Effect of Anticoagulant Administration on the Mortality of Hospitalized Patients With COVID-19: An Updated Systematic Review and Meta-Analysis

Intermediate dose enoxaparin in hospitalized patients with moderate-severe COVID-19: a pilot phase II single-arm study, INHIXACOVID19

BACKGROUND

Randomized clinical trials in non-critically ill COVID-19 patients showed that therapeutic-dose heparin increased survival with reduced organ support as compared with usual-care thromboprophylaxis, albeit with increased bleeding risk. The purpose of the study is to assess the safety of intermediate dose enoxaparin in hospitalized patients with moderate to severe COVID-19.

METHODS

A phase II single-arm interventional prospective study including patients receiving intermediate dose enoxaparin once daily according to body weight: 60 mg for 45-60 kg, 80 mg for 61-100 kg or 100 mg for > 100 kg for 14 days, with dose adjustment according to anti-factor Xa activity (target range: 0.4-0.6 UI/ml); an observational cohort (OC) included patients receiving enoxaparin 40 mg day for comparison. Follow-up was 90 days. Primary outcome was major bleeding within 30 and 90 days after treatment onset. Secondary outcome was the composite of all-cause 30 and 90-day mortality rates, disease severity at the end of treatment, intensive care unit (ICU) admission and length of ICU stay, length of hospitalization. All outcomes were adjudicated by an independent committee and analyzed before and after propensity score matching (PSm).

RESULTS

Major bleeding was similar in IC (1/98 1.02%) and in the OC (none), with only one event observed in a patient receiving concomitantly anti-platelet therapy. The composite outcome was observed in 53/98 patients (54%) in the IC and 132/203 (65%) patients in the OC (p = 0.07) before PSm, while it was observed in 50/90 patients (55.6%) in the IC and in 56/90 patients (62.2%) in the OC after PSm (p = 0.45). Length of hospitalization was lower in the IC than in OC [median 13 (IQR 8-16) vs 14 (11-21) days, p = 0.001], however it lost statistical significance after PSm (p = 0.08). At 30 days, two patients had venous thrombosis and two pulmonary embolism in the OC. Time to first negative RT-PCR were similar in the two groups.

CONCLUSIONS

Weight adjusted intermediate dose heparin with anti-FXa monitoring is safe with potential positive impact on clinical course in COVID-19 non-critically ill patients.

TRIAL REGISTRATION

The study INHIXACOVID19 was registred on ClinicalTrials.gov with the trial registration number (TRN) NCT04427098 on 11/06/2020.

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

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

Thromboprophylaxis in Hospitalized Non-Critically Ill Patients With Mild-to-Moderate COVID-19 Infection: A Systematic Review and Meta-Analysis

The prevalence of venous thromboembolism is high in patients with COVID-19, despite prophylactic anticoagulation. The evidence that supports the preferred thromboprophylaxis regimen in non-critically ill patients with mild to moderate COVID-19 is still limited. Therefore, this systematic review and meta-analysis aimed to compare the clinical outcomes of hospitalized patients with mild to moderate COVID-19 who received standard thromboprophylaxis anticoagulation with intermediate to high prophylaxis regimens. We systematically searched MEDLINE and Embase databases for published studies until August 17th, 2022. We included studies on patients with mild to moderate COVID-19 who received thromboprophylaxis during their hospital stay. Patients who received standard prophylaxis dose "control group" were compared to patients who received intermediate to high prophylaxis "intervention group". Random effect models were used when pooling crude numbers and adjusted effect estimates of study outcomes. A comprehensive analysis was conducted, encompassing seven studies involving a total of 1931 patients. The risk of all-cause thrombosis was not statistically different between the two groups (risk ratio [RR] 1.48, 95% confidence interval [CI] [0.11, 20.21]). The risk of minor bleeding was reported to be lower in patients who received intermediate to high prophylaxis (RR 0.64, 95% CI 0.21, 1.97), while had a higher risk of major bleeding compared with the standard prophylaxis (RR 1.40, 95% CI 0.43, 4.61); however, did not reach the statistical significance. The overall risk for all hospital mortality favored the utilization of intermediate to high doses over the standard thromboprophylaxis dosing (RR 0.47, 95%CI 0.29, 0.75). In medically ill patients with COVID-19, there is no difference between standard and intermediate to high prophylaxis dosing regarding thrombosis and bleeding. However, it appears that intermediate to high prophylaxis regimens are linked to additional survival benefits.

Chronic Anti-Coagulation Therapy Reduced Mortality In Patients With High Cardiovascular Risk Early In COVID-19 Pandemic

Background: Coronavirus disease 2019 (COVID-19) is associated with provoked thrombo-inflammatory responses. Early in the COVID-19 pandemic this was thought to contribute to hypercoagulability and multi-organ system complications in infected patients. Limited studies have evaluated the impact of therapeutic anti-coagulation therapy (AC) in alleviate these risks in COVID-19 positive patients. Our study aimed to investigate whether long-term therapeutic AC can decrease the risk of multi-organ system complications (MOSC) including stroke, limb ischemia, gastrointestinal (GI) bleeding, in-hospital and intensive care unit death in COVID-19 positive patients during the early phase of the pandemic in the United States. Methods: A retrospective analysis was conducted of all COVID-19 positive United States Veterans between March 2020 and October 2020. Patients receiving continuous therapeutic AC for a least 30 days prior to or after their initial COVID-19 positive test were assigned to the AC group. Patients who did not receive AC were included in a control group. We analyzed the primary study outcome of MOSC between the AC and control groups using binary logistic regression analysis (Odd-Ratio; OR). Results: We identified 48,066 COVID-19 patients, of them 879 (1.8%) were receiving continuous therapeutic AC. The AC cohort had significantly worse comorbidities than the control group. On the adjusted binary logistic regression model, therapeutic AC significantly decreased in-hospital mortality rate (OR; 0.67, p = 0.04), despite a higher incidence of GI bleeding (OR; 4.00, p = 0.02). However, therapeutic AC did not significantly reduce other adverse events. Conclusion: AC therapy reduced in-hospital death early in the COVID-19 pandemic among patients who were hospitalized with the infection. However, it did not decrease the risk of MOSC. Additional trials are needed to determine the effectiveness of AC in preventing complications associated with ongoing emerging strains of the COVID-19 virus.

Analysis of Deaths and Favorable Developments of Patients with SARS-CoV-2 Hospitalized in the Largest Hospital for Infectious Diseases and Pneumo-Phthisiology in the West of the Country

Purpose

Romania is one of the European countries that has been hit the hardest by the severe acute respiratory syndrome caused by the new coronavirus SARS-CoV-2, with over 1.91 million reported cases and over 59,257 deaths. The aim of this study was to identify the main predictors of death in hospitalized patients.

Patients and Methods

In the period from 1 March 2020 to 30 June 2021, an observational, retrospective, randomized, case-control study was conducted, which included a sample of 139 patients who died in hospital and another sample of 275 patients who had been discharged in an improved or healed condition. Confirmation of COVID-19 cases was performed by RT-PCR from nasopharyngeal and oropharyngeal exudates. Statistical data were analyzed by logistic regression, Cox regression and a comparison of survival curves by the log-rank (Mantel-Cox) test.

Results

The most powerful logistic regression model identified the following independent predictors of death: history of coagulopathy HR = 30.73 [1.94–487.09], p = 0.015; high percentage of neutrophils HR = 1.09 [1.01–1.19], p = 0.027; and decreased blood-oxygenation HR = 53881.97 [1762.24–1647489.44], p < 0.001. Cox regression identified the following factors that influenced the evolution of cases: history of coagulopathy HR = 2.44 [1.38–4.35], p = 0.000; O₂ saturation HR = 0.98 [0.96–0.99], p = 0.043; serum creatinine HR = 1.23 [1.08–1.39], p = 0.001; dyspnea on admission HR = 2.99 [1.42–6.30], p = 0.004; hospitalization directly in the ICU HR = 3.803 [1.97–7.33], p < 0.001; heart damage HR = 16.76 [1.49–188.56], p = 0.022; and decreased blood-oxygenation HR = 35.12 [5.92–208.19], p < 0.001.

Conclusion

Knowledge of the predictors of death in hospitalized patients allows for the future optimization of triage and therapeutic case management for COVID-19.

Evaluation of coagulation with TEG in patients diagnosed COVID-19

BACKGROUND

A high D-dimer level may indicate the risk of coagulopathy and mortality in COVID-19 patients. T hromboelastography (TEG) is a test that evaluates clot formation and fibrinolysis in real-time, unlike routine coagulation tests. The study aimed to investigate the coagulation process with TEG in patients diagnosed with COVID-19.

METHODS

The study was performed at our university hospital, chest diseases outpatient clinic as a cross-section study. A total of 51 patients with 23 high D-dimer levels group (HDG) and 28 low D-dimers group (LDG) were included in the study. TEG analysis was performed at the pretreatment evaluation in these two groups.

RESULTS

D-dimer and fibrinogen levels of the HDG were higher than those of the LDG (550 vs. 90 ng/mL, p < 0.001; 521 vs. 269 mg/ dL, p < 0.001, respectively). In TEG analysis, HDG's R and K values were lower than LDG, and HDG's Angle, MA, and CI values were higher than LDG (p = 0.037; p < 0.001; p < 0.001; p < 0.001; p < 0.001, respectively). ROC curve analysis suggested that the optimum TEG parameters cut-off points for thrombosis risk were as below: for K was ≤2.1 min, for R was ≤6.1 min, for Angle was >62°, MA was 60.4 mm.