The vascular side of COVID-19 disease. Position paper of the International Union of Angiology

SOFA Score as a Reliable Tool to Detect High Risk for Venous Thrombosis in Patients With Critical Stage SARS-CoV-2

Background: Severe acute respiratory syndrome from coronavirus-2 (SARS-CoV-2) has been associated with an increased risk of venous thromboembolism (VTE). Different anticoagulation protocols have been applied in several studies in the absence of clear evidence. A reliable deep venous thrombosis (DVT) indicator in critical patients with SARS-CoV-2 could guide the anticoagulation treatment; however, it has not yet been identified, and clinical applicability of the most common markers is debatable. The aim of our study was to determine the actual incidence of DVT in critically ill SARS-CoV-2 patients and to find a reliable tool to identify patients who might benefit from therapeutic-intensity anticoagulation. Methods: From March 1, 2020 to May 31, 2020, all patients admitted to the intensive care unit (ICU) for SARS-CoV-2 at Ospedale Regionale di Locarno, Locarno, Switzerland, were prospectively enrolled and screened daily with ultrasound for DVT. Following international consensus, a higher-intensity thromboprophylaxis was administered to all patients who were not at increased risk for bleeding. Sepsis-induced coagulopathy (SIC) and sequential organ failure assessment (SOFA) scores were calculated and time-to-DVT event in a COX proportional-hazard regression model was performed. A receiver operating characteristic (ROC) curve was used to determine sensitivity and specificity and the Youden's Index to establish the best threshold. Results: A total of 96 patients were enrolled. Deep venous thrombosis was detected in 37% of patients. Sepsis-induced coagulopathy and SOFA scores were both correlated to DVT. A SIC score of 1 vs. ≥2 showed a close association with DVT, with sensitivity, specificity, and positive and negative predictive values of 90.0, 48.1, and 49.1, and 89.7%, respectively. Most significantly though, a SOFA score of 1 or 2 points was shown to be the most accurate value in predicting the absence of DVT, indicating no need for therapeutic-intensity anticoagulation. Its sensitivity, specificity, and positive and negative predictive values were 87.9, 100, and 100, and 93.7%, respectively. The D-dimer test showed lower sensitivity and specificity whereas platelet count and aPTT were not found to be correlated to DVT. Conclusions: Patients with SOFA scores of 1 or 2 are at low risk of developing DVT and do not require therapeutic-intensity anticoagulation. Conversely, patients with scores ≥3 are at high risk of developing DVT.

Mortality and bleeding complications of COVID-19 critically ill patients with venous thromboembolism

BACKGROUND

VTE disease in COVID-19 patients is a remarkable issue, especially its relationship with bleeding events and mortality. The objective of this study was to describe the outcomes of critically ill patients with COVID-19 hospitalized in ICU in relationship with VTE during their stay.

METHODS

Prospective cohort study of critically ill COVID-19 patients in two hospitals that underwent a venous ultrasound at the beginning of follow-up of both lower limbs in April 2020. When clinical suspicion of new VTE during the 30-day follow-up, additional ultrasound or thoracic CT were performed. Global VTE frequency, major bleeding events and survival were collected, and their predictors were studied.

RESULTS

We included 230 patients. After 30 days of follow-up, there were 95 VTE events in 86 patients (37,4%). 13 patients (5,7%) developed major bleeding complications and 42 patients (18,3%) died. None of the comorbidities or previous treatments were related with bleeding events. D-dimer at admission was significantly related with VTE development and mortality. Independent predictors of mortality in the regression model were an older age (>66 years), D-dimer at admission (>1 500ng/mL) and low lymphocyte count (<0,45x109/L) with an AUC in the ROC curve of 0,81 (95%CI: 0,73-0,89). Patients presenting these three conditions presented a mortality of a 100% in the predictive model.

CONCLUSIONS

VTE frequency in ICU COVID-19 patients is high and risk of major bleeding is low. Comorbidities and laboratory parameters of admission in these patients can be a useful tool to predict mortality.

Thromboprophylaxis in Patients with COVID-19: Systematic Review of National and International Clinical Guidance Reports

BACKGROUND

Venous thromboembolism (VTE) is common among patients with severe coronavirus disease 2019 (COVID-19). Anticoagulation in hospitalized COVID-19 patients has been associated with survival benefits; however, the optimal thromboprophylaxis strategy has not yet been defined. <P> Objective: To identify published guidance reports by national and international societies regarding thromboprophylaxis strategies in COVID-19 patients in different settings (outpatients, hospitalized, post-discharge). <P> Methods: A systematic review of the literature (Pubmed/EMBASE) was conducted independently by two investigators. <P> Results: Among 1942 initially identified articles, 33 guidance documents were included: 20 published by national and 13 by international societies. These documents provide recommendations mainly for hospitalized (97% of reports) and post-discharge (75%) COVID-19 patients, and less so for outpatients (34%). Thrombotic and bleeding risk stratification prior to any treatment decision is the cornerstone of all suggested thromboprophylaxis strategies; 81% of the documents recommend thromboprophylaxis for all hospitalized patients with a prophylactic dosage of low molecular weight heparin irrespective of VTE risk. Intermediate or therapeutic dose intensity is recommended in high VTE risk patients by 56% and 28% of documents, respectively. Mechanical thromboprophylaxis is suggested in case of high bleeding risk or contraindication to pharmacological thromboprophylaxis (59% of documents). Extended pharmacological thromboprophylaxis is recommended for patients with high VTE risk after hospital discharge (63% of documents). For non-hospitalized outpatients, 28% of documents recommend pharmacological thromboprophylaxis for high VTE risk. <P> Conclusion: The current guidance identifies thromboprophylaxis in COVID-19 patients, especially during hospitalization, as of major importance for the prevention of VTE. Recommendations are derived from limited evidence from observational studies.

Lesson by SARS-CoV-2 disease (COVID-19): whole-body CT angiography detection of "relevant" and "other/incidental" systemic vascular findings

Objectives

Increasing evidence suggests that SARS-CoV-2 infection may lead to severe and multi-site vascular involvement. Our study aimed at assessing the frequency of vascular and extravascular events’ distribution in a retrospective cohort of 42 COVID-19 patients.

Methods

Patients were evaluated by whole-body CT angiography between March 16 and April 30, 2020. Twenty-three out of the 42 patients evaluated were admitted to the intensive care unit (ICU). Vascular and extravascular findings were categorized into “relevant” or “other/incidental,” first referring to the need for immediate patient care and management. Student T-test, Mann-Whitney U test, or Fisher exact test was used to compare study groups, where appropriate.

Results

Relevant vascular events were recorded in 71.4% of cases (n = 30). Pulmonary embolism was the most frequent in both ICU and non-ICU cases (56.5% vs. 10.5%, p = 0.002). Ischemic infarctions at several sites such as the gut, spleen, liver, brain, and kidney were detected (n = 20), with multi-site involvement in some cases. Systemic venous thrombosis occurred in 30.9% of cases compared to 7.1% of systemic arterial events, the first being significantly higher in ICU patients (p = 0.002). Among incidental findings, small-sized splanchnic arterial aneurysms were reported in 21.4% of the study population, with no significant differences in ICU and non-ICU patients.

Conclusions

Vascular involvement is not negligible in COVID-19 and should be carefully investigated as it may significantly affect disease behavior and prognosis.

Key Points

• Relevant vascular events were recorded in 71.4% of the study population, with pulmonary embolism being the most frequent event in ICU and non-ICU cases.

• Apart from the lung, other organs such as the gut, spleen, liver, brain, and kidneys were involved with episodes of ischemic infarction. Systemic venous and arterial thrombosis occurred in 30.9% and 7.1% of cases, respectively, with venous events being significantly higher in ICU patients (p = 0.002).

• Among incidental findings, small-sized splanchnic arterial aneurysms were reported in 21.4% of the whole population.