ABSTRACT
In 2020, there was a 20% increase in excess deaths in the USA due to COVID infections but also to changes in the healthcare system due to the pandemic. We hypothesized that people living with sickle cell disease (SCD) may be vulnerable to these changes as SCD can lead to rapid decompensation. We examined all deaths of people with SCD at our center in 2020. Cause of death was determined, clinical variables, and healthcare utilization, and the presence of COVID infection, sepsis, and acute organ failure during the death event was obtained from the electronic medical record. Deaths in 2020 were compared to deaths in 2017-2019. In 2020, deaths increase 244% (22 vs 9), but acute or previous COVID infections were identified in only 36% of 2020 deaths. People who died in 2020 were more likely to have developed acute organ failure during the death event (70.6% vs 21.1%, p = 0.003) compared to prior years. They were also more likely to have a history of stroke and more frequent hematology clinic visits. Deaths in 2020 doubled compared to prior years and COVID infection could not account for all of this excess mortality. People who died in 2020 may have had more severe disease as suggested by having more clinic visits and higher rates of stroke and were more likely to develop organ failure during the death event. This demonstrates that people with SCD may be especially vulnerable to delays in care. Larger multicenter studies should be conducted to examine this further.
ABSTRACT
Background: Mortality in coronavirus disease of 2019 (COVID-19) is associated with increases in prothrombotic parameters, particularly D-dimer levels. Many institutions have adopted anticoagulation guidelines, often adjusted for illness severity. We wanted to investigate whether anticoagulation improves survival in COVID-19 and if this improvement in survival is associated with disease severity.Methods: To simulate an intention to treat clinical trial, we analyzed the effect on mortality of anticoagulation therapy chosen in the first 48 hours of hospitalization. We analyzed 3,625 COVID-19+ inpatients, controlling for age, GFR, oxygen saturation, ventilation requirement and time period, all determined during the first 48 hours.Findings: Adjusted logistic regression analyses demonstrated a significant decrease in mortality with prophylactic use of apixaban (OR 0·52, p=0·005) and enoxaparin (OR=0·50, p=0·002). Therapeutic apixaban was also associated with decreased mortality (OR 0·63, p=0·025) but was not more beneficial than prophylactic use. UFH did not show the same benefit. Higher D-dimer levels were associated with increased mortality (p<0·0001). When adjusted for these same predictors within D-dimer strata, patients with D-dimer levels <1ug/ml did not appear to benefit from anticoagulation while patients with D-dimer levels >10ug/ml derived the most benefit. There was no increase in transfusion requirement with any of the anticoagulants used.Interpretation: We conclude that COVID-19+ patients with moderate or severe illness benefit from anticoagulation and that apixaban has similar efficacy to enoxaparin in decreasing mortality in this disease.Funding: There was no internal or external funding support for this study.Declaration of Interests: HHB has received research or advisory funding from Bristol Myers Squibb, Janssen Pharmaceuticals, Bayer, and Kedrion Pharmaceuticals. MK has received research or advisory funding from Bristol Myers Squibb and Janssen Pharmaceuticals. All other authors declare no competing interests. Ethics Approval Statement: Institutional Review Board approval was obtained from Albert Einstein College of Medicine.