Infectious Disease

Therapeutic anticoagulation will increase the chance of mortality in sufferers hospitalized with COVID-19

December 31, 2020

3 min read

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Patients admitted to hospital with COVID-19 who received high-dose therapeutic anticoagulation appeared to have an increased risk of mortality compared to patients on prophylactic anticoagulation, according to a research letter in Thrombosis Research.

The researchers also observed an increased risk of thrombocytopenia in patients who received therapeutic or prophylactic anticoagulation.

Patients who were hospitalized with COVID-19 and who received high-dose therapeutic anticoagulation had an increased risk of mortality compared to patients who received prophylactic anticoagulation.

Patients who were hospitalized with COVID-19 and who received high-dose therapeutic anticoagulation had an increased risk of mortality compared to patients who received prophylactic anticoagulation.

“At the beginning of this pandemic, we had a limited understanding of the COVID-19 infection. Some early studies reported an increased incidence of venous thromboembolism in patients with severe COVID-19 pneumonia, raising concerns as a possible contributor to mortality. ” Lei D. Lynn, MD, Researchers in the hospital medicine department at the George Washington University School of Medicine and Health Sciences, Healio said. “Given these concerns and the lack of clear guidelines on the use of anticoagulants, some patients were empirically treated with therapeutic anticoagulants based on either ICU status or an elevated threshold for D-dimer levels that we consider in our hospital have identified with statistically significant chances for death and have been reported in the literature from China [as associated with] an increased chance of developing clots, [whereas] others received prophylactic anticoagulation according to standard of care.

Lei D. Lynn, MD

Lei D. Lynn

Lynn and colleagues hoped that through a retrospective analysis of the effects of prophylactic vs. therapeutic anticoagulation based on the results to gain insight into better treatment for patients with COVID-19, with an emphasis on mortality and subsequent stratification for disease severity that requires critical care and D-dimer thresholds, she said.

The analysis included 402 patients (53.7% men; 57.2% aged> 60 years) who were hospitalized with COVID-19 between March 15 and May 31. Overall, 26.9% of patients required admission to the intensive care unit and 15.7% were intubated.

The researchers compared the clinical results of patients treated with therapeutic anticoagulation (n = 152; 55.7% men; 69.8% Schwarz) with those of patients treated with prophylactic anticoagulation (n = 250; 52.6% men ; 69.6% black). They used elastic net logistic regression to identify key variables influencing mortality, which they included as covariates for anticoagulation in standard multivariate logistic regression models.

The results showed that patients treated with therapeutic anticoagulation had an increased risk of mortality compared to patients treated with prophylactic anticoagulation (unadjusted hospital mortality 34.8% versus 15.2%; OR = 3.42; 95% CI 2.06 -5.67).

The researchers also found that patients with COVID-19 coagulopathy who received therapeutic anticoagulation had a higher mortality rate than patients with atrial fibrillation, atrial flutter, or previous VTE (38.3% versus 26.4%), although the difference was none reached statistical significance.

The results of a subset analysis that adjusted for the severity of the disease showed similar survival curves between the two groups. When the researchers stratified the analysis using D-dimer levels less than or greater than 3 g / ml, the log-rank test, which favored prophylactic anticoagulation in non-intensive care patients, disappeared.

The total bleeding rate was 7.2%. Compared with only 3% of patients receiving prophylactic anticoagulation, 9% of patients receiving therapeutic anticoagulation experienced clinically significant bleeding or thrombocytopenia that led to treatment discontinuation.

“Our analysis showed no clear benefit in the empirical application of therapeutic anticoagulation in patients with severe COVID-19 pneumonia. On the contrary, we saw an increased incidence of side effects such as clinically significant anemia or thrombocytopenia, ”said Lynn. “We have therefore warned against the empirical application of therapeutic anticoagulation without clear clinical indications until we have a better understanding of the role of anticoagulation. We know how difficult this is, especially given recent data suggesting that much of the VTE exposure can be seen in the intensive care unit even though patients are already on prophylactic anticoagulation. “

Lynn acknowledged the limitations of the study, including the fact that it was unable to tell a difference when the effect was analyzed solely in patients in the intensive care unit.

“We look forward to possibly answering more questions from the ongoing randomized controlled trials on a granular level,” said Lynn. “Aside from the ongoing randomized trials, future directions of the study could include exploring the role of inflammation and coagulopathy biomarkers in guiding therapeutic decisions, especially when the diagnostic modalities for diagnosing VTE in some facilities may be limited or prohibitive due to isolation requirements and patients ‘critical illness. ”

For more informations:

Lei D. Lynn, MD, reachable at George Washington University School of Medicine and Health Sciences, 900 23rd St. NW, Washington, DC, 20037; Email: ldu@mfa.gwu.edu.

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