incompletely degraded D-dimer fragments in COVID-19+ patients with low PAP, indicating impaired fibrinolytic breakdown of cross-linked fibrin.
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24
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Holmqvist J, Beck‐Friis J, Jensen C, Dalla K, Mårdstam S, Christensen J, Nordén N, Widing H, Rosén‐Wetterholm E, Cavefors O, Yilmaz A, Cronhjort M, Redfors B, Oras J. Cardiac dysfunction and mortality in critically ill patients with COVID-19: A Swedish multicentre observational study. Acta Anaesthesiol Scand 2022; 66:606-614. [PMID: 35122232 PMCID: PMC9111275 DOI: 10.1111/aas.14039] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 01/03/2022] [Accepted: 01/14/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The prevalence and importance of cardiac dysfunction in critically ill patients with COVID-19 in Sweden is not yet established. The aim of the study was to assess the prevalence of cardiac dysfunction and elevated pulmonary artery pressure (PAP), and its influence on mortality in patients with COVID-19 in intensive care in Sweden. METHODS This was a multicentre observational study performed in five intensive care units (ICUs) in Sweden. Patients admitted to participating ICU with COVID-19 were examined with echocardiography within 72 h from admission and again after 4 to 7 days. Cardiac dysfunction was defined as left ventricular (LV) dysfunction (ejection fraction <50% and/or regional hypokinesia) or right ventricular (RV) dysfunction (defined as TAPSE <17 mm or visually assessed moderate/severe RV dysfunction). RESULTS We included 132 patients, of whom 127 (96%) were intubated. Cardiac dysfunction was found in 42 (32%) patients. Most patients had cardiac dysfunction at the first assessment (n = 35) while a few developed cardiac dysfunction later (n = 7) and some changed type of dysfunction (n = 3). LV dysfunction was found in 21 and RV dysfunction in 19 patients, while 5 patients had combined dysfunction. Elevated PAP was found in 34 patients (26%) and was more common in patients with RV dysfunction. RV dysfunction and elevated PAP were independently associated with an increased risk of death (OR 3.98, p = .013 and OR 3.88, p = .007, respectively). CONCLUSIONS Cardiac dysfunction occurs commonly in critically ill patients with COVID-19 in Sweden. RV dysfunction and elevated PAP are associated with an increased risk of death.
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Affiliation(s)
- Jacob Holmqvist
- Department of Anesthesiology and Intensive Care Medicine Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
- Department of Anesthesiology and Intensive Care Medicine Sahlgrenska University Hospital/Sahlgrenska Gothenburg Sweden
| | - Josefine Beck‐Friis
- Department of Infectious Diseases Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
- Department of Infectious Diseases Sahlgrenska University Hospital Gothenburg Sweden
| | - Carl Jensen
- Department of Anesthesiology and Intensive Care Medicine NU Hospital Group Trollhättan Sweden
| | - Keti Dalla
- Department of Anesthesiology and Intensive Care Medicine Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
- Department of Anesthesiology and Intensive Care Medicine Sahlgrenska University Hospital/Mölndal Gothenburg Sweden
| | - Simon Mårdstam
- Department of Clinical Science and Education Södersjukhuset Karolinska Institutet Stockholm Sweden
- Department of Anaesthesia and Intensive Care Södersjukhuset Stockholm Sweden
| | - Jens Christensen
- Department of Clinical Science and Education Södersjukhuset Karolinska Institutet Stockholm Sweden
- Department of Anaesthesia and Intensive Care Södersjukhuset Stockholm Sweden
| | - Nina Nordén
- Department of Anesthesiology and Intensive Care Medicine Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
- Department of Anesthesiology and Intensive Care Medicine Sahlgrenska University Hospital/Mölndal Gothenburg Sweden
| | - Hannes Widing
- Department of Anesthesiology and Intensive Care Medicine Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
- Department of Anesthesiology and Intensive Care Medicine Sahlgrenska University Hospital/Östra Gothenburg Sweden
| | - Elin Rosén‐Wetterholm
- Department of Anesthesiology and Intensive Care Medicine Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
| | - Oscar Cavefors
- Department of Anesthesiology and Intensive Care Medicine Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
- Department of Anesthesiology and Intensive Care Medicine Sahlgrenska University Hospital/Sahlgrenska Gothenburg Sweden
| | - Aylin Yilmaz
- Department of Infectious Diseases Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
- Department of Infectious Diseases Sahlgrenska University Hospital Gothenburg Sweden
| | - Maria Cronhjort
- Department of Clinical Science and Education Södersjukhuset Karolinska Institutet Stockholm Sweden
- Department of Anaesthesia and Intensive Care Södersjukhuset Stockholm Sweden
| | - Björn Redfors
- Department of Cardiology Institute of Medicine Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
- Department of Cardiology Sahlgrenska University Hospital Gothenburg Sweden
| | - Jonatan Oras
- Department of Anesthesiology and Intensive Care Medicine Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
- Department of Anesthesiology and Intensive Care Medicine Sahlgrenska University Hospital/Sahlgrenska Gothenburg Sweden
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25
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Xiang M, Jing H, Wang C, Novakovic VA, Shi J. Persistent Lung Injury and Prothrombotic State in Long COVID. Front Immunol 2022; 13:862522. [PMID: 35464473 PMCID: PMC9021447 DOI: 10.3389/fimmu.2022.862522] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 03/17/2022] [Indexed: 12/19/2022] Open
Abstract
Lung injury may persist during the recovery period of COVID-19 as shown through imaging, six-minute walk, and lung function tests. The pathophysiological mechanisms leading to long COVID have not been adequately explained. Our aim is to investigate the basis of pulmonary susceptibility during sequelae and the possibility that prothrombotic states may influence long-term pulmonary symptoms of COVID-19. The patient’s lungs remain vulnerable during the recovery stage due to persistent shedding of the virus, the inflammatory environment, the prothrombotic state, and injury and subsequent repair of the blood-air barrier. The transformation of inflammation to proliferation and fibrosis, hypoxia-involved vascular remodeling, vascular endothelial cell damage, phosphatidylserine-involved hypercoagulability, and continuous changes in serological markers all contribute to post-discharge lung injury. Considering the important role of microthrombus and arteriovenous thrombus in the process of pulmonary functional lesions to organic lesions, we further study the possibility that prothrombotic states, including pulmonary vascular endothelial cell activation and hypercoagulability, may affect long-term pulmonary symptoms in long COVID. Early use of combined anticoagulant and antiplatelet therapy is a promising approach to reduce the incidence of pulmonary sequelae. Essentially, early treatment can block the occurrence of thrombotic events. Because impeded pulmonary circulation causes large pressure imbalances over the alveolar membrane leading to the infiltration of plasma into the alveolar cavity, inhibition of thrombotic events can prevent pulmonary hypertension, formation of lung hyaline membranes, and lung consolidation.
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Affiliation(s)
- Mengqi Xiang
- Department of Hematology, First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China
| | - Haijiao Jing
- Department of Hematology, First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China
| | - Chengyue Wang
- Department of Hematology, First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China
| | - Valerie A Novakovic
- Department of Research, Veterans Affairs Boston Healthcare System, Harvard Medical School, Boston, MA, United States
| | - Jialan Shi
- Department of Hematology, First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China.,Department of Research, Veterans Affairs Boston Healthcare System, Harvard Medical School, Boston, MA, United States.,Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States
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26
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Development of Evidence-Based COVID-19 Management Guidelines for Local Context: The Methodological Challenges. Glob Health Epidemiol Genom 2022; 2022:4240378. [PMID: 35492871 PMCID: PMC9020141 DOI: 10.1155/2022/4240378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 03/01/2022] [Indexed: 11/29/2022] Open
Abstract
Background The coronavirus disease 2019 (COVID-19) pandemic has presented as a therapeutic challenge for clinicians worldwide due to its rapid spread along with evolving evidence and understanding of the disease. Internationally, recommendations to guide the management of COVID-19 have been created and updated continuously by the WHO and CDC, which have been locally adapted by different countries. Similarly, Pakistan's National Command Operation Center (NCOC), in its national COVID-19 management strategy, generated guidelines for national implementation. Keeping the guidelines updated has proved challenging globally and locally. Here, we present a summary of the process to assess the evidence, including a time-restricted systematic review based on NCOC Clinical Management Guidelines for COVID-19 Infections v4 published on 11th December 2020 version, correlating it with current recommendations and with input one of the guidelines authors, particularly noting the methodological challenges. Methods We conducted a systematic review synthesizing global research on treatment options for COVID-19 hospitalized patients, limiting it to pharmacological interventions for hospitalized COVID-19 patients included in Pakistan's NCOC's national guidelines v4 published on 11th December 2020. Each treatment recommendation's strength and quality of evidence was assessed based on the grading of recommendations assessment, development, and evaluation (GRADE) methodology. These were then compared to the most current living WHO COVID-19 pharmacological treatment guidelines v7.1. One of the authors of the NCOC guidelines reviewed and commented on the findings as well. Results We note that the data from our systematic review strongly supports corticosteroids use in treating severe and critically ill COVID-19 hospitalized patients correlating with WHO v7.1 guidelines 24 September 2021. However, evidence from our review and WHO v7.1 for the use of tocilizumab had some conflicting evidence, with data from our review until December 2020 supporting only a weak recommendation for its use, compared to the strong recommendation by the WHO for the use of tocilizumab in patients with severe or critical COVID-19 infection. Regarding the use of antibiotics and ivermectin use in treating COVID-19 hospitalized patients, data from our review and WHO v 7.1 recommend against their use. Conclusion Research data about the efficacy and safety of pharmacological interventions to treat hospitalized patients with COVID-19 are rapidly evolving, and based on it, the evidence for or against recommendations changes accordingly. Our study illustrates the challenges of keeping up with the evidence; the recommendations were based on studies up till December 2021, and we have compared our recommendations with the WHO v7.1, which showed some significant changes in the use of pharmacological treatment options.
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27
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Intensive-Dose Tinzaparin in Hospitalized COVID-19 Patients: The INTERACT Study. Viruses 2022; 14:v14040767. [PMID: 35458497 PMCID: PMC9027745 DOI: 10.3390/v14040767] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/03/2022] [Accepted: 04/05/2022] [Indexed: 01/08/2023] Open
Abstract
(1) Background: It is well-established that coronavirus disease-2019 (COVID-19) is highly pro-inflammatory, leading to activation of the coagulation cascade. COVID-19-induced hypercoagulability is associated with adverse outcomes and mortality. Current guidelines recommend that hospitalized COVID-19 patients should receive pharmacological prophylaxis against venous thromboembolism (VTE). (2) INTERACT is a retrospective, phase IV, observational cohort study aiming to evaluate the overall clinical effectiveness and safety of a higher than conventionally used prophylactic dose of anticoagulation with tinzaparin administered for VTE prevention in non-critically ill COVID-19 patients with moderate disease severity. (3) Results: A total of 705 patients from 13 hospitals in Greece participated in the study (55% men, median age 62 years). Anticoagulation with tinzaparin was initiated immediately after admission. A full therapeutic dose was received by 36.3% of the participants (mean ± SD 166 ± 33 IU/Kgr/day) and the remaining patients (63.9%) received an intermediate dose (mean ± SD 114 ± 22 IU/Kgr/day). The median treatment duration was 13 days (Q1−Q3: 8−20 days). During the study (April 2020 to November 2021), 14 thrombotic events (2.0%) were diagnosed (i.e., three cases of pulmonary embolism (PE) and 11 cases of deep venous thrombosis, DVT). Four bleeding events were recorded (0.6%). In-hospital death occurred in 12 patients (1.7%). Thrombosis was associated with increasing age (median: 74.5 years, Q1−Q3: 62−79, for patients with thrombosis vs. 61.9 years, Q1−Q3: 49−72, p = 0.0149), increased D-dimer levels for all three evaluation time points (at admission: 2490, Q1−Q3: 1580−6480 vs. 700, Q1−Q3: 400−1475, p < 0.0001), one week ± two days after admission (3510, Q1−Q3: 1458−9500 vs. 619, Q1−Q3: 352−1054.5, p < 0.0001), as well as upon discharge (1618.5, Q1−Q3: 1010−2255 vs. 500, Q1−Q3: 294−918, p < 0.0001). Clinical and laboratory improvement was affirmed by decreasing D-dimer and CRP levels, increasing platelet numbers and oxygen saturation measurements, and a drop in the World Health Organization (WHO) progression scale. (4) Conclusions: The findings of our study are in favor of prophylactic anticoagulation with an intermediate to full therapeutic dose of tinzaparin among non-critically ill patients hospitalized with COVID-19.
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28
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Wang C, Yu C, Jing H, Wu X, Novakovic VA, Xie R, Shi J. Long COVID: The Nature of Thrombotic Sequelae Determines the Necessity of Early Anticoagulation. Front Cell Infect Microbiol 2022; 12:861703. [PMID: 35449732 PMCID: PMC9016198 DOI: 10.3389/fcimb.2022.861703] [Citation(s) in RCA: 52] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 03/15/2022] [Indexed: 12/24/2022] Open
Abstract
Many discharged COVID-19 patients affected by sequelae experience reduced quality of life leading to an increased burden on the healthcare system, their families and society at large. Possible pathophysiological mechanisms of long COVID include: persistent viral replication, chronic hypoxia and inflammation. Ongoing vascular endothelial damage promotes platelet adhesion and coagulation, resulting in the impairment of various organ functions. Meanwhile, thrombosis will further aggravate vasculitis contributing to further deterioration. Thus, long COVID is essentially a thrombotic sequela. Unfortunately, there is currently no effective treatment for long COVID. This article summarizes the evidence for coagulation abnormalities in long COVID, with a focus on the pathophysiological mechanisms of thrombosis. Extracellular vesicles (EVs) released by various types of cells can carry SARS-CoV-2 through the circulation and attack distant tissues and organs. Furthermore, EVs express tissue factor and phosphatidylserine (PS) which aggravate thrombosis. Given the persistence of the virus, chronic inflammation and endothelial damage are inevitable. Pulmonary structural changes such as hypertension, embolism and fibrosis are common in long COVID. The resulting impaired lung function and chronic hypoxia again aggravates vascular inflammation and coagulation abnormalities. In this article, we also summarize recent research on antithrombotic therapy in COVID-19. There is increasing evidence that early anticoagulation can be effective in improving outcomes. In fact, persistent systemic vascular inflammation and dysfunction caused by thrombosis are key factors driving various complications of long COVID. Early prophylactic anticoagulation can prevent the release of or remove procoagulant substances, thereby protecting the vascular endothelium from damage, reducing thrombotic sequelae, and improving quality of life for long-COVID patients.
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Affiliation(s)
- Chengyue Wang
- Department of Hematology, The First Hospital of Harbin, Harbin Medical University, Harbin, China
- Department of Nephrology, The First Hospital of Harbin, Harbin Medical University, Harbin, China
| | - Chengyuan Yu
- Department of Hematology, The First Hospital of Harbin, Harbin Medical University, Harbin, China
- Department of Geriatric, Shenzhen People’s Hospital, The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology, Shenzhen, China
| | - Haijiao Jing
- Department of Hematology, The First Hospital of Harbin, Harbin Medical University, Harbin, China
| | - Xiaoming Wu
- Department of Hematology, The First Hospital of Harbin, Harbin Medical University, Harbin, China
| | - Valerie A. Novakovic
- Department of Research, Veterans Affairs (VA) Boston Healthcare System, Harvard Medical School, Boston, MA, United States
| | - Rujuan Xie
- Department of Nephrology, The First Hospital of Harbin, Harbin Medical University, Harbin, China
- *Correspondence: Rujuan Xie, ; Jialan Shi,
| | - Jialan Shi
- Department of Hematology, The First Hospital of Harbin, Harbin Medical University, Harbin, China
- Department of Research, Veterans Affairs (VA) Boston Healthcare System, Harvard Medical School, Boston, MA, United States
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States
- *Correspondence: Rujuan Xie, ; Jialan Shi,
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29
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Aljuhani O, Al Sulaiman K, Hafiz A, Eljaaly K, Alharbi A, Algarni R, Al Homaid S, Kahtani K, Alsulaiman T, Vishwakarma R, Al Ghamdi G, Alalawi M, Korayem GB. Comparison between standard Vs. Escalated dose venous thromboembolism (VTE) prophylaxis in critically ill patients with COVID-19: A two centers, observational study. Saudi Pharm J 2022; 30:398-406. [PMID: 35136364 PMCID: PMC8812085 DOI: 10.1016/j.jsps.2022.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 01/28/2022] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION The risk of mortality in patients with COVID-19 was found to be significantly higher in patients who experienced thromboembolic events. Thus, several guidelines recommend using prophylactic anticoagulants in all COVID-19 hospitalized patients. However, there is uncertainty about the appropriate dosing regimen and safety of anticoagulation in critically ill patients with COVID-19. Thus, this study aims to compare the effectiveness and safety of standard versus escalated dose pharmacological venous thromboembolism (VTE) prophylaxis in critically ill patients with COVID-19. METHODS A two-center retrospective cohort study including critically ill patients aged ≥ 18-years with confirmed COVID-19 admitted to the intensive care unit (ICU) at two tertiary hospitals in Saudi Arabia from March 1st, 2020, until January 31st, 2021. Patients who received either Enoxaparin 40 mg daily or Unfractionated heparin 5000 Units three times daily were grouped under the "standard dose VTE prophylaxis and patients who received higher than the standard dose but not as treatment dose were grouped under "escalated VTE prophylaxis dose". The primary outcome was the occurance of thrombotic events, and the secondary outcomes were bleeding, mortality, and other ICU-related complications. RESULTS A total of 758 patients were screened; 565 patients were included in the study. We matched 352 patients using propensity score matching (1:1). In patients who received escalated dose pharmacological VTE prophylaxis, any case of thrombosis and VTE were similar between the two groups (OR 1.22;95 %CI 0.52-2.86; P = 0.64 and OR 0.75; 95% CI 0.16-3.38; P = 0.70 respectively). However, the odds of minor bleeding was higher in patients who received escalated VTE prophylaxis dose (OR 3.39; 95% CI 1.08-10.61; P = 0.04). There was no difference in the 30-day mortality nor in-hospital mortality between the two groups (HR 1.17;95 %CI0.79-1.73; P = 0.43 and HR 1.08;95 %CI 0.76-1.53; P = 0.83, respectively). CONCLUSION Escalated-dose pharmacological VTE prophylaxis in critically ill patients with COVID-19 was not associated with thrombosis, or mortality benefits but led to an increased risk of minor bleeding. This study supports previous evidence regarding the optimal dosing VTE pharmacological prophylaxis regimen for critically ill patients with COVID-19.
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Affiliation(s)
- Ohoud Aljuhani
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Khalid Al Sulaiman
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Biostatistics and Bioinformatics Department, Riyadh, Saudi Arabia
| | - Awatif Hafiz
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Khalid Eljaaly
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
- College of Pharmacy, University of Arizona, Tucson, AZ, United States
| | - Aisha Alharbi
- Pharmaceutical Care Department, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Rahmah Algarni
- Pharmaceutical Care Department, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Sarah Al Homaid
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Khawla Kahtani
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Tareq Alsulaiman
- Department of Orthopedic Surgery, Imam Abdulrahman Al Faisal Hospital, Riyadh, Saudi Arabia
| | - Ramesh Vishwakarma
- Statistics Department, European Organization for Research and Treatment of Cancer (EORTC) Headquarters, Brussels, Belgium
| | - Ghassan Al Ghamdi
- King Abdullah International Medical Research Center, Biostatistics and Bioinformatics Department, Riyadh, Saudi Arabia
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Saudi Arabia
- Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Mai Alalawi
- Fakeeh College of Medical Sciences, Jeddah, Saudi Arabia
| | - Ghazwa B. Korayem
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
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Renin-angiotensin system blocker and the COVID-19 aggravation in patients with hypertension, diabetes, renal failure, Cerebro-cardiovascular disease, or pulmonary disease: Report by the COVID-19 REGISTRY JAPAN. J Cardiol 2022; 80:292-297. [PMID: 35469713 PMCID: PMC8989871 DOI: 10.1016/j.jjcc.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 03/08/2022] [Accepted: 03/27/2022] [Indexed: 11/23/2022]
Abstract
Background The role of angiotensin-converting enzyme inhibitors (ACEi) and angiotensin II receptor blockers (ARB) in the pandemic context of coronavirus disease 2019 (COVID-19) continues to be debated. Patients with hypertension, diabetes mellitus, chronic renal failure, cerebro-cardiovascular disease, or chronic obstructive pulmonary disease (COPD), who often use ACEi/ARB, may be at risk of severe COVID-19. However, there are no data available on the association of ACEi/ARB use with COVID-19 severity in this population. Methods This study is an observational study of patients with a positive severe acute respiratory syndrome coronavirus 2 test and inpatient treatment at a healthcare facility, using the registry information of COVIREGI-JP. Our primary outcomes were in-hospital death, ventilator support, extracorporeal membrane oxygenation support, and intensive care unit admission. Out of the 6055 patients, 1921 patients with preexisting hypertension, diabetes mellitus, chronic renal failure, cerebro-cardiovascular disease, or COPD were enrolled. Results Factors associated with an increased risk of the primary outcomes were aging, male sex, COPD, severe renal impairment, and diabetes mellitus. No correlations were observed with ACEi/ARB, cerebro-cardiovascular diseases, or hypertension. Associated factors in male patients were aging, renal impairment, hypertension, and diabetes. In female patients, factors associated with an increased risk were aging, ACEi/ARB, renal impairment, and diabetes, whereas hypertension was associated with a lower risk of the primary outcomes. Conclusions Independent factors for the primary outcomes were aging, male sex, COPD, severe renal impairment, and diabetes, but not ACEi/ARB. Based on this registry data analysis, more detailed data collection and analysis is needed with the cooperation of multiple healthcare facilities.
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Anžej Doma S, Lukič M. Severe COVID-19 Infection Management in a Patient with Mild Haemophilia-A Case Report. Hematol Rep 2022; 14:103-107. [PMID: 35466179 PMCID: PMC9036283 DOI: 10.3390/hematolrep14020015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/21/2022] [Accepted: 03/28/2022] [Indexed: 11/27/2022] Open
Abstract
Patients with haemophilia present a significant challenge when admitted into the intensive care unit. To prevent haemorrhagic complications related to the infection or due to invasive procedures factor (F) VIII/IX must be substituted. As thromboembolic complications are frequent among critically ill COVID-19 patients, thromboprophylaxis is also applied to patients with haemophilia. This requires careful monitoring of FVIII/IX activity as well as other haemostatic parameters, such as D-dimer and antiXa. We describe a 44-year old patient with mild haemophilia A (FVIII activity of 6%), who required a prolonged intensive care unit stay due to a severe SARS-CoV-2 infection. FVIII was substituted via boluses, and dalteparin was given according to recommendations. The patient successfully recovered from the disease.
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Affiliation(s)
- Saša Anžej Doma
- Hematology Department, UMC Ljubljana, 1000 Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia;
| | - Milica Lukič
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia;
- Infectious Diseases Department, UMC Ljubljana, 1000 Ljubljana, Slovenia
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Yasuda H, Mayumi T, Okano H. Efficacy of different anticoagulant doses for patients with COVID-19: a systematic review and network meta-analysis. Infection 2022; 50:1453-1463. [PMID: 35355236 PMCID: PMC8966866 DOI: 10.1007/s15010-022-01809-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 03/17/2022] [Indexed: 02/08/2023]
Abstract
Purpose Methods Results Conclusions Trial registration number and registration dates Supplementary Information
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Almskog LM, Wikman A, Svensson J, Bottai M, Kotormán M, Wahlgren CM, Wanecek M, van der Linden J, Ågren A. Hypercoagulation Detected by Rotational Thromboelastometry Predicts Mortality in COVID-19: A Risk Model Based on a Prospective Observational Study. TH OPEN : COMPANION JOURNAL TO THROMBOSIS AND HAEMOSTASIS 2022; 6:e50-e59. [PMID: 35265789 PMCID: PMC8901374 DOI: 10.1055/a-1725-9221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 12/15/2021] [Indexed: 12/02/2022]
Abstract
Background Severe disease due to the novel coronavirus disease 2019 (COVID-19) has been shown to be associated with hypercoagulation. The aim of this study was to assess the Rotational Thromboelastometry (ROTEM) as a marker of coagulopathy in hospitalized COVID-19 patients. Methods This was a prospective, observational study where patients hospitalized due to a COVID-19 infection were eligible for inclusion. Conventional coagulation tests and ROTEM were taken after hospital admission, and patients were followed for 30 days. A prediction model, including variables ROTEM EXTEM-MCF (Maximum Clot Firmness) which in previous data has been suggested a suitable marker of hypercoagulation, age, and respiratory frequency, was developed using logistic regression to evaluate the probability of death. Results Out of the 141 patients included, 18 (13%) died within 30 days. In the final prediction model, the risk of death within 30 days for a patient hospitalized due to COVID-19 was increased with increased EXTEM-MCF, age, and respiratory frequency. Longitudinal ROTEM data in the severely ill subpopulation showed enhanced hypercoagulation. In an in vitro analysis, no heparin effect on EXTEM-coagulation time (CT) was observed, supporting a severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) effect on prolonged initiation of coagulation. Conclusion Here, we show that hypercoagulation measured with ROTEM predicts 30-day mortality in COVID-19. Longitudinal ROTEM data strengthen the hypothesis of hypercoagulation as a driver of severe disease in COVID-19. Thus, ROTEM may be a useful tool to assess disease severity in COVID-19 and could potentially guide anticoagulation therapy.
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Affiliation(s)
- Lou M. Almskog
- Department of Anaesthesiology and Intensive Care, Capio St. Göran's Hospital, Stockholm, Sweden,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden,Address for correspondence Lou M. Almskog Department of Molecular Medicine and Surgery, Karolinska University HospitalStockholm, 171 67Sweden
| | - Agneta Wikman
- Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden,Department of CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Svensson
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Karolinska University Hospital, Stockholm, Sweden
| | - Matteo Bottai
- Division of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Mariann Kotormán
- Department of Anaesthesiology and Intensive Care, Capio St. Göran's Hospital, Stockholm, Sweden
| | - Carl-Magnus Wahlgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden,Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Michael Wanecek
- Department of Anaesthesiology and Intensive Care, Capio St. Göran's Hospital, Stockholm, Sweden,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Jan van der Linden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden,Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Ågren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden,Coagulation Unit, Hematology Centre, Karolinska University Hospital, Stockholm, Sweden,Department of Clinical Sciences, Danderyd Hospital and Karolinska Institutet, Stockholm, Sweden
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Flumignan RL, Civile VT, Tinôco JDDS, Pascoal PI, Areias LL, Matar CF, Tendal B, Trevisani VF, Atallah ÁN, Nakano LC. Anticoagulants for people hospitalised with COVID-19. Cochrane Database Syst Rev 2022; 3:CD013739. [PMID: 35244208 PMCID: PMC8895460 DOI: 10.1002/14651858.cd013739.pub2] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND The primary manifestation of coronavirus disease 2019 (COVID-19) is respiratory insufficiency that can also be related to diffuse pulmonary microthrombosis and thromboembolic events, such as pulmonary embolism, deep vein thrombosis, or arterial thrombosis. People with COVID-19 who develop thromboembolism have a worse prognosis. Anticoagulants such as heparinoids (heparins or pentasaccharides), vitamin K antagonists and direct anticoagulants are used for the prevention and treatment of venous or arterial thromboembolism. Besides their anticoagulant properties, heparinoids have an additional anti-inflammatory potential. However, the benefit of anticoagulants for people with COVID-19 is still under debate. OBJECTIVES To assess the benefits and harms of anticoagulants versus active comparator, placebo or no intervention in people hospitalised with COVID-19. SEARCH METHODS We searched the CENTRAL, MEDLINE, Embase, LILACS and IBECS databases, the Cochrane COVID-19 Study Register and medRxiv preprint database from their inception to 14 April 2021. We also checked the reference lists of any relevant systematic reviews identified, and contacted specialists in the field for additional references to trials. SELECTION CRITERIA Eligible studies were randomised controlled trials (RCTs), quasi-RCTs, cluster-RCTs and cohort studies that compared prophylactic anticoagulants versus active comparator, placebo or no intervention for the management of people hospitalised with COVID-19. We excluded studies without a comparator group and with a retrospective design (all previously included studies) as we were able to include better study designs. Primary outcomes were all-cause mortality and necessity for additional respiratory support. Secondary outcomes were mortality related to COVID-19, deep vein thrombosis, pulmonary embolism, major bleeding, adverse events, length of hospital stay and quality of life. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. We used Cochrane RoB 1 to assess the risk of bias for RCTs, ROBINS-I to assess risk of bias for non-randomised studies (NRS) and GRADE to assess the certainty of evidence. We meta-analysed data when appropriate. MAIN RESULTS We included seven studies (16,185 participants) with participants hospitalised with COVID-19, in either intensive care units, hospital wards or emergency departments. Studies were from Brazil (2), Iran (1), Italy (1), and the USA (1), and two involved more than country. The mean age of participants was 55 to 68 years and the follow-up period ranged from 15 to 90 days. The studies assessed the effects of heparinoids, direct anticoagulants or vitamin K antagonists, and reported sparse data or did not report some of our outcomes of interest: necessity for additional respiratory support, mortality related to COVID-19, and quality of life. Higher-dose versus lower-dose anticoagulants (4 RCTs, 4647 participants) Higher-dose anticoagulants result in little or no difference in all-cause mortality (risk ratio (RR) 1.03, 95% CI 0.92 to 1.16, 4489 participants; 4 RCTs) and increase minor bleeding (RR 3.28, 95% CI 1.75 to 6.14, 1196 participants; 3 RCTs) compared to lower-dose anticoagulants up to 30 days (high-certainty evidence). Higher-dose anticoagulants probably reduce pulmonary embolism (RR 0.46, 95% CI 0.31 to 0.70, 4360 participants; 4 RCTs), and slightly increase major bleeding (RR 1.78, 95% CI 1.13 to 2.80, 4400 participants; 4 RCTs) compared to lower-dose anticoagulants up to 30 days (moderate-certainty evidence). Higher-dose anticoagulants may result in little or no difference in deep vein thrombosis (RR 1.08, 95% CI 0.57 to 2.03, 3422 participants; 4 RCTs), stroke (RR 0.91, 95% CI 0.40 to 2.03, 4349 participants; 3 RCTs), major adverse limb events (RR 0.33, 95% CI 0.01 to 7.99, 1176 participants; 2 RCTs), myocardial infarction (RR 0.86, 95% CI 0.48 to 1.55, 4349 participants; 3 RCTs), atrial fibrillation (RR 0.35, 95% CI 0.07 to 1.70, 562 participants; 1 study), or thrombocytopenia (RR 0.94, 95% CI 0.71 to 1.24, 2789 participants; 2 RCTs) compared to lower-dose anticoagulants up to 30 days (low-certainty evidence). It is unclear whether higher-dose anticoagulants have any effect on necessity for additional respiratory support, mortality related to COVID-19, and quality of life (very low-certainty evidence or no data). Anticoagulants versus no treatment (3 prospective NRS, 11,538 participants) Anticoagulants may reduce all-cause mortality but the evidence is very uncertain due to two study results being at critical and serious risk of bias (RR 0.64, 95% CI 0.55 to 0.74, 8395 participants; 3 NRS; very low-certainty evidence). It is uncertain if anticoagulants have any effect on necessity for additional respiratory support, mortality related to COVID-19, deep vein thrombosis, pulmonary embolism, major bleeding, stroke, myocardial infarction and quality of life (very low-certainty evidence or no data). Ongoing studies We found 62 ongoing studies in hospital settings (60 RCTs, 35,470 participants; 2 prospective NRS, 120 participants) in 20 different countries. Thirty-five ongoing studies plan to report mortality and 26 plan to report necessity for additional respiratory support. We expect 58 studies to be completed in December 2021, and four in July 2022. From 60 RCTs, 28 are comparing different doses of anticoagulants, 24 are comparing anticoagulants versus no anticoagulants, seven are comparing different types of anticoagulants, and one did not report detail of the comparator group. AUTHORS' CONCLUSIONS When compared to a lower-dose regimen, higher-dose anticoagulants result in little to no difference in all-cause mortality and increase minor bleeding in people hospitalised with COVID-19 up to 30 days. Higher-dose anticoagulants possibly reduce pulmonary embolism, slightly increase major bleeding, may result in little to no difference in hospitalisation time, and may result in little to no difference in deep vein thrombosis, stroke, major adverse limb events, myocardial infarction, atrial fibrillation, or thrombocytopenia. Compared with no treatment, anticoagulants may reduce all-cause mortality but the evidence comes from non-randomised studies and is very uncertain. It is unclear whether anticoagulants have any effect on the remaining outcomes compared to no anticoagulants (very low-certainty evidence or no data). Although we are very confident that new RCTs will not change the effects of different doses of anticoagulants on mortality and minor bleeding, high-quality RCTs are still needed, mainly for the other primary outcome (necessity for additional respiratory support), the comparison with no anticoagulation, when comparing the types of anticoagulants and giving anticoagulants for a prolonged period of time.
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Affiliation(s)
- 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
| | | | - Patricia If Pascoal
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Libnah L Areias
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Charbel F Matar
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Britta Tendal
- Living Guidelines Program, Cochrane Australia, Melbourne, Australia
| | - Virginia Fm Trevisani
- Cochrane Brazil, Universidade Federal de São Paulo, São Paulo, Brazil
- Medicina de Urgência, Universidade Federal de São Paulo, 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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Jonmarker S, Litorell J, Dahlberg M, Stackelberg O, Everhov ÅH, Söderberg M, Rubenson‐Wahlin R, Günther M, Mårtensson J, Hollenberg J, Joelsson‐Alm E, Cronhjort M. An observational study of intermediate- or high-dose thromboprophylaxis for critically ill COVID-19 patients. Acta Anaesthesiol Scand 2022; 66:365-374. [PMID: 34875111 DOI: 10.1111/aas.14013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 10/13/2021] [Accepted: 11/16/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Critically ill COVID-19 patients have a high reported incidence of thromboembolic complications and the optimal dose of thromboprophylaxis is not yet determined. The aim of this study was to investigate if 90-day mortality differed between patients treated with intermediate- or high-dose thromboprophylaxis. METHOD In this retrospective study, all critically ill COVID-19 patients admitted to intensive care from March 6th until July 15th, 2020, were eligible. Patients were categorized into groups according to daily dose of thromboprophylaxis. Dosing was based on local standardized recommendations, not on degree of critical illness or risk of thrombosis. Cox proportional hazards regression was used to estimate hazard ratios of death within 90 days from ICU admission. Multivariable models were adjusted for sex, age, body-mass index, Simplified Acute Physiology Score III, invasive respiratory support, glucocorticoids, and dosing strategy of thromboprophylaxis. RESULTS A total of 165 patients were included; 92 intermediate- and 73 high-dose thromboprophylaxis. Baseline characteristics did not differ between groups. The 90-day mortality was 19.6% in patients with intermediate-dose and 19.2% in patients with high-dose thromboprophylaxis. Multivariable hazard ratio of death within 90 days was 0.74 (95% CI, 0.36-1.53) for the high-dose group compared to intermediate-dose group. Multivariable hazard ratio for thromboembolic events and bleedings within 28 days was 0.93 (95% CI 0.37-2.29) and 0.84 (95% CI 0.28-2.54) for high versus intermediate dose, respectively. CONCLUSIONS A difference in 90-day mortality between intermediate- and high-dose thromboprophylaxis could neither be confirmed nor rejected due to a small sample size.
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Affiliation(s)
- Sandra Jonmarker
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet Stockholm Sweden
- Department of Anaesthesia and Intensive Care Södersjukhuset Stockholm Sweden
| | - Jacob Litorell
- Department of Anaesthesia and Intensive Care Södersjukhuset Stockholm Sweden
| | - Martin Dahlberg
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet Stockholm Sweden
- Department of Surgery Södersjukhuset Stockholm Sweden
| | - Otto Stackelberg
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet Stockholm Sweden
- Department of Surgery Södersjukhuset Stockholm Sweden
- Institute of Environmental Medicine Unit of Cardiovascular and Nutritional Epidemiology, Karolinska Institutet Stockholm Sweden
| | - Åsa H. Everhov
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet Stockholm Sweden
- Department of Surgery Södersjukhuset Stockholm Sweden
| | - Mårten Söderberg
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet Stockholm Sweden
- Department of Internal Medicine Södersjukhuset Stockholm Sweden
| | - Rebecka Rubenson‐Wahlin
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet Stockholm Sweden
- Department of Anaesthesia and Intensive Care Södersjukhuset Stockholm Sweden
| | - Mattias Günther
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet Stockholm Sweden
- Department of Anaesthesia and Intensive Care Södersjukhuset Stockholm Sweden
| | - Johan Mårtensson
- Department of Physiology and Pharmacology Section of Anaesthesia and Intensive Care, Karolinska Institutet Stockholm Sweden
- Department of Perioperative Medicine and Intensive Care Karolinska University Hospital Stockholm Sweden
| | - Jacob Hollenberg
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet Stockholm Sweden
- Department of Cardiology Södersjukhuset Stockholm Sweden
| | - Eva Joelsson‐Alm
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet Stockholm Sweden
- Department of Anaesthesia and Intensive Care Södersjukhuset Stockholm Sweden
| | - Maria Cronhjort
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet Stockholm Sweden
- Department of Anaesthesia and Intensive Care Södersjukhuset Stockholm Sweden
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Kory P, Meduri GU, Iglesias J, Varon J, Cadegiani FA, Marik PE. "MATH+" Multi-Modal Hospital Treatment Protocol for COVID-19 Infection: Clinical and Scientific Rationale. J Clin Med Res 2022; 14:53-79. [PMID: 35317360 PMCID: PMC8912998 DOI: 10.14740/jocmr4658] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/08/2022] [Indexed: 11/17/2022] Open
Abstract
In December 2019, coronavirus disease 2019 (COVID-19), a severe respiratory illness caused by the new coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in Wuhan, China. The greatest impact that COVID-19 had was on intensive care units (ICUs), given that approximately 20% of hospitalized cases developed acute respiratory failure (ARF) requiring ICU admission. Based on the assumption that COVID-19 represented a viral pneumonia and no anti-coronaviral therapy existed, nearly all national and international health care societies recommended "supportive care only" avoiding other therapies outside of randomized controlled trials, with a specific prohibition against the use of corticosteroids in treatment. However, early studies of COVID-19-associated ARF reported inexplicably high mortality rates, with frequent prolonged durations of mechanical ventilation (MV), even from centers expert in such supportive care strategies. These reports led the authors to form a clinical expert panel called the Front-Line COVID-19 Critical Care Alliance (www.flccc.net). The panel collaboratively reviewed the emerging clinical, radiographic, and pathological reports of COVID-19 while initiating multiple discussions among a wide clinical network of front-line clinical ICU experts from initial outbreak areas in China, Italy, and New York. Based on the shared early impressions of "what was working and what wasn't working", the increasing medical journal publications and the rapidly accumulating personal clinical experiences with COVID-19 patients, a treatment protocol was created for the hospitalized patients based on the core therapies of methylprednisolone, ascorbic acid, thiamine, heparin and non-antiviral co-interventions (MATH+). This manuscript reviews the scientific and clinical rationale behind MATH+ based on published in-vitro, pre-clinical, and clinical data in support of each medicine, with a special emphasis of studies supporting their use in the treatment of patients with viral syndromes and COVID-19 specifically.
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Affiliation(s)
- Pierre Kory
- Front Line Critical Care Consortium (FLCCC.org), Washington DC, USA
| | | | - Jose Iglesias
- Jersey Shore University Medical Center, Hackensack School of Medicine at Seton Hall, NJ, USA
| | - Joseph Varon
- University of Texas Health Science Center, Houston, TX, USA
| | | | - Paul E. Marik
- Front Line Critical Care Consortium (FLCCC.org), Washington DC, USA
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Hoogenboom WS, Lu JQ, Musheyev B, Borg L, Janowicz R, Pamlayne S, Hou W, Duong TQ. Prophylactic versus therapeutic dose anticoagulation effects on survival among critically ill patients with COVID-19. PLoS One 2022; 17:e0262811. [PMID: 35045130 PMCID: PMC8769345 DOI: 10.1371/journal.pone.0262811] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 01/05/2022] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Although patients with severe COVID-19 are known to be at high risk of developing thrombotic events, the effects of anticoagulation (AC) dose and duration on in-hospital mortality in critically ill patients remain poorly understood and controversial. The goal of this study was to investigate survival of critically ill COVID-19 patients who received prophylactic or therapeutic dose AC and analyze the mortality rate with respect to detailed demographic and clinical characteristics. MATERIALS AND METHODS We conducted a retrospective, observational study of critically ill COVID-19 patients admitted to the ICU at Stony Brook University Hospital in New York who received either prophylactic (n = 158) or therapeutic dose AC (n = 153). Primary outcome was in-hospital death assessed by survival analysis and covariate-adjusted Cox proportional hazard model. RESULTS For the first 3 weeks of ICU stay, we observed similar survival curves for prophylactic and therapeutic AC groups. However, after 3 or more weeks of ICU stay, the therapeutic AC group, characterized by high incidence of acute kidney injury (AKI), had markedly higher death incidence rates with 8.6 deaths (95% CI = 6.2-11.9 deaths) per 1,000 person-days and about 5 times higher risk of death (adj. HR = 4.89, 95% CI = 1.71-14.0, p = 0.003) than the prophylactic group (2.4 deaths [95% CI = 0.9-6.3 deaths] per 1,000 person-days). Among therapeutic AC users with prolonged ICU admission, non-survivors were characterized by older males with depressed lymphocyte counts and cardiovascular disease. CONCLUSIONS Our findings raise the possibility that prolonged use of high dose AC, independent of thrombotic events or clinical background, might be associated with higher risk of in-hospital mortality. Moreover, AKI, age, lymphocyte count, and cardiovascular disease may represent important risk factors that could help identify at-risk patients who require long-term hospitalization with therapeutic dose AC treatment.
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Affiliation(s)
- Wouter S. Hoogenboom
- Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, United States of America
- * E-mail: (WSH); (TQD)
| | - Joyce Q. Lu
- Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, United States of America
| | - Benjamin Musheyev
- Stony Brook University, Renaissance School of Medicine, Stony Brook, New York, United States of America
| | - Lara Borg
- Stony Brook University, Renaissance School of Medicine, Stony Brook, New York, United States of America
| | - Rebeca Janowicz
- Stony Brook University, Renaissance School of Medicine, Stony Brook, New York, United States of America
| | - Stacey Pamlayne
- Stony Brook University, Renaissance School of Medicine, Stony Brook, New York, United States of America
| | - Wei Hou
- Stony Brook University, Renaissance School of Medicine, Stony Brook, New York, United States of America
| | - Tim Q. Duong
- Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, United States of America
- * E-mail: (WSH); (TQD)
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Reichman-Warmusz E, Warmusz O, Wojnicz R. The rationale for using low-molecular weight heparin in the therapy of symptomatic COVID-19 patients. Open Med (Wars) 2022; 17:216-220. [PMID: 35178474 PMCID: PMC8812716 DOI: 10.1515/med-2021-0374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 07/01/2021] [Accepted: 09/29/2021] [Indexed: 11/30/2022] Open
Abstract
Accumulated evidence suggest that the adverse outcome of severe coronavirus disease 2019 (COVID-19) is closely related to prothrombotic microvascular pathology with a high risk of venous thromboembolism. Furthermore, the first observational studies indicated that adjunct therapy with low-molecular weight heparin (LMWH) was associated with lower mortality in this cohort of patients. However, the timing of starting LMWH and the dose remain controversial in COVID-19 patients. Considering the above, the aim of this study was to reveal the rationale for using LMWH in the therapy of symptomatic COVID-19 patients based on experimental and clinical studies on LMWH in inflammatory settings with special consideration given to randomized trials.
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Affiliation(s)
- Edyta Reichman-Warmusz
- Department of Histology and Cell Pathology in Zabrze, School of Medicine with the Division of Dentistry, Medical University of Silesia in Katowice , Jordana 19 , 41-808 Zabrze , Poland
| | - Oliwia Warmusz
- Department of Histology and Cell Pathology in Zabrze, School of Medicine with the Division of Dentistry, Medical University of Silesia in Katowice , Zabrze , Poland
| | - Romuald Wojnicz
- Department of Histology and Cell Pathology in Zabrze, School of Medicine with the Division of Dentistry, Medical University of Silesia in Katowice , Jordana 19 , 41-808 Zabrze , Poland
- Silesian Centre for Heart Disease in Zabrze , Zabrze , Poland
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Robinson K, Schott LL, Matthews T, Tyagi M, Ajmani VB, Sacco N, Cao Z. Assessment of Healthcare Resource Utilization by Anticoagulant Heparinoid Dosage Level in Patients Hospitalized with COVID-19. Clin Appl Thromb Hemost 2022; 28:10760296221137848. [DOI: 10.1177/10760296221137848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The aim was to describe inpatients with COVID-19 empirically prescribed heparinoid anticoagulants and compare resource utilization between prophylactic/low-dose and therapeutic/high-dose groups. Methods: This retrospective observational study used real-world data from 880 US hospitals in the PINC AI™ Healthcare Database during 4/1/2020–11/30/2020. Descriptive analysis was used to characterize patients. Multivariable regression was used to evaluate intensive care unit (ICU) admissions, length of stay (LOS), mortality, and costs by anticoagulation dose group, adjusting for cohort characteristics. Among 122,508 inpatients, 29,225 (23.9%) received therapeutic/high-dose, and 93,283 (76.1%) received prophylactic/low-dose anticoagulation. The high-dose group had more comorbidities and worse laboratory values compared with low-dose. Respectively, ICU admission rates were 36.7% and 19.1% and LOS median (Q1, Q3) was 8 (5, 15) and 5 (3, 9) days. In separate adjusted models, high-dose anticoagulation was associated with a 45% increase in odds of ICU admission, 26% increase in odds of in-hospital mortality, 21% longer average LOS, and 28% greater average total cost compared with low-dose (each P < 0.001). Prophylactic/low-dose anticoagulation treatment was associated with decreased healthcare resource utilization (HRU) in hospitalized patients with COVID-19.
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Affiliation(s)
- Keith Robinson
- Medical and Scientific Management, Syneos Health, Morrisville, NC, USA
| | - Laura L. Schott
- PINC AI™ Applied Sciences®, Premier Inc., Charlotte, NC, USA
| | - Tom Matthews
- Specialty Pharma, Meitheal Pharmaceuticals, Inc., Chicago, IL, USA
| | - Manu Tyagi
- PINC AI™ Applied Sciences®, Premier Inc., Charlotte, NC, USA
| | - Vivek B. Ajmani
- PINC AI™ Applied Sciences®, Premier Inc., Charlotte, NC, USA
| | - Nancy Sacco
- Specialty Pharma, Meitheal Pharmaceuticals, Inc., Chicago, IL, USA
| | - Zhun Cao
- PINC AI™ Applied Sciences®, Premier Inc., Charlotte, NC, USA
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Malek RJ, Bill CA, Vines CM. Clinical drug therapies and biologicals currently used or in clinical trial to treat COVID-19. Biomed Pharmacother 2021; 144:112276. [PMID: 34624681 PMCID: PMC8486678 DOI: 10.1016/j.biopha.2021.112276] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/19/2021] [Accepted: 09/28/2021] [Indexed: 01/18/2023] Open
Abstract
The potential emergence of SARS-CoV-2 variants capable of escaping vaccine-generated immune responses poses a looming threat to vaccination efforts and will likely prolong the duration of the COVID-19 pandemic. Additionally, the prevalence of beta coronaviruses circulating in animals and the precedent they have set in jumping into human populations indicates that they pose a continuous threat for future pandemics. Currently, only one therapeutic is approved by the U.S. Food and Drug Administration (FDA) for use in treating COVID-19, remdesivir, although other therapies are authorized for emergency use due to this pandemic being a public health emergency. In this review, twenty-four different treatments are discussed regarding their use against COVID-19 and any potential future coronavirus-associated illnesses. Their traditional use, mechanism of action against COVID-19, and efficacy in clinical trials are assessed. Six treatments evaluated are shown to significantly decrease mortality in clinical trials, and ten treatments have shown some form of clinical efficacy.
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Affiliation(s)
- Rory J. Malek
- University of Texas at Austin, Austin TX 78705, United States
| | - Colin A. Bill
- Department of Biological Sciences, Border Biomedical Research Center, The University of Texas at El Paso, El Paso TX 79968, United States
| | - Charlotte M. Vines
- Department of Biological Sciences, Border Biomedical Research Center, The University of Texas at El Paso, El Paso TX 79968, United States,Corresponding author
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Sjöström B, Månsson E, Viklund Kamienny J, Östberg E. Characteristics and definitive outcomes of COVID-19 patients admitted to a secondary hospital intensive care unit in Sweden. Health Sci Rep 2021; 4:e446. [PMID: 34938894 PMCID: PMC8670731 DOI: 10.1002/hsr2.446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 11/11/2021] [Accepted: 11/11/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND AND AIMS Most published reports of COVID-19 Intensive Care Unit (ICU) patients are from large tertiary hospitals and often present short-term or incomplete outcome data. There are reports indicating that ICUs with fewer beds are associated with higher mortality. This study aimed to investigate the definitive outcome and patient characteristics of the complete first wave of COVID-19 patients admitted to ICU in a secondary hospital. METHODS In this prospective observational study, all patients with respiratory failure and a positive SARS-CoV-2 test admitted to Västerås Hospital ICU between 24 March and July 22, 2020 were included. The primary outcome was defined as 90-day mortality. Secondary outcomes included ICU length of stay, hospital length of stay, number of days with invasive ventilation, need for vasopressors/inotropes, and use of renal replacement therapy. RESULTS Fifty-three patients were included. Median age (range) was 59 (33-76) and 74% were men. Obesity and hypertension were the most common comorbidities and 45% of the patients were born outside Europe. Ninety-day mortality was 30%. Median ICU length of stay (interquartile range) was 14 (5-24) days and the duration of invasive mechanical ventilation 16 (12-26) days. No patients received dialysis at 90-day follow-up. CONCLUSION In this cohort of COVID-19 patients treated in a secondary hospital ICU, mortality rates were low compared to early studies from China, Italy, and the United States, but similar to other government-funded hospitals in Scandinavia. A preparatory reorganization enabled an increase in ICU capacity, hence avoiding an overwhelmed intensive care organization.
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Affiliation(s)
- Björn Sjöström
- Department of Anaesthesia and Intensive CareVästerås HospitalVästeråsSweden
| | - Emeli Månsson
- Department of Infectious Diseases, Västerås Hospital, Västerås, and School of Medical Sciences, Faculty of Medicine and HealthÖrebro University, Örebro, and Region Västmanland—Uppsala University, Centre for Clinical Research, Västerås HospitalVästeråsSweden
| | | | - Erland Östberg
- Department of Anaesthesia and Intensive CareVästerås Hospital, Västerås, and Region Västmanland—Uppsala University, Centre for Clinical Research, Västerås HospitalVästeråsSweden
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Kollias A, Kyriakoulis KG, Trontzas IP, Rapti V, Kyriakoulis IG, Theochari CA, Dimakakos E, Poulakou G, Syrigos K. High versus Standard Intensity of Thromboprophylaxis in Hospitalized Patients with COVID-19: A Systematic Review and Meta-Analysis. J Clin Med 2021; 10:jcm10235549. [PMID: 34884258 PMCID: PMC8658422 DOI: 10.3390/jcm10235549] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 11/21/2021] [Accepted: 11/24/2021] [Indexed: 12/17/2022] Open
Abstract
Thromboprophylaxis in hospitalized patients with COVID-19 has been associated with a survival benefit and is strongly recommended. However, the optimal dose of thromboprophylaxis remains unclear. A systematic review and meta-analysis (PubMed/EMBASE) of studies comparing high (intermediate or therapeutic dose) versus standard (prophylactic dose) intensity of thrombo-prophylaxis with regard to outcome of hospitalized patients with COVID-19 was performed. Randomized and non-randomized studies that provided adjusted effect size estimates were included. Meta-analysis of 7 studies comparing intermediate versus prophylactic dose of thromboprophylaxis (2 randomized and 5 observational, n = 2009, weighted age 61 years, males 61%, ICU 53%) revealed a pooled adjusted relative risk (RR) for death at 0.56 (95% confidence intervals (CI) 0.34, 0.92) in favor of the intermediate dose. For the same comparison arms, the pooled RR for venous thromboembolism was 0.84 (95% CI 0.54, 1.31), and for major bleeding events was 1.63 (95% CI 0.79, 3.37). Meta-analysis of 17 studies comparing therapeutic versus prophylactic dose of thromboprophylaxis (2 randomized and 15 observational, n = 7776, weighted age 64 years, males 54%, ICU 21%) revealed a pooled adjusted RR for death at 0.73 (95% CI 0.47, 1.14) for the therapeutic dose. An opposite trend was observed in the unadjusted analysis of 15 observational studies (RR 1.24 (95% CI 0.88, 1.74)). For the same comparison arms, the pooled RR for venous thromboembolism was 1.13 (95% CI 0.52, 2.48), and for major bleeding events 3.32 (95% CI 2.51, 4.40). In conclusion, intermediate compared with standard prophylactic dose of thromboprophylaxis appears to be rather safe and is associated with additional survival benefit, although most data are derived from observational retrospective analyses. Randomized studies are needed to define the optimal thromboprophylaxis in hospitalized patients with COVID-19.
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Zhang S, Li Y, Liu G, Su B. Intermediate-to-therapeutic versus prophylactic anticoagulation for coagulopathy in hospitalized COVID-19 patients: a systemic review and meta-analysis. Thromb J 2021; 19:91. [PMID: 34819094 PMCID: PMC8611638 DOI: 10.1186/s12959-021-00343-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 11/04/2021] [Indexed: 02/08/2023] Open
Abstract
Background Anticoagulation in hospitalized COVID-19 patients has been associated with survival benefit; however, the optimal anticoagulant strategy has not yet been defined. The objective of this meta-analysis was to investigate the effect of intermediate-to-therapeutic versus prophylactic anticoagulation for thromboprophylaxis on the primary outcome of in-hospital mortality and other patient-centered secondary outcomes in COVID-19 patients. Methods MEDLINE, EMBASE, and Cochrane databases were searched from inception to August 10th 2021. Cohort studies and randomized clinical trials that assessed the efficacy and safety of intermediate-to-therapeutic versus prophylactic anticoagulation in hospitalized COVID-19 patients were included. Baseline characteristics and relevant data of each study were extracted in a pre-designed standardized data-collection form. The primary outcome was all-cause in-hospital mortality and the secondary outcomes were incidence of thrombotic events and incidence of any bleeding and major bleeding. Pooled analysis with random effects models yielded relative risk with 95 % CIs. Results This meta-analysis included 42 studies with 28,055 in-hospital COVID-19 patients totally. Our pooled analysis demonstrated that intermediate-to-therapeutic anticoagulation was not associated with lower in-hospital mortality (RR=1.12, 95 %CI 0.99-1.25, p=0.06, I2=77 %) and lower incidence of thrombotic events (RR=1.30, 95 %CI 0.79-2.15, p=0.30, I2=88 %), but increased the risk of any bleeding events (RR=2.16, 95 %CI 1.79-2.60, p<0.01, I2=31 %) and major bleeding events significantly (RR=2.10, 95 %CI 1.77-2.51, p<0.01, I2=11 %) versus prophylactic anticoagulation. Moreover, intermediate-to-therapeutic anticoagulation decreased the incidence of thrombotic events (RR=0.71, 95 %CI 0.56-0.89, p=0.003, I2=0 %) among critically ill COVID-19 patients admitted to intensive care units (ICU), with increased bleeding risk (RR=1.66, 95 %CI 1.37-2.00, p<0.01, I2=0 %) and unchanged in-hospital mortality (RR=0.94, 95 %CI 0.79-1.10, p=0.42, I2=30 %) in such patients. The Grading of Recommendation, Assessment, Development, and Evaluation certainty of evidence ranged from very low to moderate. Conclusions We recommend the use of prophylactic anticoagulation against intermediate-to-therapeutic anticoagulation among unselected hospitalized COVID-19 patients considering insignificant survival benefits but higher risk of bleeding in the escalated thromboprophylaxis strategy. For critically ill COVID-19 patients, the benefits of intermediate-to-therapeutic anticoagulation in reducing thrombotic events should be weighed cautiously because of its association with higher risk of bleeding. Trial registration The protocol was registered at PROSPERO on August 17th 2021 (CRD42021273780). Graphical abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1186/s12959-021-00343-1.
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Affiliation(s)
- Sirui Zhang
- West China School of Medicine, Sichuan University, 610041, Chengdu, China
| | - Yupei Li
- Department of Nephrology, Med+ Biomaterial Institute, West China Hospital, Sichuan University, 610041, Chengdu, China.,Institute for Disaster Management and Reconstruction, Sichuan University, 610207, Chengdu, China
| | - Guina Liu
- West China School of Medicine, Sichuan University, 610041, Chengdu, China
| | - Baihai Su
- West China School of Medicine, Sichuan University, 610041, Chengdu, China. .,Department of Nephrology, Med+ Biomaterial Institute, West China Hospital, Sichuan University, 610041, Chengdu, China. .,Institute for Disaster Management and Reconstruction, Sichuan University, 610207, Chengdu, China. .,The first People's Hospital of Shuangliu District, 610200, Chengdu, China. .,Med-X Center for Materials, Sichuan University, 610041, Chengdu, China.
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Guglielmetti L, Aschieri D, Kontsevaya I, Calabrese F, Donisi A, Faggi A, Ferrante P, Fronti E, Gerna L, Leoni MC, Paolillo F, Ratti G, Ruggieri A, Sacchini D, Scotti M, Valdatta C, Stabile M, Taliani G, Codeluppi M. Treatment for COVID-19-a cohort study from Northern Italy. Sci Rep 2021; 11:20964. [PMID: 34697322 PMCID: PMC8545945 DOI: 10.1038/s41598-021-00243-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 08/31/2021] [Indexed: 11/30/2022] Open
Abstract
Multicentre, retrospective cohort study with multivariable Cox proportional-hazards modelling and survival-time inverse-probability-weighting, evaluating the impact of different treatments on survival of proven COVID-19 patients admitted to two Hospitals in the province of Piacenza, Italy. Use of tocilizumab and of high doses of low molecular weight heparin, but not of antivirals (either alone or in combination), azithromycin, and any corticosteroid, was independently associated with lower mortality. Our results support further clinical evaluation of high doses of low molecular weight heparin and tocilizumab as COVID-19 therapeutics.
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Affiliation(s)
- Lorenzo Guglielmetti
- Sorbonne Université, INSERM, U1135, Centre d'Immunologie et des Maladies Infectieuses, Cimi-Paris, équipe 13, Paris, France.
- APHP, Groupe Hospitalier Universitaire Sorbonne Université, Hôpital Pitié-Salpêtrière, Centre National de Référence Des Mycobactéries Et de La Résistance Des Mycobactéries Aux Antituberculeux, Paris, France.
- Infectious Diseases Unit, Guglielmo da Saliceto Hospital, Piacenza, Italy.
| | | | - Irina Kontsevaya
- Research Center Borstel, Borstel, Germany
- German Center for Infection Research, Hamburg-Lübeck-Borstel-Riems, Borstel, Germany
- International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany
| | | | - Alessandra Donisi
- Migration Health Unit, Primary Health Care Department, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - Alberto Faggi
- Infectious Diseases Unit, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - Patrizia Ferrante
- Infectious Diseases Unit, Guglielmo da Saliceto Hospital, Piacenza, Italy
- Institute for Cross-Disciplinary Physics and Complex Systems IFISC (UIB-CSIC), Campus Universitat Illes Balears, 07122, Palma de Mallorca, Spain
| | - Elisa Fronti
- Infectious Diseases Unit, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - Laura Gerna
- Infectious Diseases Unit, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | | | - Franco Paolillo
- Infectious Diseases Unit, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - Giovanna Ratti
- Infectious Diseases Unit, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | | | - Daria Sacchini
- Infectious Diseases Unit, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - Marta Scotti
- Infectious Diseases Unit, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - Caterina Valdatta
- Infectious Diseases Unit, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - Marco Stabile
- Plastic Surgery Unit, Castel San Giovanni Hospital, Piacenza, Italy
| | - Gloria Taliani
- Infectious Diseases Unit, Guglielmo da Saliceto Hospital, Piacenza, Italy
- Infectious and Tropical Disease Unit, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
- Anti-COVID Task Force of the Italian Civil Protection, Rome, Italy
| | - Mauro Codeluppi
- Infectious Diseases Unit, Guglielmo da Saliceto Hospital, Piacenza, Italy
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Schandl A, Hedman A, Lyngå P, Fathi Tachinabad S, Svefors J, Roël M, Geborek A, Andersson Franko M, Söderberg M, Joelsson‐Alm E, Darlington P. Long-term consequences in critically ill COVID-19 patients: A prospective cohort study. Acta Anaesthesiol Scand 2021; 65:1285-1292. [PMID: 34097753 PMCID: PMC8212104 DOI: 10.1111/aas.13939] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 05/17/2021] [Accepted: 05/19/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND COVID-19 can cause severe disease with need of treatment in the intensive care unit (ICU) for several weeks. Increased knowledge is needed about the long-term consequences. METHODS This is a single-center prospective follow-up study of COVID-19 patients admitted to the ICU for respiratory organ support between March and July 2020. Patients with invasive ventilation were compared with those with high-flow nasal oxygen (HFNO) or non-invasive ventilation (NIV) regarding functional outcome and health-related qualify of life. The mean follow-up time was 5 months after ICU discharge and included clinical history, three well-validated questionnaires about health-related quality of life and psychological health, pulmonary function test, 6-minute walk test (6MWT) and work ability. Data were analyzed with multivariable general linear and logistic regression models with 95% confidence intervals. RESULTS Among 248 ICU patients, 200 patients survived. Of these, 113 patients came for follow-up. Seventy patients (62%) had received invasive ventilation. Most patients reported impaired health-related quality of life. Approximately one-third suffered from post-traumatic stress, anxiety and depression. Twenty-six percent had reduced total lung capacity, 34% had reduced 6MWT and 50% worked fulltime. The outcomes were similar regardless of ventilatory support, but invasive ventilation was associated with more bodily pain (MSD -19, 95% CI: -32 to -5) and <80% total lung capacity (OR 4.1, 95% CI: 1.3-16.5). CONCLUSION Among survivors of COVID-19 who required respiratory organ support, outcomes 5 months after discharge from ICU were largely similar among those requiring invasive compared to non-invasive ventilation.
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Affiliation(s)
- Anna Schandl
- Department of Anesthesiology and Intensive Care Södersjukhuset Stockholm Sweden
- Department of Clinical Science and Education SödersjukhusetKarolinska Institutet Stockholm Sweden
- Department of Molecular medicine and surgery Karolinska Institutet Stockholm Sweden
| | - Anders Hedman
- Department of Clinical Science and Education SödersjukhusetKarolinska Institutet Stockholm Sweden
- Department of Cardiology Södersjukhuset Stockholm Sweden
| | - Patrik Lyngå
- Department of Clinical Science and Education SödersjukhusetKarolinska Institutet Stockholm Sweden
- Department of Cardiology Södersjukhuset Stockholm Sweden
| | | | - Jessica Svefors
- Department of Internal Medicine Södersjukhuset Stockholm Sweden
| | - Mari Roël
- Department of Internal Medicine Södersjukhuset Stockholm Sweden
| | - Anne Geborek
- Department of Internal Medicine Södersjukhuset Stockholm Sweden
| | - Mikael Andersson Franko
- Department of Clinical Science and Education SödersjukhusetKarolinska Institutet Stockholm Sweden
| | - Mårten Söderberg
- Department of Clinical Science and Education SödersjukhusetKarolinska Institutet Stockholm Sweden
- Department of Internal Medicine Södersjukhuset Stockholm Sweden
| | - Eva Joelsson‐Alm
- Department of Anesthesiology and Intensive Care Södersjukhuset Stockholm Sweden
- Department of Clinical Science and Education SödersjukhusetKarolinska Institutet Stockholm Sweden
| | - Pernilla Darlington
- Department of Clinical Science and Education SödersjukhusetKarolinska Institutet Stockholm Sweden
- Department of Internal Medicine Södersjukhuset Stockholm Sweden
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Kumar G, Patel D, Odeh T, Rojas E, Sakhuja A, Meersman M, Dalton D, Nanchal R, Guddati AK. Incidence of Venous Thromboembolism and Effect of Anticoagulant Dosing in Hospitalized COVID-19 Patients. J Hematol 2021; 10:162-170. [PMID: 34527112 PMCID: PMC8425807 DOI: 10.14740/jh836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 05/07/2021] [Indexed: 12/15/2022] Open
Abstract
Background Coronavirus disease 2019 (COVID-19) is characterized by coagulopathy and thrombotic events. We examined factors associated with development of venous thromboembolism (VTE) in COVID-19 and to discern if higher dose of anticoagulation was beneficial in these patients. Methods This study involves an observational study of prospectively collected data in the setting of a large community hospital in a rural setting in Northeast Georgia with COVID-19 between March 1, 2020 and February 5, 2021. Anticoagulation dose (none, standard, intermediate, and therapeutic dosages) was studied in adult patients (≥ 18 years). We constructed multivariable logistic regression model to examine the association of clinical characteristics with VTE. To examine the effect of dose of anticoagulation in preventing VTE, we used inverse probability weighted regression adjustment. Results Of the 4,645 patients with COVID-19, 251 (5.4%) patients were found to have VTE. Of these, 91 had pulmonary embolism, 148 had deep venous thrombosis (DVT) and 12 had both. A total of 129 of VTE cases were diagnosed at admission. Of all admissions, 12.9% did not receive any DVT prophylaxis, 70.4% received prophylactic dose, 1.3% received intermediate dose and 15.5% received therapeutic dose. Male gender (odds ratio (OR): 1.55, 95% confidence interval (CI): 1.0 - 2.4, P = 0.04) and Black race (OR: 2.0, 95% CI: 1.2 - 3.4, P = 0.01), along with higher levels of lactate dehydrogenase (LDH) and D-dimer were associated with higher odds of developing VTE. Patients receiving steroids had lower rates of VTE (3.9% vs. 8.3%, P < 0.001). Use of intermediate or therapeutic anticoagulation was not associated with lower odds of developing VTE. However, patients on therapeutic anticoagulation had lower odds of in hospital mortality when compared to standard dose (OR: 0.47, 95% CI: 0.27 - 0.80, P = 0.006). Conclusions In COVID-19, D-dimer and LDH can be useful in predicting VTE. Steroids appear to have some protective role in development of VTE. Therapeutic anticoagulation did not result in lower rates of VTE but was associated with in-hospital mortality.
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Affiliation(s)
- Gagan Kumar
- Department of Pulmonary and Critical Care, Northeast Georgia Health System, Gainesville, GA 30501, USA
| | - Dhaval Patel
- Department of Pulmonary and Critical Care, Northeast Georgia Health System, Gainesville, GA 30501, USA
| | - Tariq Odeh
- Department of Internal Medicine, Northeast Georgia Health System, Gainesville, GA 30501, USA
| | - Erine Rojas
- Department of Pulmonary and Critical Care, Northeast Georgia Health System, Gainesville, GA 30501, USA
| | - Ankit Sakhuja
- Division of Cardiovascular Critical Care, Department of Cardiovascular and Thoracic Surgery, West Virginia University, WV 26506, USA
| | - Mark Meersman
- IPC Global, 4080 McGinnis Ferry Road, Building 100, Suite 103, Alpharetta, GA 30005, USA
| | - Drew Dalton
- IPC Global, 4080 McGinnis Ferry Road, Building 100, Suite 103, Alpharetta, GA 30005, USA
| | - Rahul Nanchal
- Division of Pulmonary and Critical Care, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Achuta Kumar Guddati
- Division of Hematology/Oncology, Georgia Cancer Center, Augusta University, Augusta, GA 30909, USA
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Giossi R, Menichelli D, Pani A, Tratta E, Romandini A, Roncato R, Nani A, Schenardi P, Diani E, Fittipaldo VA, Farcomeni A, Scaglione F, Pastori D. A Systematic Review and a Meta-Analysis Comparing Prophylactic and Therapeutic Low Molecular Weight Heparins for Mortality Reduction in 32,688 COVID-19 Patients. Front Pharmacol 2021; 12:698008. [PMID: 34539396 PMCID: PMC8443784 DOI: 10.3389/fphar.2021.698008] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 08/05/2021] [Indexed: 12/13/2022] Open
Abstract
Background: Antithrombotic treatment, including low molecular weight heparin (LMWH) or unfractionated heparin (UFH), has been proposed as a potential therapy for coronavirus disease 2019 (COVID-19) to lower diffuse intravascular clotting activation. However, it is unclear whether prophylactic or therapeutic doses have similar efficacy in reducing mortality. Methods: We performed a systematic review (PROSPERO registration CRD42020179955) and meta-analysis including observational cohort studies and randomized controlled trials (RCT) evaluating the effectiveness of heparins (either LMWH, UFH, or fondaparinux) in COVID-19 patients. Heparin treatment was compared to no anticoagulation. A subgroup analysis on prophylactic or therapeutic doses compared to no anticoagulation was performed. Prophylactic dose was also compared to full dose anticoagulation. Primary endpoint was all-cause mortality. Secondary endpoints were major bleeding and length of hospital stay (LOS). Results: 33 studies (31 observational, 2 RCT) were included for a total overall population of 32,688 patients. Of these, 21,723 (66.5%) were on heparins. 31 studies reported data on all-cause mortality, showing that both prophylactic and full dose reduced mortality (pooled Hazard Ratio [HR] 0.63, 95% confidence interval [CI] 0.57-0.69 and HR 0.56, 95% CI 0.47-0.66, respectively). However, the full dose was associated with a higher risk of major bleeding (Odds Ratio [OR] 2.01, 95% CI 1.14-3.53) compared to prophylactic dose. Finally, LOS was evaluated in 3 studies; no difference was observed between patients with and without heparins (0.98, -3.87, 5.83 days). Conclusion: Heparin at both full and prophylactic dose is effective in reducing mortality in hospitalized COVID-19 patients, compared to no treatment. However, full dose was associated with an increased risk of bleeding. Systematic Review Registration: https://clinicaltrials.gov/, identifier CRD42020179955.
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Affiliation(s)
- Riccardo Giossi
- Postgraduate School of Clinical Pharmacology, Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Danilo Menichelli
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Arianna Pani
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Elena Tratta
- Postgraduate School of Clinical Pharmacology, Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
- Central Pharmacy, ASST Spedali Civili, Brescia, Italy
| | - Alessandra Romandini
- Postgraduate School of Clinical Pharmacology, Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Rossana Roncato
- Experimental and Clinical Pharmacology Unit, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
| | - Alessandro Nani
- Postgraduate School of Clinical Pharmacology, Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Paolo Schenardi
- Postgraduate School of Clinical Pharmacology, Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Erika Diani
- Postgraduate School of Clinical Pharmacology, Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
- Pharmacy Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| | | | - Alessio Farcomeni
- Department of Economics and Finance, University of Rome “Tor Vergata”, Rome, Italy
| | - Francesco Scaglione
- Postgraduate School of Clinical Pharmacology, Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
- Department of Laboratory Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Daniele Pastori
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
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48
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Jiang L, Li Y, Du H, Qin Z, Su B. Effect of Anticoagulant Administration on the Mortality of Hospitalized Patients With COVID-19: An Updated Systematic Review and Meta-Analysis. Front Med (Lausanne) 2021; 8:698935. [PMID: 34422860 PMCID: PMC8371681 DOI: 10.3389/fmed.2021.698935] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 07/05/2021] [Indexed: 02/05/2023] Open
Abstract
Background: Anticoagulation is generally used in hospitalized patients with coronavirus disease 2019 (COVID-19) as thromboprophylaxis. However, results from different studies comparing the effect of anticoagulation on the mortality of COVID-19 patients with non-anticoagulation are inconclusive. Methods: Our systematic review included observational trials if they studied anticoagulant therapy in hospitalized patients with COVID-19 for mortality or bleeding events. Dichotomous variables from individual studies were pooled by risk ratio (RR) and their 95% confidence interval (95% CI) using the random-effects model. Grading of Recommendations Assessment, Development and Evaluation was used to assess the quality of evidence. Results: A total of 11 observational studies enrolling 20,748 hospitalized COVID-19 patients overall were included. A pooled meta-analysis of these studies showed that anticoagulation therapy, compared with non-anticoagulation therapy, was associated with lower mortality risk (RR 0.70, 95% CI 0.52–0.93, p = 0.01). The evidence of benefit was stronger among critically ill COVID-19 patients in the intensive care units (RR 0.59, 95% CI 0.43–0.83, p = 0.002). Additionally, severe bleeding events were not associated with the administration of anticoagulants (RR 0.93, 95% CI 0.71–1.23, p = 0.63). Conclusion: Among patients with COVID-19 admitted to hospital, the administration of anticoagulants was associated with a decreased mortality without increasing the incidence of bleeding events.
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Affiliation(s)
- Luojia Jiang
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China.,Department of Nephrology, Jiujiang No. 1 People's Hospital, Jiujiang, China
| | - Yupei Li
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China.,Disaster Medicine Center, Institute for Disaster Management and Reconstruction, Sichuan University, Chengdu, China
| | - Heyue Du
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Zheng Qin
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Baihai Su
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China.,Disaster Medicine Center, Institute for Disaster Management and Reconstruction, Sichuan University, Chengdu, China.,The First People's Hospital of Shuangliu District, Chengdu, China.,Med-X Center for Materials, Sichuan University, Chengdu, China
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49
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Bristogiannis S, Swan D, Thachil J. Thromboprophylaxis in COVID-19 - Rationale and considerations. Adv Biol Regul 2021; 81:100819. [PMID: 34332403 PMCID: PMC8299150 DOI: 10.1016/j.jbior.2021.100819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/20/2021] [Accepted: 07/21/2021] [Indexed: 12/27/2022]
Abstract
The Corona Virus Disease-2019 (COVID-19) pandemic is associated with a very high incidence of thrombotic complications. The exact mechanisms for this excess risk for clots have not been elucidated although one of the often-quoted pathophysiological entity is immunothrombosis. Recognition of thrombotic complications early on in this pandemic led to an over-explosion of studies which looked at the benefits of anticoagulation to mitigate this risk. In this review, we examine the rationale for thromboprophylaxis in COVID-19 with particular reference to dosing and discuss what may guide the decision-making process to consider anticoagulation. In addition, we explore the rationale for thrombosis prevention measures in special populations including outpatient setting, pregnant females, children, those with high body mass index and those on extracorporeal membrane oxygenation.
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Affiliation(s)
- Sotirios Bristogiannis
- Department of Haematology, NHS Hillingdon Hospital, Pield Health Road, Uxbridge, United Kingdom.
| | - Dawn Swan
- Department of Haematology, University Hospital Galway, Galway, Ireland.
| | - Jecko Thachil
- Department of Haematology, Manchester University Hospitals, Oxford Road, Manchester, United Kingdom.
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50
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Qian Z, Lu S, Luo X, Chen Y, Liu L. Mortality and Clinical Interventions in Critically ill Patient With Coronavirus Disease 2019: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2021; 8:635560. [PMID: 34368175 PMCID: PMC8342953 DOI: 10.3389/fmed.2021.635560] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 06/10/2021] [Indexed: 01/11/2023] Open
Abstract
Objective: The aims of this systematic review and meta-analysis were to summarize the current existing evidence on the outcome of critically ill patients with COVID-19 as well as to evaluate the effectiveness of clinical interventions. Data Sources: We searched MEDLINE, the Cochrane library, Web of Science, the China Biology Medicine disc, China National Knowledge Infrastructure, and Wanfang Data from their inception to May 15, 2021. The search strings consisted of various search terms related to the concepts of mortality of critically ill patients and clinical interventions. Study Selection: After eliminating duplicates, two reviewers independently screened all titles and abstracts first, and then the full texts of potentially relevant articles were reviewed to identify cohort studies and case series that focus on the mortality of critically ill patients and clinical interventions. Main Outcomes and Measures: The primary outcome was the mortality of critically ill patients with COVID-19. The secondary outcomes included all sorts of supportive care. Results: There were 27 cohort studies and six case series involving 42,219 participants that met our inclusion criteria. All-cause mortality in the intensive care unit (ICU) was 35% and mortality in hospital was 32% in critically ill patients with COVID-19 for the year 2020, with very high between-study heterogeneity (I 2 = 97%; p < 0.01). In a subgroup analysis, the mortality during ICU hospitalization in China was 39%, in Asia-except for China-it was 48%, in Europe it was 34%, in America it was 15%, and in the Middle East it was 39%. Non-surviving patients who had an older age [-8.10, 95% CI (-9.31 to -6.90)], a higher APACHE II score [-4.90, 95% CI (-6.54 to -3.27)], a higher SOFA score [-2.27, 95% CI (-2.95 to -1.59)], and a lower PaO2/FiO2 ratio [34.77, 95% CI (14.68 to 54.85)] than those who survived. Among clinical interventions, invasive mechanical ventilation [risk ratio (RR) 0.49, 95% CI (0.39-0.61)], kidney replacement therapy [RR 0.34, 95% CI (0.26-0.43)], and vasopressor [RR 0.54, 95% CI (0.34-0.88)] were used more in surviving patients. Conclusions: Mortality was high in critically ill patients with COVID-19 based on low-quality evidence and regional difference that existed. The early identification of critical characteristics and the use of support care help to indicate the outcome of critically ill patients.
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Affiliation(s)
- Zhicheng Qian
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
- Department of Critical Care Medicine, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Shuya Lu
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Department of Pediatric, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Xufei Luo
- School of Public Health, Lanzhou University, Lanzhou, China
| | - Yaolong Chen
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Institute of Health Data Science, Lanzhou University, Lanzhou, China
- World Health Organization Collaborating Centre for Guideline Implementation and Knowledge Translation, Lanzhou, China
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou University, Lanzhou, China
| | - Ling Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
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