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Sadeghipour P, Talasaz AH, Rashidi F, Sharif-Kashani B, Beigmohammadi MT, Farrokhpour M, Sezavar SH, Payandemehr P, Dabbagh A, Moghadam KG, Jamalkhani S, Khalili H, Yadollahzadeh M, Riahi T, Rezaeifar P, Tahamtan O, Matin S, Abedini A, Lookzadeh S, Rahmani H, Zoghi E, Mohammadi K, Sadeghipour P, Abri H, Tabrizi S, Mousavian SM, Shahmirzaei S, Bakhshandeh H, Amin A, Rafiee F, Baghizadeh E, Mohebbi B, Parhizgar SE, Aliannejad R, Eslami V, Kashefizadeh A, Kakavand H, Hosseini SH, Shafaghi S, Ghazi SF, Najafi A, Jimenez D, Gupta A, Madhavan MV, Sethi SS, Parikh SA, Monreal M, Hadavand N, Hajighasemi A, Maleki M, Sadeghian S, Piazza G, Kirtane AJ, Van Tassell BW, Dobesh PP, Stone GW, Lip GYH, Krumholz HM, Goldhaber SZ, Bikdeli B. Effect of Intermediate-Dose vs Standard-Dose Prophylactic Anticoagulation on Thrombotic Events, Extracorporeal Membrane Oxygenation Treatment, or Mortality Among Patients With COVID-19 Admitted to the Intensive Care Unit: The INSPIRATION Randomized Clinical Trial. JAMA 2021; 325:1620-1630. [PMID: 33734299 PMCID: PMC7974835 DOI: 10.1001/jama.2021.4152] [Citation(s) in RCA: 427] [Impact Index Per Article: 142.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Thrombotic events are commonly reported in critically ill patients with COVID-19. Limited data exist to guide the intensity of antithrombotic prophylaxis. OBJECTIVE To evaluate the effects of intermediate-dose vs standard-dose prophylactic anticoagulation among patients with COVID-19 admitted to the intensive care unit (ICU). DESIGN, SETTING, AND PARTICIPANTS Multicenter randomized trial with a 2 × 2 factorial design performed in 10 academic centers in Iran comparing intermediate-dose vs standard-dose prophylactic anticoagulation (first hypothesis) and statin therapy vs matching placebo (second hypothesis; not reported in this article) among adult patients admitted to the ICU with COVID-19. Patients were recruited between July 29, 2020, and November 19, 2020. The final follow-up date for the 30-day primary outcome was December 19, 2020. INTERVENTIONS Intermediate-dose (enoxaparin, 1 mg/kg daily) (n = 276) vs standard prophylactic anticoagulation (enoxaparin, 40 mg daily) (n = 286), with modification according to body weight and creatinine clearance. The assigned treatments were planned to be continued until completion of 30-day follow-up. MAIN OUTCOMES AND MEASURES The primary efficacy outcome was a composite of venous or arterial thrombosis, treatment with extracorporeal membrane oxygenation, or mortality within 30 days, assessed in randomized patients who met the eligibility criteria and received at least 1 dose of the assigned treatment. Prespecified safety outcomes included major bleeding according to the Bleeding Academic Research Consortium (type 3 or 5 definition), powered for noninferiority (a noninferiority margin of 1.8 based on odds ratio), and severe thrombocytopenia (platelet count <20 ×103/µL). All outcomes were blindly adjudicated. RESULTS Among 600 randomized patients, 562 (93.7%) were included in the primary analysis (median [interquartile range] age, 62 [50-71] years; 237 [42.2%] women). The primary efficacy outcome occurred in 126 patients (45.7%) in the intermediate-dose group and 126 patients (44.1%) in the standard-dose prophylaxis group (absolute risk difference, 1.5% [95% CI, -6.6% to 9.8%]; odds ratio, 1.06 [95% CI, 0.76-1.48]; P = .70). Major bleeding occurred in 7 patients (2.5%) in the intermediate-dose group and 4 patients (1.4%) in the standard-dose prophylaxis group (risk difference, 1.1% [1-sided 97.5% CI, -∞ to 3.4%]; odds ratio, 1.83 [1-sided 97.5% CI, 0.00-5.93]), not meeting the noninferiority criteria (P for noninferiority >.99). Severe thrombocytopenia occurred only in patients assigned to the intermediate-dose group (6 vs 0 patients; risk difference, 2.2% [95% CI, 0.4%-3.8%]; P = .01). CONCLUSIONS AND RELEVANCE Among patients admitted to the ICU with COVID-19, intermediate-dose prophylactic anticoagulation, compared with standard-dose prophylactic anticoagulation, did not result in a significant difference in the primary outcome of a composite of adjudicated venous or arterial thrombosis, treatment with extracorporeal membrane oxygenation, or mortality within 30 days. These results do not support the routine empirical use of intermediate-dose prophylactic anticoagulation in unselected patients admitted to the ICU with COVID-19. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04486508.
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Affiliation(s)
| | - Parham Sadeghipour
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Clinical Trial Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Azita H Talasaz
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Farid Rashidi
- Tuberculosis and Lung Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Babak Sharif-Kashani
- Tobacoo Prevention and control Research center, National Research institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Lung Transplantation Research Center, Department of Cardiology, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Taghi Beigmohammadi
- Anesthesiology and Intensive Care, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohsen Farrokhpour
- Firouzgar hospital, Department of internal medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Seyed Hashem Sezavar
- Research Center for Prevention of Cardiovascular Disease, Institute of Endocrinology & Metabolism, Iran University of Medical Sciences, Tehran, Iran
| | | | - Ali Dabbagh
- Department of Anesthesiology, School of Medicine Anesthesiology Research Center Shahid Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Sepehr Jamalkhani
- Student Research Committee, Iran University of Medical Sciences, Tehran, Iran
| | - Hossein Khalili
- Department of Pharmacotherapy, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahdi Yadollahzadeh
- Firouzgar hospital, Department of internal medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Taghi Riahi
- Rasoul-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Parisa Rezaeifar
- Tuberculosis and Lung Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ouria Tahamtan
- Tuberculosis and Lung Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Samira Matin
- Tuberculosis and Lung Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Atefeh Abedini
- Chronic Respiratory Disease Research Center, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Somayeh Lookzadeh
- Chronic Respiratory Disease Research Center, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamid Rahmani
- Department of Pharmacotherapy, Faculty of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Elnaz Zoghi
- School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Keyhan Mohammadi
- School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Pardis Sadeghipour
- Firouzgar hospital, Department of internal medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Homa Abri
- Firouzgar hospital, Department of internal medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Sanaz Tabrizi
- Rasoul-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | | | | | - Hooman Bakhshandeh
- Clinical Trial Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Rajaie Cardiovascular Medical and Research Center, Iran university of Medical sciences, Tehran, Iran
| | - Ahmad Amin
- Rajaie Cardiovascular Medical and Research Center, Iran university of Medical sciences, Tehran, Iran
| | - Farnaz Rafiee
- Rajaie Cardiovascular Medical and Research Center, Iran university of Medical sciences, Tehran, Iran
| | - Elahe Baghizadeh
- Rajaie Cardiovascular Medical and Research Center, Iran university of Medical sciences, Tehran, Iran
| | - Bahram Mohebbi
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Seyed Ehsan Parhizgar
- Rajaie Cardiovascular Medical and Research Center, Iran university of Medical sciences, Tehran, Iran
| | - Rasoul Aliannejad
- School of Medicine, Department of Pulmonary and Critical Care, Shariati Hospital, Tehran, Iran
- Advanced Thoracic Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Vahid Eslami
- Cardiovascular Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Alireza Kashefizadeh
- Shahid Dr Labbafinejad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hessam Kakavand
- School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Shadi Shafaghi
- Lung Transplantation Research Center, Department of Cardiology, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Samrand Fattah Ghazi
- Anesthesiology and Intensive Care, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Atabak Najafi
- Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain
- Medicine Department, Universidad de Alcalá (IRYCIS), Madrid, Spain
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Aakriti Gupta
- Cardiovascular Research Foundation (CRF), New York, New York
- Division of Cardiology, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York
- Yale/YNHH Center for Outcomes Research & Evaluation, New Haven, Connecticut
| | - Mahesh V Madhavan
- Cardiovascular Research Foundation (CRF), New York, New York
- Division of Cardiology, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York
| | - Sanjum S Sethi
- Cardiovascular Research Foundation (CRF), New York, New York
- Division of Cardiology, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York
| | - Sahil A Parikh
- Cardiovascular Research Foundation (CRF), New York, New York
- Division of Cardiology, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Germans Trias i Pujol, Badalona, Barcelona, Universidad Católica de Murcia, Murcia, Spain
| | - Naser Hadavand
- Rajaie Cardiovascular Medical and Research Center, Iran university of Medical sciences, Tehran, Iran
| | | | - Majid Maleki
- Rajaie Cardiovascular Medical and Research Center, Iran university of Medical sciences, Tehran, Iran
| | - Saeed Sadeghian
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Gregory Piazza
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ajay J Kirtane
- Cardiovascular Research Foundation (CRF), New York, New York
- Division of Cardiology, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York
| | - Benjamin W Van Tassell
- School of Pharmacy, Department of Pharmacotherapy and Outcome Science, Virginia Commonwealth University, Richmond, Virginia
- School of Pharmacy, Pauley Heart Center, Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Paul P Dobesh
- College of Pharmacy, University of Nebraska Medical Center, Omaha
| | - Gregg W Stone
- Cardiovascular Research Foundation (CRF), New York, New York
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Aalborg University, Aalborg, Denmark
| | - Harlan M Krumholz
- Yale/YNHH Center for Outcomes Research & Evaluation, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Administration, Yale School of Public Health, New Haven, Connecticut
| | - Samuel Z Goldhaber
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Behnood Bikdeli
- Cardiovascular Research Foundation (CRF), New York, New York
- Yale/YNHH Center for Outcomes Research & Evaluation, New Haven, Connecticut
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Bikdeli B, Talasaz AH, Rashidi F, Bakhshandeh H, Rafiee F, Rezaeifar P, Baghizadeh E, Matin S, Jamalkhani S, Tahamtan O, Sharif-Kashani B, Beigmohammadi MT, Farrokhpour M, Sezavar SH, Payandemehr P, Dabbagh A, Moghadam KG, Khalili H, Yadollahzadeh M, Riahi T, Abedini A, Lookzadeh S, Rahmani H, Zoghi E, Mohammadi K, Sadeghipour P, Abri H, Tabrizi S, Mousavian SM, Shahmirzaei S, Amin A, Mohebbi B, Parhizgar SE, Aliannejad R, Eslami V, Kashefizadeh A, Dobesh PP, Kakavand H, Hosseini SH, Shafaghi S, Ghazi SF, Najafi A, Jimenez D, Gupta A, Madhavan MV, Sethi SS, Parikh SA, Monreal M, Hadavand N, Hajighasemi A, Maleki M, Sadeghian S, Piazza G, Kirtane AJ, Van Tassell BW, Stone GW, Lip GYH, Krumholz HM, Goldhaber SZ, Sadeghipour P. Intermediate-Dose versus Standard-Dose Prophylactic Anticoagulation in Patients with COVID-19 Admitted to the Intensive Care Unit: 90-Day Results from the INSPIRATION Randomized Trial. Thromb Haemost 2021; 122:131-141. [PMID: 33865239 DOI: 10.1055/a-1485-2372] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Thrombotic complications are considered among the main extrapulmonary manifestations of coronavirus disease 2019 (COVID-19). The optimal type and duration of prophylactic antithrombotic therapy in these patients remain unknown. METHODS This article reports the final (90-day) results of the Intermediate versus Standard-dose Prophylactic anticoagulation In cRitically-ill pATIents with COVID-19: An opeN label randomized controlled trial (INSPIRATION) study. Patients with COVID-19 admitted to intensive care were randomized to intermediate-dose versus standard-dose prophylactic anticoagulation for 30 days, irrespective of hospital discharge status. The primary efficacy outcome was a composite of adjudicated venous or arterial thrombosis, treatment with extracorporeal membrane oxygenation (ECMO), or all-cause death. The main safety outcome was major bleeding. RESULTS Of 600 randomized patients, 562 entered the modified intention-to-treat analysis (median age [Q1, Q3]: 62 [50, 71] years; 237 [42.2%] women), of whom 336 (59.8%) survived to hospital discharge. The primary outcome occurred in 132 (47.8%) of patients assigned to intermediate dose and 130 (45.4%) patients assigned to standard-dose prophylactic anticoagulation (hazard ratio [HR]: 1.21, 95% confidence interval [CI]: 0.95-1.55, p = 0.11). Findings were similar for other efficacy outcomes, and in the landmark analysis from days 31 to 90 (HR: 1.59, 95% CI: 0.45-5.06). There were 7 (2.5%) major bleeding events in the intermediate-dose group (including 3 fatal events) and 4 (1.4%) major bleeding events in the standard-dose group (none fatal) (HR: 1.82, 95% CI: 0.53-6.24). CONCLUSION Intermediate-dose compared with standard-dose prophylactic anticoagulation did not reduce a composite of death, treatment with ECMO, or venous or arterial thrombosis at 90-day follow-up.
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Affiliation(s)
- Behnood Bikdeli
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States.,Yale/YNHH Center for Outcomes Research and Evaluation, New Haven, Connecticut, United States.,Cardiovascular Research Foundation, New York, New York, United States
| | - Azita H Talasaz
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Farid Rashidi
- Tuberculosis and Lung Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hooman Bakhshandeh
- Clinical Trial Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran.,Rajaie Cardiovascular Medical and Research Center, Iran university of Medical Sciences, Tehran, Iran
| | - Farnaz Rafiee
- Rajaie Cardiovascular Medical and Research Center, Iran university of Medical Sciences, Tehran, Iran
| | - Parisa Rezaeifar
- Tuberculosis and Lung Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Elahe Baghizadeh
- Rajaie Cardiovascular Medical and Research Center, Iran university of Medical Sciences, Tehran, Iran
| | - Samira Matin
- Tuberculosis and Lung Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sepehr Jamalkhani
- Student Research Committee, Iran University of Medical Sciences, Tehran, Iran
| | - Ouria Tahamtan
- Tuberculosis and Lung Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Babak Sharif-Kashani
- Tobacoo Prevention and Control Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Department of Cardiology, Lung Transplantation Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Taghi Beigmohammadi
- Anesthesiology and Intensive Care, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohsen Farrokhpour
- Department of Internal Medicine, Firouzgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Seyed Hashem Sezavar
- Research Center for Prevention of Cardiovascular Disease, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran
| | | | - Ali Dabbagh
- Department of Anesthesiology, School of Medicine Anesthesiology Research Center, Shahid Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Hossein Khalili
- Department of Pharmacotherapy, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahdi Yadollahzadeh
- Department of Internal Medicine, Firouzgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Taghi Riahi
- Rasoul-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Atefeh Abedini
- Chronic Respiratory Disease Research Center, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Somayeh Lookzadeh
- Chronic Respiratory Disease Research Center, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamid Rahmani
- Department of Pharmacotherapy, Faculty of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Elnaz Zoghi
- School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Keyhan Mohammadi
- School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Pardis Sadeghipour
- Department of Internal Medicine, Firouzgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Homa Abri
- Department of Internal Medicine, Firouzgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Sanaz Tabrizi
- Rasoul-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | | | | | - Ahmad Amin
- Rajaie Cardiovascular Medical and Research Center, Iran university of Medical Sciences, Tehran, Iran
| | - Bahram Mohebbi
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Seyed Ehsan Parhizgar
- Rajaie Cardiovascular Medical and Research Center, Iran university of Medical Sciences, Tehran, Iran
| | - Rasoul Aliannejad
- Department of Pulmonary and Critical Care, School of Medicine, Shariati Hospital, Tehran, Iran.,Advanced Thoracic Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Vahid Eslami
- Cardiovascular Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Alireza Kashefizadeh
- Shahid Dr. Labbafinejad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Paul P Dobesh
- College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska, United States
| | - Hessam Kakavand
- School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Shadi Shafaghi
- Department of Cardiology, Lung Transplantation Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Samrand Fattah Ghazi
- Anesthesiology and Intensive Care, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Atabak Najafi
- Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal, Madrid, Spain.,Medicine Department, Universidad de Alcalá, Madrid, Spain.,CIBER Enfermedades Respiratorias, Madrid, Spain
| | - Aakriti Gupta
- Yale/YNHH Center for Outcomes Research and Evaluation, New Haven, Connecticut, United States.,Cardiovascular Research Foundation, New York, New York, United States.,Division of Cardiology, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York, United States
| | - Mahesh V Madhavan
- Cardiovascular Research Foundation, New York, New York, United States.,Division of Cardiology, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York, United States
| | - Sanjum S Sethi
- Cardiovascular Research Foundation, New York, New York, United States.,Division of Cardiology, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York, United States
| | - Sahil A Parikh
- Cardiovascular Research Foundation, New York, New York, United States.,Division of Cardiology, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York, United States
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain.,Universidad Católica de Murcia, Murcia, Spain
| | - Naser Hadavand
- Rajaie Cardiovascular Medical and Research Center, Iran university of Medical Sciences, Tehran, Iran
| | | | - Majid Maleki
- Rajaie Cardiovascular Medical and Research Center, Iran university of Medical Sciences, Tehran, Iran
| | - Saeed Sadeghian
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Ajay J Kirtane
- Cardiovascular Research Foundation, New York, New York, United States.,Division of Cardiology, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York, United States
| | - Benjamin W Van Tassell
- Department of Pharmacotherapy and Outcome Science, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia, United States.,Division of Cardiology, Department of Internal Medicine, Pauley Heart Center, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia, United States
| | - Gregg W Stone
- Cardiovascular Research Foundation, New York, New York, United States.,The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.,Aalborg University, Aalborg, Denmark
| | - Harlan M Krumholz
- Yale/YNHH Center for Outcomes Research and Evaluation, New Haven, Connecticut, United States.,Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, United States.,Department of Health Policy and Administration, Yale School of Public Health, New Haven, Connecticut, United States
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Parham Sadeghipour
- Clinical Trial Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran.,Rajaie Cardiovascular Medical and Research Center, Iran university of Medical Sciences, Tehran, Iran.,School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
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3
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Rashidi F, Barco S, Kamangar F, Heresi GA, Emadi A, Kaymaz C, Jansa P, Reis A, Rashidi A, Taghizadieh A, Rezaeifar P, Moghimi M, Ghodrati S, Mozafari A, Foumani AA, Tahamtan O, Rafiee E, Abbaspour Z, Khodadadi K, Alamdari G, Boodaghi Y, Rezaei M, Muhammadi MJ, Abbasi M, Movaseghi F, Koohi A, Shakourzad L, Ebrahimi F, Radvar S, Amoozadeh M, Fereidooni F, Naseari H, Movalled K, Ghorbani O, Ansarin K. Incidence of symptomatic venous thromboembolism following hospitalization for coronavirus disease 2019: Prospective results from a multi-center study. Thromb Res 2020; 198:135-138. [PMID: 33338976 PMCID: PMC7836837 DOI: 10.1016/j.thromres.2020.12.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/29/2020] [Accepted: 12/04/2020] [Indexed: 12/23/2022]
Abstract
Background Thrombosis and pulmonary embolism appear to be major causes of mortality in hospitalized coronavirus disease 2019 (COVID-19) patients. However, few studies have focused on the incidence of venous thromboembolism (VTE) after hospitalization for COVID-19. Methods In this multi-center study, we followed 1529 COVID-19 patients for at least 45 days after hospital discharge, who underwent routine telephone follow-up. In case of signs or symptoms of pulmonary embolism (PE) or deep vein thrombosis (DVT), they were invited for an in-hospital visit with a pulmonologist. The primary outcome was symptomatic VTE within 45 days of hospital discharge. Results Of 1529 COVID-19 patients discharged from hospital, a total of 228 (14.9%) reported potential signs or symptoms of PE or DVT and were seen for an in-hospital visit. Of these, 13 and 12 received Doppler ultrasounds or pulmonary CT angiography, respectively, of whom only one patient was diagnosed with symptomatic PE. Of 51 (3.3%) patients who died after discharge, two deaths were attributed to VTE corresponding to a 45-day cumulative rate of symptomatic VTE of 0.2% (95%CI 0.1%–0.6%; n = 3). There was no evidence of acute respiratory distress syndrome (ARDS) in these patients. Other deaths after hospital discharge included myocardial infarction (n = 13), heart failure (n = 9), and stroke (n = 9). Conclusions We did not observe a high rate of symptomatic VTE in COVID-19 patients after hospital discharge. Routine extended thromboprophylaxis after hospitalization for COVID-19 may not have a net clinical benefit. Randomized trials may be warranted. In a large multi-center study, the incidence of venous thromboembolism in COVID-19 patients followed for 45 days after hospitalization was relatively low. Routine extended thromboprophylaxis in COVID-19 patients who have been discharged from the hospital may not have a net clinical benefit. Older age, history of recent cancer, and history of recent diabetes were associated with higher risk of mortality after hospital discharge
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Affiliation(s)
- Farid Rashidi
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, Johannes Gutenberg University Mainz, Mainz, Germany; Clinic of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Farin Kamangar
- Department of Biology, School of Computer, Mathematical, and Natural Sciences, Morgan State University, Baltimore, MD, USA
| | - Gustavo A Heresi
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, OH, USA
| | - Ashkan Emadi
- Department of Medicine, School of Medicine, University of Maryland, Baltimore, USA; Greenebaum Comprehensive Cancer Center, University of Maryland, Baltimore, MD, USA
| | - Cihangir Kaymaz
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, 34844 Istanbul, Turkey
| | - Pavel Jansa
- 2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Abilio Reis
- Pulmonary Vascular Disease Unit, Medicine Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Arash Rashidi
- Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center Cleveland, OH, USA
| | - Ali Taghizadieh
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Parisa Rezaeifar
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Minoosh Moghimi
- Department of Hematology & Medical Oncology, Vali-e-Asr Hospital, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Samad Ghodrati
- Department of Pulmonology, Vali-e-Asr Hospital, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Abolfazl Mozafari
- Department of Internal Medical, Qom Branch, Islamic Azad University, Qom, Iran
| | - Ali Alavi Foumani
- Inflammatory Lung Disease Research Center, Department of Internal Medicine, Razi Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Ouria Tahamtan
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Effat Rafiee
- Department of Pulmonology, Vali-e-Asr Hospital, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Zahra Abbaspour
- Department of Endocrinology, Vali-e-Asr Hospital, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Kasra Khodadadi
- Department of Internal Medicine, Vali-e-Asr Hospital, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Golsa Alamdari
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Yasman Boodaghi
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Maryam Rezaei
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Meysam Abbasi
- Student Research Center, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Fatemeh Movaseghi
- Department of Internal Medical, Qom Branch, Islamic Azad University, Qom, Iran
| | - Ata Koohi
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Leila Shakourzad
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Fatemeh Ebrahimi
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sarvin Radvar
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Maryam Amoozadeh
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Fatemeh Fereidooni
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hanieh Naseari
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Kobra Movalled
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ozra Ghorbani
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Khalil Ansarin
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Bikdeli B, Talasaz AH, Rashidi F, Sharif-Kashani B, Farrokhpour M, Bakhshandeh H, Sezavar H, Dabbagh A, Beigmohammadi MT, Payandemehr P, Yadollahzadeh M, Riahi T, Khalili H, Jamalkhani S, Rezaeifar P, Abedini A, Lookzadeh S, Shahmirzaei S, Tahamtan O, Matin S, Amin A, Parhizgar SE, Jimenez D, Gupta A, Madhavan MV, Parikh SA, Monreal M, Hadavand N, Hajighasemi A, Maleki M, Sadeghian S, Mohebbi B, Piazza G, Kirtane AJ, Lip GYH, Krumholz HM, Goldhaber SZ, Sadeghipour P. Intermediate versus standard-dose prophylactic anticoagulation and statin therapy versus placebo in critically-ill patients with COVID-19: Rationale and design of the INSPIRATION/INSPIRATION-S studies. Thromb Res 2020; 196:382-394. [PMID: 32992075 PMCID: PMC7513771 DOI: 10.1016/j.thromres.2020.09.027] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 09/17/2020] [Accepted: 09/18/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Microvascular and macrovascular thrombotic events are among the hallmarks of coronavirus disease 2019 (COVID-19). Furthermore, the exuberant immune response is considered an important driver of pulmonary and extrapulmonary manifestations of COVID-19. The optimal management strategy to prevent thrombosis in critically-ill patients with COVID-19 remains unknown. METHODS The Intermediate versus Standard-dose Prophylactic anticoagulation In cRitically-ill pATIents with COVID-19: An opeN label randomized controlled trial (INSPIRATION) and INSPIRATION-statin (INSPIRATION-S) studies test two independent hypotheses within a randomized controlled trial with 2 × 2 factorial design. Hospitalized critically-ill patients with reverse transcription polymerase chain reaction confirmed COVID-19 will be randomized to intermediate-dose versus standard dose prophylactic anticoagulation. The 600 patients undergoing this randomization will be screened and if meeting the eligibility criteria, will undergo an additional double-blind stratified randomization to atorvastatin 20 mg daily versus matching placebo. The primary endpoint, for both hypotheses will be tested for superiority and includes a composite of adjudicated acute arterial thrombosis, venous thromboembolism (VTE), use of extracorporeal membrane oxygenation, or all-cause death within 30 days from enrollment. Key secondary endpoints include all-cause mortality, adjudicated VTE, and ventilator-free days. Key safety endpoints include major bleeding according to the Bleeding Academic Research Consortium definition and severe thrombocytopenia (platelet count <20,000/fL) for the anticoagulation hypothesis. In a prespecified secondary analysis for non-inferiority, the study will test for the non-inferiority of intermediate intensity versus standard dose anticoagulation for major bleeding, considering a non-inferiority margin of 1.8 based on odds ratio. Key safety endpoints for the statin hypothesis include rise in liver enzymes >3 times upper normal limit and clinically-diagnosed myopathy. The primary analyses will be performed in the modified intention-to-treat population. Results will be tested in exploratory analyses across key subgroups and in the intention-to-treat and per-protocol cohorts. CONCLUSIONS INSPIRATION and INSPIRATON-S studies will help address clinically-relevant questions for antithrombotic therapy and thromboinflammatory therapy in critically-ill patients with COVID-19.
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Affiliation(s)
- Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Yale/YNHH Center for Outcomes Research & Evaluation, New Haven, CT, USA; Cardiovascular Research Foundation (CRF), New York, NY, USA.
| | - Azita H Talasaz
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Farid Rashidi
- Tuberclosis and Lung Diseases Research Center, Tabriz, Iran
| | - Babak Sharif-Kashani
- Tobacoo Prevention and control Research center, National Research lnstitute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran; Lung Transplantion Research Center, Department of Cardiology, National Research Institute of Tuberculosls and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohsen Farrokhpour
- Firouzgar Hospital, Department of Internal Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Hooman Bakhshandeh
- Rajaie Cardiovascular Medical and Research Center, Iran university of Medical sciences, Tehran, Iran
| | - Hashem Sezavar
- Rasoul-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Dabbagh
- Department of Anesthesiology, School of Medicine Anesthesiology Research Center Shahid Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Taghi Beigmohammadi
- Anesthesiology and Intensive Care, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Mahdi Yadollahzadeh
- Firouzgar Hospital, Department of Internal Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Taghi Riahi
- Rasoul-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Hossein Khalili
- Department of Pharmacotherapy, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Sepehr Jamalkhani
- Student Research Committee, Iran University of Medical Sciences, Tehran, Iran; Aalborg University, Aalborg, Denmark
| | | | - Atefeh Abedini
- Chronic Respiratory Disease Research Center, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Somayeh Lookzadeh
- Chronic Respiratory Disease Research Center, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Ouria Tahamtan
- Tuberclosis and Lung Diseases Research Center, Tabriz, Iran
| | - Samira Matin
- Tuberclosis and Lung Diseases Research Center, Tabriz, Iran
| | - Ahmad Amin
- Rajaie Cardiovascular Medical and Research Center, Iran university of Medical sciences, Tehran, Iran
| | - Seyed Ehsan Parhizgar
- Rajaie Cardiovascular Medical and Research Center, Iran university of Medical sciences, Tehran, Iran
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain; Medicine Department, Universidad de Alcalá (IRYCIS), Madrid, Spain; CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Aakriti Gupta
- Cardiovascular Research Foundation (CRF), New York, NY, USA; Division of Cardiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Mahesh V Madhavan
- Cardiovascular Research Foundation (CRF), New York, NY, USA; Division of Cardiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Sahil A Parikh
- Cardiovascular Research Foundation (CRF), New York, NY, USA; Division of Cardiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Germans Trias i Pujol, Badalona, Barcelona, Universidad Católica de Murcia, Murcia, Spain
| | - Naser Hadavand
- Rajaie Cardiovascular Medical and Research Center, Iran university of Medical sciences, Tehran, Iran
| | | | - Majid Maleki
- Rajaie Cardiovascular Medical and Research Center, Iran university of Medical sciences, Tehran, Iran
| | - Saeed Sadeghian
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Bahram Mohebbi
- Rajaie Cardiovascular Medical and Research Center, Iran university of Medical sciences, Tehran, Iran
| | - Gregory Piazza
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ajay J Kirtane
- Cardiovascular Research Foundation (CRF), New York, NY, USA; Division of Cardiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Aalborg University, Aalborg, Denmark
| | - Harlan M Krumholz
- Yale/YNHH Center for Outcomes Research & Evaluation, New Haven, CT, USA; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA; Department of Health Policy and Adminitration, Yale School of Public Health, New Haven, CT, USA
| | - Samuel Z Goldhaber
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Parham Sadeghipour
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Iran; Clinical Trial Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Iran.
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