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Lancet Haematol ; 8(7): e524-e533, 2021 Jul.
Article in English | MEDLINE | ID: covidwho-1208801


COVID-19 is associated with a high incidence of thrombotic complications, which can be explained by the complex and unique interplay between coronaviruses and endothelial cells, the local and systemic inflammatory response, and the coagulation system. Empirically, an intensified dose of thrombosis prophylaxis is being used in patients admitted to hospital with COVID-19 and several guidelines on this topic have been published, although the insufficiency of high quality and direct evidence has led to weak recommendations. In this Viewpoint we summarise the pathophysiology of COVID-19 coagulopathy in the context of patients who are ambulant, admitted to hospital, and critically ill or non-critically ill, and those post-discharge from hospital. We also review data from randomised controlled trials in the past year of antithrombotic therapy in patients who are critically ill. These data provide the first high-quality evidence on optimal use of antithrombotic therapy in patients with COVID-19. Pharmacological thromboprophylaxis is not routinely recommended for patients who are ambulant and post-discharge. A first ever trial in non-critically ill patients who were admitted to hospital has shown that a therapeutic dose of low-molecular-weight heparin might improve clinical outcomes in this population. In critically ill patients, this same treatment does not improve outcomes and prophylactic dose anticoagulant thromboprophylaxis is recommended. In the upcoming months we expect numerous data from the ongoing antithrombotic COVID-19 studies to guide clinicians at different stages of the disease.

Anticoagulants/therapeutic use , Blood Coagulation Disorders/physiopathology , COVID-19/complications , Heparin, Low-Molecular-Weight/therapeutic use , Aged , Aged, 80 and over , Blood Coagulation/physiology , Blood Coagulation Disorders/drug therapy , Blood Coagulation Disorders/epidemiology , COVID-19/diagnosis , COVID-19/epidemiology , COVID-19/virology , Critical Illness/therapy , Endothelial Cells/pathology , Endothelial Cells/virology , Hospitalization , Humans , Incidence , Outcome Assessment, Health Care , Patient Discharge/standards , Randomized Controlled Trials as Topic , SARS-CoV-2/genetics , SARS-CoV-2/isolation & purification , Systemic Inflammatory Response Syndrome/physiopathology , Venous Thromboembolism/prevention & control
J Thromb Haemost ; 18(8): 1995-2002, 2020 Aug.
Article in English | MEDLINE | ID: covidwho-186482


BACKGROUND: Coronavirus disease 2019 (COVID-19) can lead to systemic coagulation activation and thrombotic complications. OBJECTIVES: To investigate the incidence of objectively confirmed venous thromboembolism (VTE) in hospitalized patients with COVID-19. METHODS: Single-center cohort study of 198 hospitalized patients with COVID-19. RESULTS: Seventy-five patients (38%) were admitted to the intensive care unit (ICU). At time of data collection, 16 (8%) were still hospitalized and 19% had died. During a median follow-up of 7 days (IQR, 3-13), 39 patients (20%) were diagnosed with VTE of whom 25 (13%) had symptomatic VTE, despite routine thrombosis prophylaxis. The cumulative incidences of VTE at 7, 14 and 21 days were 16% (95% CI, 10-22), 33% (95% CI, 23-43) and 42% (95% CI 30-54) respectively. For symptomatic VTE, these were 10% (95% CI, 5.8-16), 21% (95% CI, 14-30) and 25% (95% CI 16-36). VTE appeared to be associated with death (adjusted HR, 2.4; 95% CI, 1.02-5.5). The cumulative incidence of VTE was higher in the ICU (26% (95% CI, 17-37), 47% (95% CI, 34-58), and 59% (95% CI, 42-72) at 7, 14 and 21 days) than on the wards (any VTE and symptomatic VTE 5.8% (95% CI, 1.4-15), 9.2% (95% CI, 2.6-21), and 9.2% (2.6-21) at 7, 14, and 21 days). CONCLUSIONS: The observed risk for VTE in COVID-19 is high, particularly in ICU patients, which should lead to a high level of clinical suspicion and low threshold for diagnostic imaging for DVT or PE. Future research should focus on optimal diagnostic and prophylactic strategies to prevent VTE and potentially improve survival.

Betacoronavirus , Coronavirus Infections/blood , Pandemics , Pneumonia, Viral/blood , Pulmonary Embolism/epidemiology , Venous Thromboembolism/epidemiology , Venous Thrombosis/epidemiology , Aged , Anticoagulants/therapeutic use , Biomarkers , COVID-19 , Catheterization, Central Venous/adverse effects , Coronavirus Infections/complications , Female , Fibrin Fibrinogen Degradation Products/analysis , Humans , Incidence , Intensive Care Units/statistics & numerical data , Male , Middle Aged , Netherlands/epidemiology , Patients' Rooms/statistics & numerical data , Pneumonia, Viral/complications , Pulmonary Embolism/blood , Pulmonary Embolism/diagnostic imaging , Pulmonary Embolism/etiology , Retrospective Studies , Risk Factors , SARS-CoV-2 , Thrombophilia/drug therapy , Thrombophilia/etiology , Thrombophlebitis/epidemiology , Thrombophlebitis/etiology , Venous Thromboembolism/blood , Venous Thromboembolism/diagnostic imaging , Venous Thromboembolism/etiology , Venous Thrombosis/blood , Venous Thrombosis/diagnostic imaging , Venous Thrombosis/etiology