Venous and arterial thromboembolic complications

Abstract

Methods

We studied consecutive symptomatic patients with laboratory-proven COVID-19 admitted to a university hospital in Milan, Italy (13.02.2020–10.04.2020). The primary outcome was any thromboembolic complication, including venous thromboembolism (VTE), ischemic stroke, and acute coronary syndrome (ACS)/myocardial infarction (MI). Secondary outcome was overt disseminated intravascular coagulation (DIC).

Results

We included 388 patients (median age 66 years, 68% men, 16% requiring intensive care [ICU]). Thromboprophylaxis was used in 100% of ICU patients and 75% of those on the general ward. Thromboembolic events occurred in 28 (7.7% of closed cases; 95%CI 5.4%–11.0%), corresponding to a cumulative rate of 21% (27.6% ICU, 6.6% general ward). Half of the thromboembolic events were diagnosed within 24 h of hospital admission. Forty-four patients underwent VTE imaging tests and VTE was confirmed in 16 (36%). Computed tomography pulmonary angiography (CTPA) was performed in 30 patients, corresponding to 7.7% of total, and pulmonary embolism was confirmed in 10 (33% of CTPA). The rate of ischemic stroke and ACS/MI was 2.5% and 1.1%, respectively. Overt DIC was present in 8 (2.2%) patients.

Conclusions

The high number of arterial and, in particular, venous thromboembolic events diagnosed within 24 h of admission and the high rate of positive VTE imaging tests among the few COVID-19 patients tested suggest that there is an urgent need to improve specific VTE diagnostic strategies and investigate the efficacy and safety of thromboprophylaxis in ambulatory COVID-19 patients.

SOURCE: Thrombosis Research

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Thrombotic complications in critically ill patients with COVID-19

Abstract

COVID-19 may predispose to both venous and arterial thromboembolism due to excessive inflammation, hypoxia, immobilisation and diffuse intravascular coagulation.

Methods

We evaluated the incidence of the composite outcome of symptomatic acute pulmonary embolism (PE), deep-vein thrombosis, ischemic stroke, myocardial infarction or systemic arterial embolism in all COVID-19 patients admitted to the ICU of three Dutch academic centers.

Results

We studied 184 ICU patients with proven COVID-19 pneumonia of whom 23 died (13%), 22 were discharged alive (12%) and 139 (76%) were still on the ICU on April 5th 2020. All patients received at least standard doses thromboprophylaxis. The cumulative incidence of the composite outcome was 31% (95%CI 20-41), of which CTPA and/or ultrasonography confirmed VTE in 27% (95%CI 17-37%) and arterial thrombotic events in 3.7% (95%CI 0-8.2%). PE was the most frequent thrombotic complication (n = 25, 81%).

Age (adjusted hazard ratio (aHR) 1.05/per year, 95%CI 1.004-1.01) and coagulopathy, defined as spontaneous prolongation of the prothrombin time > 3 seconds or activated partial thromboplastin time > 5 seconds (aHR 4.1, 95%CI 1.9-9.1), were independent predictors of thrombotic complications.

Conclusion

The 31% incidence of thrombotic complications in ICU patients with COVID-19 infections is remarkably high. Our findings reinforce the recommendation to strictly apply pharmacological thrombosis prophylaxis in all COVID-19 patients admitted to the ICU, and are strongly suggestive of increasing the prophylaxis towards high-prophylactic doses, even in the absence of randomized evidence.

SOURCE: Thrombosis Research

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Elevated plasmin(ogen) as a risk factor for COVID-19 susceptibility

Excerpt

Patients with preexisting hypertension, diabetes, coronary heart disease, cerebrovascular disease, chronic obstructive pulmonary disease (COPD), and kidney dysfunction (comorbidities) have worse clinical outcomes when infected with SARS-CoV-2. The mechanisms for high morbidity and mortality of patients with comorbidities are unknown.

The existence of significantly increased fibrin degradation products (FDPs) and reduced platelets in severe COVID-19 patients is consistent with the presence of hyperfibrinolysis. This opinion is supported by the presence of hemorrhage in multiple organs and a positive correlation between fibrinolysis and mortality.

Plasmin, a key player in fibrinolysis, enhances the virulence and pathogenicity of viruses containing a furin site in their envelope proteins, as is the case with the SARS-CoV-2. The purpose of this review is to summarize the clinical and preclinical evidence for the existence of elevated plasmin(ogen) in these comorbid conditions of COVID-19 and to highlight the importance of plasmin-induced proteolytic cleavage of the SARS-COV-2 S protein and fibrin in the development of COVID-19.

SOURCE: Physiological Reviews

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Abnormal coagulation parameters are associated with poor prognosis

Abstract

Background

In the recent outbreak of novel coronavirus infection in Wuhan, China, significantly abnormal coagulation parameters in severe novel coronavirus pneumonia (NCP) cases were a concern.

Objectives

To describe the coagulation feature of patients with NCP.

Methods

Conventional coagulation results and outcomes of 183 consecutive patients with confirmed NCP in Tongji hospital were retrospectively analyzed.

Results

The overall mortality was 11.5%, the non‐survivors revealed significantly higher D‐dimer and fibrin degradation product (FDP) levels, longer prothrombin time and activated partial thromboplastin time compared to survivors on admission (P < .05); 71.4% of non‐survivors and 0.6% survivors met the criteria of disseminated intravascular coagulation during their hospital stay.

Conclusions

The present study shows that abnormal coagulation results, especially markedly elevated D‐dimer and FDP are common in deaths with NCP.

SOURCE: J Thrombosis + Haemostasis

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