Hematoma of the rectus abdominis sheath in the course of COVID-19

Introduction: Spontaneous abdominal wall hematoma is a rare clinical entity in medical practice. In the context of COVID-19, intra-abdominal hematoma presented as a complication of the imposed therapy and was not taken into consideration when making the differential diagnosis of abdominal pain and arterial hypotension. Objective: To report the appearance of rectus abdominis sheath hematoma as a complication of the use of anticoagulants in the course of COVID-19 treatment. Clinical case: A 71-year-old patient with COVID-19 is presented who was receiving anticoagulant treatment and began with acute abdominal pain, with abdominal ultrasound that was inconclusive, laparotomy was performed and a large hematoma was found in the abdominal Retzius space. She evolved favourably and is discharged after 7 days. Conclusions: The trans-operative diagnosis together with the drainage of the hematoma and the opportune fluid therapy allowed a favourable evolution and the recovery of the patient. © 2023, Editorial Ciencias Medicas. All rights reserved.

COVID-19 CHALLENGE IN THE ANTIPHOSPHOLIPID SYNDROME – AN OBSERVATIONAL STUDY OF A SERBIAN COHORT

BackgroundFacing the outburst of the COVID-19 pandemic, we gradually comprehend its pathophysiology as a coagulopathy characterized by increased risks of arterial, venous, and microvascular thrombosis. Antiphospholipid syndrome (APS) is an autoimmune, thrombo-inflammatory disease characterized by thrombosis and/or pregnancy loss in the presence of one or more antiphospholipid antibodies (aPL).ObjectivesTo evaluate the clinical scenario of COVID-19 in the APS population of patients.MethodsThis is a single-center, observational, cross-sectional study. Data regarding the severity of COVID-19 (severe COVID-19 considered if interstitial pneumonia was diagnosed), COVID-19 vaccinal status, and post-vaccinal reactions (divided into mild, consisting of fever, myalgia, nausea, and severe if thrombosis at any point occurred) were collected from 44 APS patients (21 with primary and 23 with APS associated with systemic lupus erythematosus (SLE), 90.1% female). aPL analysis included the detection of aCL (IgG/IgM), ß2GPI (IgG/IgM), and LA Results were compared to the control group consisting of 31 healthy individuals, with no APS, matched to the APS group regarding age and gender.ResultsAt the moment of COVID-19 infection, 75% of the APS group was taking Aspirin, 15.9% warfarin, 2.3% non-vitamin K oral anticoagulant, 59.1% chloroquine, 31.8% corticosteroid, 2.3% methotrexate. None of the above-mentioned medications were taken from a control group. There was no difference regarding the severity of COVID-19 between APS patients and healthy controls: 84.1% of APS had mild and 15.9% severe COVID-19 (p=0.509, p=0.292 respectively). But the difference regarding the need for hospitalization was significant (none of the healthy controls compared to 11.4% APS patients, p=0.0073). Interestingly, COVID-19 occurred in 72.7% of APS patients before the COVID-19 vaccination compared to 35.5% of healthy controls, p=0.001, conversely, a significantly lower percentage of vaccinated APS patients had COVID-19 compared to healthy controls (34.1% to 71.0%, p=0.002). 27% of APS patients had mild post-vaccinal reactions, none with severe.ConclusionDuring the COVID-19 pandemic, APS patients in Serbia were at higher risk for hospitalization. However, there was no difference in the severity of clinical presentation compared to non -the APS population. We can only speculate that APS therapy consisting of Aspirin, Chloroquine, and oral anticoagulant therapy contributed to this finding. Moreover, COVID-19 vaccination in the APS population, followed by a low incidence of mild post-vaccinal reactions, had more benefits in protection than in non-APS individuals.REFERENCES:NIL.Acknowledgements:NIL.Disclosure of InterestsNone Declared.

Changes in anticoagulant and antiplatelet drug supply at US hospitals before and during the COVID-19 pandemic (2018-2021).

PURPOSE: Antithrombotic agents have a role in coronavirus disease 2019 (COVID-19) treatment, but the pandemic disrupted medication supply. This study examined changes in the volume of oral and parenteral anticoagulant and antiplatelet medications at US hospitals during the pandemic. METHODS: IQVIA National Sales Perspective (NSP) data was used to determine the monthly volume of anticoagulants and antiplatelets purchased at US hospitals between January 2018 and February 2021. Mean monthly medication volumes, reported as extended units (EUs), and year-over-year changes in medication volume were determined. A single-group interrupted time series analysis was used to evaluate changes in the rate of growth of monthly medication volumes before (January 2019-February 2020) and during (March 2020-February 2021) the COVID-19 pandemic. RESULTS: Overall, there was a 43.4% decline in the total volume of anticoagulants and antiplatelets at US hospitals in March 2020, driven by a decrease in heparin volume. Mean monthly volumes decreased significantly (P < 0.05) for parenteral anticoagulants (-106,691,340 EU [95% CI, -200,033,910 to -13,348,780]), oral anticoagulants (-354,800 EU [95% CI, -612,180 to -97,420]), and parenteral antiplatelets (-391,880 EU [95% CI, -535,420 to -248,330]). During the pandemic, the monthly volume of oral anticoagulants, parenteral anticoagulants, and parenteral antiplatelets grew significantly more than in the prepandemic period. This growth was primarily seen in volumes of apixaban, argatroban, enoxaparin, heparin, eptifibatide, and tirofiban. Apixaban and heparin volumes continued a prepandemic uptrend, while argatroban and eptifibatide volumes reversed trend. CONCLUSION: Rapid changes in anticoagulant and antiplatelet volume at US hospitals during the COVID-19 pandemic highlight the need for institutional protocols to manage fluctuating medication volume demands.

Bilateral pulmonary embolism associated with peripheral blood eosinophilia and positive antiphospholipid antibodies in a patient with cellulitis.

Key Clinical Message: This report described the pathophysiology, diagnostic workup, and management of thrombosis possibly associated with peripheral blood eosinophilia and transient positive antiphospholipid antibodies in the setting of cellulitis. Abstract: Peripheral blood eosinophilia is a risk factor for thrombosis and the presence of other prothrombotic factors such as antiphospholipid antibodies can potentiate that risk. The authors present a case of acute pulmonary embolism which developed at the peak of eosinophilia, later found to have transient positive antiphospholipid antibodies in a male patient with right lower limb cellulitis and a history of intravenous drug abuse. This report illustrates the pathophysiology, diagnosis workup, and therapeutic options of thrombosis possibly associated with peripheral blood eosinophilia and positive antiphospholipid antibodies, which include anticoagulants, corticosteroids, and immunosuppressants. Clinicians should be aware of this possible association which may guide the choice and duration of anticoagulants. Although direct oral anticoagulants are effective anticoagulants in various thromboembolic events, studies showed unfavorable outcomes for their use in antiphospholipid syndrome.

Comparison of safety and efficacy between therapeutic or intermediate versus prophylactic anticoagulation for thrombosis in COVID-19 patients: a systematic review and meta-analysis.

BACKGROUND: Patients with coronavirus disease 2019 (COVID-19) infections often have macrovascular or microvascular thrombosis and inflammation, which are known to be associated with a poor prognosis. Heparin has been hypothesized that administration of heparin with treatment dose rather than prophylactic dose for prevention of deep vein thrombosis in COVID-19 patients. METHODS: Studies comparing therapeutic or intermediate anticoagulation with prophylactic anticoagulation in COVID-19 patients were eligible. Mortality, thromboembolic events, and bleeding were the primary outcomes. PubMed, Embase, the Cochrane Library, and KMbase were searched up to July 2021. A meta-analysis was performed using random-effect model. Subgroup analysis was conducted according to disease severity. RESULTS: Six randomized controlled trials (RCTs) with 4,678 patients and four cohort studies with 1,080 patients were included in this review. In the RCTs, the therapeutic or intermediate anticoagulation was associated with significant reductions in the occurrence of thromboembolic events (5 studies, n=4,664; relative risk [RR], 0.72; P=0.01), and a significant increase in bleeding events (5 studies, n=4,667; RR, 1.88; P=0.004). In the moderate patients, therapeutic or intermediate anticoagulation was more beneficial than prophylactic anticoagulation in terms of thromboembolic events, but showed significantly higher bleeding events. In the severe patients, the incidence of thromboembolic and bleeding events in the therapeutic or intermediate. CONCLUSIONS: The study findings suggest that prophylactic anticoagulant treatment should be used in patients with moderate and severe COVID-19 infection groups. Further studies are needed to determine more individualized anticoagulation guidance for all COVID-19 patients.

Antithrombotic therapy in the management of hospitalised patients with COVID-19.

Hospitalised patients with coronavirus disease 2019 (COVID-19) are at a significantly higher risk of having thromboembolic events while in hospital and in the immediate post-hospital discharge period. Based on early data from observational studies, multiple high quality randomised controlled trials have been conducted worldwide to evaluate optimal thromboprophylaxis regimens to reduce thromboembolism and other COVID-19-related adverse outcomes in hospitalised patients. The International Society on Thrombosis and Haemostasis has published evidence-based guideline recommendations using established methodology for the management of antithrombotic therapy of COVID-19 patients, both in-hospital and in the immediate post-hospital discharge period. A good clinical practice statement supplemented these guidelines based on topics for which there was no or limited high-quality evidence. This review summarises the main recommendations of these documents to serve as a quick access tool for hospital doctors to use in their everyday practice when treating COVID-19 patients.

Reduced anticoagulation strategy is associated with a lower incidence of intracerebral hemorrhage in COVID-19 patients on extracorporeal membrane oxygenation.

BACKGROUND: Optimal anticoagulation strategies for COVID-19 patients with the acute respiratory distress syndrome (ARDS) on venovenous extracorporeal membrane oxygenation (VV ECMO) remain uncertain. A higher incidence of intracerebral hemorrhage (ICH) during VV ECMO support compared to non-COVID-19 viral ARDS patients has been reported, with increased bleeding rates in COVID-19 attributed to both intensified anticoagulation and a disease-specific endotheliopathy. We hypothesized that lower intensity of anticoagulation during VV ECMO would be associated with a lower risk of ICH. In a retrospective, multicenter study from three academic tertiary intensive care units, we included patients with confirmed COVID-19 ARDS requiring VV ECMO support from March 2020 to January 2022. Patients were grouped by anticoagulation exposure into higher intensity, targeting anti-factor Xa activity (anti-Xa) of 0.3-0.4 U/mL, versus lower intensity, targeting anti-Xa 0.15-0.3 U/mL, cohorts. Mean daily doses of unfractionated heparin (UFH) per kg bodyweight and effectively measured daily anti-factor Xa activities were compared between the groups over the first 7 days on ECMO support. The primary outcome was the rate of ICH during VV ECMO support. RESULTS: 141 critically ill COVID-19 patients were included in the study. Patients with lower anticoagulation targets had consistently lower anti-Xa activity values over the first 7 ECMO days (p < 0.001). ICH incidence was lower in patients in the lower anti-Xa group: 4 (8%) vs 32 (34%) events. Accounting for death as a competing event, the adjusted subhazard ratio for the occurrence of ICH was 0.295 (97.5% CI 0.1-0.9, p = 0.044) for the lower anti-Xa compared to the higher anti-Xa group. 90-day ICU survival was higher in patients in the lower anti-Xa group, and ICH was the strongest risk factor associated with mortality (odds ratio [OR] 6.8 [CI 2.1-22.1], p = 0.001). CONCLUSIONS: For COVID-19 patients on VV ECMO support anticoagulated with heparin, a lower anticoagulation target was associated with a significant reduction in ICH incidence and increased survival.

Factors of venous thromboembolism among COVID-19 patients

Context: Anticoagulants are used to prevent and treat venous thromboembolism (VTE), such as deep-vein thrombosis (DVT) and pulmonary embolism (PE) in COVID-19 for better outcomes. Aim: This study aims to explore clinical outcomes and factors affecting VTE among COVID-19 patients. Settings and Design: The study design involved a retrospective cohort study. Study Methods: Hospitalized COVID-19 patients in a tertiary hospital prescribed subcutaneous (SC) anticoagulants were included. Statistical Analysis Used: Multiple logistic regression was performed to determine factors affecting VTE among subjects. Results: A total of 450 patients were included. Types of anticoagulants include fondaparinux (n = 114, 38.1%), enoxaparin (n = 113, 37.8%), and heparin (n = 72, 24.1%). 423 (94.0%) patients were discharged well, 27 (6.0%) patients were admitted to the intensive care unit (ICU). The primary outcome was the prevalence of VTE, which occurred in 19.3% (n = 87) patients, with 80 (92.0%) reporting DVT and 7 (8.0%) reporting PE. The secondary outcome, which was the average length of hospital stay was 9.9 (+/-4.7) days. Factors of VTE occurrence were likely in patients not prescribed SC anticoagulants compared to those prescribed with SC anticoagulants (adjusted odds ratio [aOR] 54.330, 95% confidence interval [CI]: 7.086, 416.526), treatment with fondaparinux compared to heparin (aOR 2.502, 95% CI: 1.175, 5.327), and less likely in those discharged well compared to patients in the ICU (aOR 0.139, 95% CI: 0.053, 0.361). Conclusions: Careful monitoring is required to reduce VTE risk in COVID-19 patients.

Optimal dosing of heparin for prophylactic anticoagulation in critically ill COVID-19 patients a systematic review and meta-analysis of randomized controlled trials.

PURPOSE: The optimal amount of anticoagulation for critically ill COVID-19 patients is controversial. Therefore, we aimed to evaluate the efficacy and safety of escalated doses of anticoagulation in critically ill patients with severe COVID-19. MATERIALS AND METHODS: We conducted a systematic search of three major databases, including PubMed, Cochrane Library, and Embase, from inception to May 2022. Randomized controlled trials (RCTs) were included comparing therapeutic or intermediate doses to standard prophylactic doses of anticoagulants in critically ill COVID-19 patients, with heparins as the only anticoagulation therapy considered. RESULTS: Out of the six RCTs, 2130 patients were administered escalated dose anticoagulation (50.2%) and standard thromboprophylaxis therapy (49.8%). The escalated dose showed no significant impact on mortality (RR, 1.01; 95% CI, 0.90-1.13). Although there was no significant difference in DVT (RR, 0.81; 95% CI, 0.61-1.08), the risk of PE was significantly reduced in patients receiving escalated dose anticoagulation (RR, 0.35; 95% CI, 0.21-0.60), with an increased risk of bleeding events (RR, 1.65; 95% CI, 1.08-2.53). CONCLUSION: This systematic review and meta-analysis fail to support escalated anticoagulation doses to reduce mortality in critically ill COVID-19 patients. However, higher doses of anticoagulants appear to reduce thrombotic events while increasing the risk of bleeding effectively.

COVID-19 associated coagulopathy: A bibliometric investigation.

Infection with SARS-CoV-2 initiates an immune-hemostatic response. While both systems are intimately connected and necessary for an efficient immune response to contain the infection, excessive coagulation activation might exceed the valuable benefits by causing thrombotic consequences and excessive inflammation. This biological response is new to clinicians and researchers, and accordingly, tremendous studies have been conducted on coagulopathy and its relationship to COVID-19 disease during this pandemic. Therefore, it takes a research insight from a bibliometric perspective to determine research hotspots and trends of COVID-19 associated coagulopathy (C19-CA). The analysis relies on the Scopus database for bibliographic content and Visualization of Similarities viewer software to map bibliometric data of C19-CA. Our study finds the most eminent authors, journals, institutions, funding organizations, and countries that publish in the C19-CA. Additionally; this research employs bibliometric analysis of co-authorship, co-citations, bibliographic coupling, and co-occurrence of keywords. A total of 2242 studies were retrieved, and the number of annual publications of C19-CA showed remarkable growth. The top-publishing authors on C19-CA are Smadja, D.M., Diehl, J.L., and Gendron, N (France). The total number of articles published in English in these three years was 1241, with the original article accounting for 99.8% and conference papers accounting for 0.2%. Huazhong University of Science and Technology (China) is the top-productive institution, with the US being the top-publishing country. Journal of Thrombosis and Thrombolysis received the highest number of original articles. The research results were mainly published in the fields of Medicine, Biochemistry, Genetics, and Molecular Biology, Immunology and Microbiology. Yuanyuan Li, who is (China), is the top-collaborating author. China and its authors have the highest number of citations. Keywords' co-occurrence analyses of the authors and all keywords revealed the following themes in C19-CA; abnormal coagulation parameters, pulmonary coagulopathy, venous and arterial thrombotic disorders, distinct features of coagulopathy, inflammation, and thrombosis in COVID-19, and anticoagulants and thrombolytic therapies. By combining bibliometric analysis with VOSviewer software, we identified C19-CA's leaders, collaborating institutions, and research hotspots, as well as give references for future research paths.

Development of Written Counseling Tool for Subcutaneous Anticoagulant Use in COVID-19 Patients

There is a lack of subcutaneous anticoagulant counseling tools for COVID-19 patients. This study aims to develop and validate a written counseling tool for subcutaneous anticoagulant use in COVID-19 patients. A prospective cohort study was performed with expert panels and patients. The tool was validated by hospital pharmacists using Content Validity Index (I-CVI), Scale-level-CVI (S-CVI), and Universal Acceptance (UA). Face validation by patients was determined using Item Acceptance Index (IAI), and Universal Acceptance (UA). Hospital pharmacists (n=26) were mostly female (n=18, 69.2%) and Chinese (n=20, 76.9%), with a mean age of 35.8 +/- 2.9 years. All items were assessed relevantly (n=18, 100%), I-CVIs ranging from 0.96-1.00 by hospital pharmacists. The average proportion of items, I-CVI average, (Sum of I-CVI/no. of items: 17.88/18) was reported as 0.99. S-CVI/UA (Sum of UA/no. of items: 15/18) was reported as 0.83, and S-CVI/Average (Sum of I-CVI/no. of items: 17.88/18) was reported as 0.99 indicating high content validity. Patients (n=28) involved in face validation of the construct were mostly female (n=19, 67.9%), Malay (n=46.4%), and tertiary educated (n=20, 71.4%) with a mean age of 38.0 +/- 9.8 years. All items were marked as relevant (n=18, 100%), with IAI ranging from 0.93-1.00, suggesting patients accepted each item of the construct. The average proportion of items was reported as 0.99 (Sum of IAI/no. of items: 17.82/18), indicating excellent acceptance and content comprehension among patients. The developed counseling tool is acceptable for anticoagulant education among COVID-19 patients.

Pharmacological Agents Targeting Coagulopathy in COVID-19: A Review

Infection with severe acute respiratory syndrome coronavirus (SARS-CoV-2) and the resultant syndrome COVID-19 has wrecked the entire world. The disease mostly manifests as mild viral pneumonia but in a small proportion of patients it can produce an intense inflammatory and prothrombotic state leading to multiorgan failure and even death. Varying incidences of venous thromboembolism (VTE) have been found in COVID-19 patients. This review describes the role of various pharmacological agents used prophylactically as well as therapeutically for thromboembolism in such patients. The anticoagulants which are administered as antithrombotic therapy can be used parenterally (heparin and direct thrombin inhibitors) or orally (direct oral thrombin inhibitors). The mechanism of action, pharmacology, usage, and adverse effects of such agents has been discussed especially in the context of ongoing COVID-19 pandemic. As a result of various completed and ongoing clinical trials, scientific community has collected promising evidence and formulated guidelines regarding the role of anticoagulants in COVID-19 patients. © The Author(s), under exclusive licence to Springer Nature Singapore Pte Ltd. 2021.

Impact of thromboprophylaxis on hospital acquired thrombosis following discharge in patients admitted with COVID-19: Multicentre observational study in the UK.

Post-discharge thromboprophylaxis in patients admitted with COVID-19 remains controversial. We aimed to determine the impact of thromboprophylaxis on hospital acquired thrombosis (HAT) in patients (≥18 years) discharged following admission for COVID-19 in an observational study across 26 NHS Trusts in the UK (01.04.2020-31.12.2021). Overall, 8895 patients were included to the study: 971 patients were discharged with thromboprophylaxis and propensity score matched (PSM) with a desired ratio of 1:1, from patients discharged without thromboprophylaxis. Patients with heparin induced thrombocytopenia, major bleeding during admission and pregnant women were excluded. As expected from 1:1 PSM, no difference was observed in parameters between the two groups, including duration of hospital stay, except the thromboprophylaxis group had a significantly higher proportion who had received therapeutic dose anticoagulation during admission. There were no differences in the laboratory parameters especially D-dimers between the two groups at admission or discharge. Median duration of thromboprophylaxis following discharge from hospital was 4 weeks (1-8 weeks). No difference was found in HAT in patients discharged with TP versus no TP (1.3% vs. 0.92%, p = 0.52). Increasing age and smoking significantly increased the risk of HAT. Many patients in both cohorts had raised D-dimer at discharge but D-dimer was not associated with increased risk of HAT.

Examining the frequency of endoscopic findings in patients with COVID-19 with upper gastrointestinal bleeding referred to al-Zahra Hospital of Isfahan

Background: Gastrointestinal bleeding is one of the consequences of COVID-19, which is associated with increased hospitalization and patient mortality. This study was conducted to determine the prevalence of endoscopic findings and the outcome of gastrointestinal bleeding in patients with COVID-19 who were hospitalized from September to December 2019 in Al-Zahra Hospital, Isfahan. Methods: In this cross-sectional study, out of 5800 patients who were admitted to Al- Zahra Hospital in Isfahan from September to December 2019 due to COVID-19 (according to the positive PCR test result), 87 patients who underwent endoscopy due to upper gastrointestinal bleeding by a skilled gastroenterologist, were selected and studied. Demographic characteristics, underlying diseases, use of anticoagulants, and laboratory findings were studied and evaluated and finally, the disease was evaluated and compared based on endoscopic findings. Results: Based on the results obtained from this research, the patients with endoscopic lesions had higher average age (P=0.041), lower blood oxygen saturation percentage (P=0.028), and higher bleeding intensity (P=0.018). The frequency of using anticoagulant drugs in the group whose endoscopy results were abnormal was higher but insignificant. Hemoglobin, platelet, lymphocyte, and CRP levels were higher in the group whose endoscopy was normal, and NLR, LDH, and D-dimer levels were higher in the group whose endoscopy was abnormal (P<0.050). Three people (11.55%) from the group with normal endoscopy and 18 people (29.5%) from the group with abnormal endoscopy died, but the frequency of death was not significantly different between the two groups (P=0.070). Conclusion: The findings of the present study showed that the COVID patients with upper gastrointestinal bleeding who had endoscopic lesions had significant differences in some characteristics such as age, bleeding intensity, and blood oxygen saturation percentage with patients with normal endoscopy. Also, the frequency of death in patients with endoscopic lesions was relatively higher. Therefore, COVID patients with gastrointestinal bleeding should undergo endoscopy as soon as possible and necessary measures should be taken to control and prevent gastrointestinal bleeding.

A case series on upper GI bleeding among patients admitted with COVID-19 infection

Background: Patients with COVID-19 infection are liable to develop coagulopathies and bleeding. An increase in the use of anticoagulants among this group of patients may be associated with an increase in the risk of developing GI bleeding. We aimed to evaluate the endoscopic characteristics of patients with COVID-19 that developed a GI bleed. Methods: A retrospective analysis of patients admitted to Rashid hospital with Upper GI bleeding, and COVID was done. We collected details on patient demographics, comorbid conditions, the severity of COVID infection, use of antiplatelet/anticoagulants, and their endoscopic findings. Results: 14 cases of Upper GI bleeding were included, half of which were on antiplatelet/anticoagulant. Endoscopic findings included peptic ulcer disease, Mallory Weis, gastritis, dieulafouy lesion, esophageal varices, and small gastric erosions. Peptic ulcer disease was the most common finding on endoscopy. Conclusion: Coagulopathy and bleeding risk remains a challenge in patients with COVID-19. Although peptic ulcer disease was the commonest etiology, it is still unclear whether the risk of bleeding was secondary to COVID-19 infection itself or the use of anticoagulants. We recommend physicians to be cognizant of the possible endoscopic features that may be encountered in COVID-19 infected patients presenting with GI bleeding so as to provide optimal management.

Efficacy and Safety of Direct Oral Anticoagulants Compared With Heparin for Preventing Thromboembolism in Hospitalized Patients With COVID-19: A Systematic Review and Meta-Analysis.

A high rate of thromboembolism and a high risk of death have been reported regarding hospitalized patients with coronavirus disease 2019 (COVID-19). Recently, we noticed that clinicians in some comparative studies used direct oral anticoagulants (DOACs) to prevent thromboembolism in patients with COVID-19. However, it is uncertain whether DOACs are better than recommended heparin for hospitalized patients with COVID-19. Therefore, a direct comparison of the prophylactic effects and safety between DOACs and heparin is needed. We systematically searched PubMed, Embase, Web of Science, and the Cochrane Library from 2019 to December 1, 2022. Randomized controlled trials or retrospective studies comparing the efficacy or safety of DOACs with that of heparin in preventing thromboembolism for hospitalized patients with COVID-19 were included. We assessed endpoints and publication bias using Stata 14.0. Five studies comprising 1360 hospitalized COVID-19 patients with mild to moderate cases were identified in the databases. Comparing the embolism incidence, we found that DOACs had a better effect than heparin, mainly low-molecular-weight heparin (LMWH), in preventing thromboembolism (risk ratio [RR] = 0.63, 95% confidence interval [CI] [0.43-0.91], P = 0.014). Considering safety, DOACs resulted in less bleeding than heparin during hospitalization (RR = 0.52, 95% CI [0.11-2.44], P = 0.411). Similar mortality was discovered in the 2 groups (RR = 0.94, 95% CI [0.59-1.51], P = 0.797). In noncritically hospitalized patients with COVID-19, DOACs are superior to heparin, even LMWH, in preventing thromboembolism. Compared with heparin, DOACs have a lower trend of bleeding and yield a similar mortality rate. Therefore, DOACs may be a better alternative for patients with mild to moderate COVID-19.

Risk and Management of Bleeding Complications with Direct Oral Anticoagulants in Patients with Atrial Fibrillation and Venous Thromboembolism: a Narrative Review.

Atrial fibrillation (AF) and venous thromboembolism (VTE) are highly prevalent conditions with a significant healthcare burden, and represent the main indications for anticoagulation. Direct oral anticoagulants (DOACs) are the first choice treatment of AF/VTE, and have become the most prescribed class of anticoagulants globally, overtaking vitamin K antagonists (VKAs). Compared to VKAs, DOACs have a similar or better efficacy/safety profile, with reduced risk of intracerebral hemorrhage (ICH), while the risk of major bleeding and other bleeding harms may vary depending on the type of DOAC. We have critically reviewed available evidence from randomized controlled trials and observational studies regarding the risk of bleeding complications of DOACs compared to VKAs in patients with AF and VTE. Special patient populations (e.g., elderly, extreme body weights, chronic kidney disease) have specifically been addressed. Management of bleeding complications and possible resumption of anticoagulation, in particular after ICH and gastrointestinal bleeding, are also discussed. Finally, some suggestions are provided to choose the optimal DOAC to minimize adverse events according to individual patient characteristics and bleeding risk.