Antithrombotic strategies in COVID-19 patients: a systematic review and Bayesian network meta-analysis

Introduction: COVID-19 is a public health emergency of international concern. Clinicians are likely to adopt various antithrombotic strategies to prevent embolic events, but the optimal antithrombotic strategy remains uncertain. We performed a Bayesian network meta-analysis to evaluate various antithrombotic strategies comprehensively. Method(s): We systematically searched PubMed, Cochrane Library, Web of Science, EMBASE and Clinical trials. gov to screen trials comparing different antithrombotic strategies. The primary outcome is 28-day mortality, and the secondary outcomes include major thrombotic event, major bleeding and in-hospital mortality, etc. We assessed the risk of bias using the Cochrane Collaboration's tool and the quality of evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. We successively performed traditional pairwise and Bayesian network meta-analysis using R v4.2.1 software. Result(s): Twenty-six eligible randomized controlled trials were included, giving a total of 35 paired comparisons with 32,041 patients randomized to 7 antithrombotic strategies. In comparison to standard of care (SoC) strategy, therapeutic anticoagulation (TA) (RR 0.36, 95% CrI 0.13-0.86) and prophylactic anticoagulation (PA) (RR 0.35, 95% CrI 0.12-0.85) strategy significantly reduced the mortality of COVID-19 patients (Fig. 1). The antiplatelet (AP) strategy was associated with high risk of major bleeding when compared with SoC strategy (RR 2.5, 95% CrI 1.1-8.9), and the TA (RR 0.43, 95% CrI 0.17-0.98), PA (RR 0.27, 95% CrI 0.10-0.63) and PA with Fibrinolytic agents (FA) strategy (RR 0.12, 95% CrI 0.01-0.81) was associated with low risk of major thrombotic event. Conclusion(s): This network meta-analysis indicates that the TA and PA strategies probably reduce mortality and confer other important benefits in COVID-19 patients. These findings provide guidance on how to choose optimal antithrombotic strategies for COVID-19 patients.

[The keypoints in treatment of the critical coronavirus disease 2019 patient(1)].

COVID-19 has been prevalent in Wuhan and spread rapidly to all of our country. Some cases can develop into ARDS, or even death. We will share the treatment experience of severe COVID-19 with the first-line treatment experience. The best respiratory support mode should be selected, but the timing of intubation and protection during intubation are two difficulties; patients with high level peep and poor effect in prone position can be given ECMO support. For COVID-19 patients with mechanical ventilation, reasonable sedation and analgesia strategies should be formulated; delirium should not be ignored. In addition, there is up regulation of inflammatory factors in patients with severe COVID-19, but the effect of renal replacement therapy needs to be further confirmed by clinical research.

[Therapy of coronavirus disease 2019 induced acute respiratory distress syndrome is different from traditional acute respiratory distress syndrome].

Coronavirus disease 2019 (COVID-19) has become a global public health emergency threatening people's lives around the world. Although the acute respiratory distress syndrome (ARDS) induced by COVID-19 is similar to the ARDS caused by other diseases in terms of pathophysiological basis and clinical manifestations, they are also different in many aspects, which lead to different clinical therapies. Therefore, understanding the differences and similarities of ARDS induced by COVID-19 and other diseases currently are the basis for clinicians to make decisions for the treatment of COVID-19 induced ARDS.

[The keypoints in treatment of the critical coronavirus disease 2019 patient(2)].

The treatment of critically ill patients with coronavirus disease 2019(COVID-19) faces compelling challenges. In this issue, we'd like to share our first-line treatment experience in treating COVID-19. Hemodynamics need be closely monitored and different types of shock should be distinguished. Vasoconstrictor drugs should be used rationally and alerting of complications is of the same importance. The risk of venous thromboembolism (VTE) needs to be assessed, and effective prevention should be carried out for high-risk patients. It is necessary to consider the possibility of pulmonary thromboembolism (PTE) in patients with sudden onset of oxygenation deterioration, respiratory distress, reduced blood pressure. However, comprehensive analysis of disease state should be taken into the interpretation of abnormally elevated D-Dimer. Nutritional support is the basis of treatment. It's important to establish individual therapy regimens and to evaluate, monitor and adjust dynamically. Under the current epidemic situation, convalescent plasma can only be used empirically, indications need to be strictly screened, the blood transfusion process should be closely monitored and the curative effect should be dynamically evaluated.

[Pharmacotherapeutics for the New Coronavirus Pneumonia].

The New Coronavirus Pneumonia (NCP, also named as COVID-19 by WHO on Feb 11 2020, is now causing a severe public health emergency in China since. The number of diagnosed cases is more than 40,000 until the submission of this manuscript. Coronavirus has caused several epidemic situations world widely, but the present contagious disease caused by 2019 new Coronavirus is unprecedentedly fulminating. The published cohorts of 2019 new Coronavirus (n-Cov) are single-center studies, or retrospective studies. We here share the therapeutic experiences of NCP treatment with literature review. Combination of Ribavirin and Interferon-α is recommended by the 5(th) edition National Health Commission's Regimen (Revised Edition) because of the effect on MERS (Middle East Respiratory Syndrome), and the effectiveness of Lopinavir/Ritonavir and Remdisivir needs to be confirmed by randomized controlled trial (RCT), given the situation of no specific antivirus drug on NCP is unavailable. Systemic glucocorticosteroid is recommended as a short term use (1~2 mg.kg(-1).d(-1), 3~5d ) by the 5(th) edition National Health Commission's Regimen (Revised Edition) yet RCTs are expected to confirm the effectiveness. Inappropriate application of antibiotics should be avoided, especially the combination of broad-spectrum antibiotics, for the NCP is not often complicated with bacterial infection.