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1.
Kardiol Pol ; 78(6): 642-646, 2020 06 25.
Article in English | MEDLINE | ID: covidwho-701600

ABSTRACT

The coronavirus disease 2019 (COVID-19) pandemic affects anticoagulation not only in those infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) but also in most patients who require daily anticoagulant therapy and are facing substantial limitations in medical care these days. Concomitant venous thromboembolism (VTE), a potential cause of unexplained deaths, has frequently been reported in patients with COVID-19, but its management is still challenging due to the complexity between antithrombotic therapy and hematological alterations. In the era of COVID-19 pandemic, it is highly recommended for patients who require chronic anticoagulation to continue therapy to prevent thromboembolic events. To avoid regular and frequent blood tests and unnecessary exposure to SARS-CoV-2 during contacts with medical personnel, direct oral anticoagulants should be strongly preferred whenever possible. Current evidence is insufficient to recommend routine pharmacological antithrombotic prophylaxis in all hospitalized patients with COVID-19. In patients with COVID-19 who are suspected of VTE or in whom the diagnosis is confirmed, parenteral therapy with low-molecular-weight heparin should be initiated in the absence of contraindications. If heparin-induced thrombocytopenia is suspected, nonheparin anticoagulants should be used such as bivalirudin or fondaparinux. In case of confirmed acute pulmonary embolism, treatment should be guided by risk stratification as defined in the current guidelines.


Subject(s)
Anticoagulants/therapeutic use , Coronavirus Infections/complications , Expert Testimony , Pneumonia, Viral/complications , Practice Guidelines as Topic , Venous Thromboembolism/drug therapy , Betacoronavirus , Blood Coagulation , Coronavirus Infections/therapy , Hospitalization/statistics & numerical data , Humans , Pandemics , Pneumonia, Viral/therapy , Poland , Pulmonary Embolism/complications , Risk Factors , Societies, Medical
2.
Kardiologiia ; 60(6): 1180, 2020 May 25.
Article in Russian | MEDLINE | ID: covidwho-689072

ABSTRACT

This article discusses relevant aspects in the treatment of patients with COVID-19. Up-to-date information about principles for administration of statins, antithrombotics, and antiarrhythmics is presented. The authors addressed in detail specific features of reversing heart rhythm disorders in patients with coronavirus infection and the interaction of antiarrhythmic and antiviral drugs. Recommendations are provided for outpatient and inpatient antithrombotic therapy for patients with COVID-19. Issues of antithrombotic and antiviral drug interaction are discussed.


Subject(s)
Anticoagulants , Cardiology , Coronavirus Infections , Hydroxymethylglutaryl-CoA Reductase Inhibitors , Pandemics , Pneumonia, Viral , Anti-Arrhythmia Agents/therapeutic use , Anticoagulants/therapeutic use , Betacoronavirus , Coronavirus Infections/drug therapy , Coronavirus Infections/epidemiology , Humans , Hydroxymethylglutaryl-CoA Reductase Inhibitors/therapeutic use , Pneumonia, Viral/drug therapy , Pneumonia, Viral/epidemiology , Russia , Societies, Medical
3.
Circulation ; 142(2): 114-128, 2020 07 14.
Article in English | MEDLINE | ID: covidwho-684109

ABSTRACT

BACKGROUND: To investigate deep vein thrombosis (DVT) in hospitalized patients with coronavirus disease 2019 (COVID-19), we performed a single institutional study to evaluate its prevalence, risk factors, prognosis, and potential thromboprophylaxis strategies in a large referral and treatment center. METHODS: We studied a total of 143 patients with COVID-19 from January 29, 2020 to February 29, 2020. Demographic and clinical data, laboratory data, including ultrasound scans of the lower extremities, and outcome variables were obtained, and comparisons were made between groups with and without DVT. RESULTS: Of the 143 patients hospitalized with COVID-19 (age 63±14 years, 74 [51.7%] men), 66 patients developed lower extremity DVT (46.1%: 23 [34.8%] with proximal DVT and 43 [65.2%] with distal DVT). Compared with patients who did not have DVT, patients with DVT were older and had a lower oxygenation index, a higher rate of cardiac injury, and worse prognosis, including an increased proportion of deaths (23 [34.8%] versus 9 [11.7%]; P=0.001) and a decreased proportion of patients discharged (32 [48.5%] versus 60 [77.9%]; P<0.001). Multivariant analysis showed an association only between CURB-65 (confusion status, urea, respiratory rate, and blood pressure) score 3 to 5 (odds ratio, 6.122; P=0.031), Padua prediction score ≥4 (odds ratio, 4.016; P=0.04), D-dimer >1.0 µg/mL (odds ratio, 5.818; P<0.014), and DVT in this cohort, respectively. The combination of a CURB-65 score 3 to 5, a Padua prediction score ≥4, and D-dimer >1.0 µg/mL has a sensitivity of 88.52% and a specificity of 61.43% for screening for DVT. In the subgroup of patients with a Padua prediction score ≥4 and whose ultrasound scans were performed >72 hours after admission, DVT was present in 18 (34.0%) patients in the subgroup receiving venous thromboembolism prophylaxis versus 35 (66.0%) patients in the nonprophylaxis group (P=0.010). CONCLUSIONS: The prevalence of DVT is high and is associated with adverse outcomes in hospitalized patients with COVID-19. Prophylaxis for venous thromboembolism may be protective in patients with a Padua protection score ≥4 after admission. Our data seem to suggest that COVID-19 is probably an additional risk factor for DVT in hospitalized patients.


Subject(s)
Coronavirus Infections/diagnosis , Pneumonia, Viral/diagnosis , Venous Thrombosis/diagnosis , Adult , Aged , Anticoagulants/therapeutic use , Betacoronavirus/isolation & purification , Blood Pressure , China/epidemiology , Coronavirus Infections/complications , Coronavirus Infections/mortality , Coronavirus Infections/physiopathology , Female , Fibrin Fibrinogen Degradation Products/analysis , Humans , Kaplan-Meier Estimate , Lower Extremity/diagnostic imaging , Male , Middle Aged , Odds Ratio , Pandemics , Pneumonia, Viral/complications , Pneumonia, Viral/mortality , Pneumonia, Viral/physiopathology , Prevalence , Prognosis , Respiratory Rate , Retrospective Studies , Risk Factors , Treatment Outcome , Venous Thrombosis/complications , Venous Thrombosis/drug therapy , Venous Thrombosis/epidemiology
4.
Rev Cardiovasc Med ; 21(2): 289-295, 2020 06 30.
Article in English | MEDLINE | ID: covidwho-676696

ABSTRACT

Consideration of thrombolysis as first-line reperfusion therapy in patients with COVID-19 and STEMI is recommended by ACC/SCAI guidelines. We describe a patient with COVID-19, who presented with ST-elevation myocardial infarction and was treated with thrombolysis and anticoagulation. He was later found to have a significant persistent thrombus burden requiring thrombectomy and stent placement. Invasive hemodynamics on multiple high-dose pressers revealed a high cardiac output state with low systemic vascular resistance, consistent with distributive rather than cardiogenic shock. Our case illustrates that thrombolytic therapy alone may not be adequate in patients with STEMI and COVID-19, as well as the importance of early invasive hemodynamics in management of shock in patient with STEMI and COVID-19 infection.


Subject(s)
Coronary Thrombosis/therapy , Coronavirus Infections/complications , Pneumonia, Viral/complications , ST Elevation Myocardial Infarction/therapy , Thrombectomy , Thrombolytic Therapy/methods , Anticoagulants/therapeutic use , Betacoronavirus , Coronary Angiography , Coronary Thrombosis/diagnostic imaging , Electrocardiography , Humans , Male , Middle Aged , Pandemics , Percutaneous Coronary Intervention , ST Elevation Myocardial Infarction/diagnostic imaging
5.
Clin Appl Thromb Hemost ; 26: 1076029620943671, 2020.
Article in English | MEDLINE | ID: covidwho-676150

ABSTRACT

Severe acute respiratory syndrome coronavirus 2 infection (COVID-19) is known to induce severe inflammation and activation of the coagulation system, resulting in a prothrombotic state. Although inflammatory conditions and organ-specific diseases have been shown to be strong determinants of morbidity and mortality in patients with COVID-19, it is unclear whether preexisting differences in coagulation impact the severity of COVID-19. African Americans have higher rates of COVID-19 infection and disease-related morbidity and mortality. Moreover, African Americans are known to be at a higher risk for thrombotic events due to both biological and socioeconomic factors. In this review, we explore whether differences in baseline coagulation status and medical management of coagulation play an important role in COVID-19 disease severity and contribute to racial disparity trends within COVID-19.


Subject(s)
African Americans , Betacoronavirus , Coronavirus Infections/ethnology , Pandemics , Pneumonia, Viral/ethnology , Thrombophilia/ethnology , Venous Thromboembolism/ethnology , African Americans/genetics , Anemia, Sickle Cell/blood , Anemia, Sickle Cell/ethnology , Anticoagulants/therapeutic use , Blood Proteins/analysis , Blood Proteins/genetics , Clinical Trials as Topic , Comorbidity , Coronavirus Infections/blood , Coronavirus Infections/complications , Factor VIII/analysis , Female , Fibrin Fibrinogen Degradation Products/analysis , Genetic Association Studies , Genetic Predisposition to Disease , Healthcare Disparities , Humans , Lupus Erythematosus, Systemic/blood , Lupus Erythematosus, Systemic/ethnology , Male , Patient Selection , Pneumonia, Viral/blood , Pneumonia, Viral/complications , Polymorphism, Single Nucleotide , Prevalence , Renal Insufficiency, Chronic/blood , Renal Insufficiency, Chronic/ethnology , Risk Factors , Social Determinants of Health , Socioeconomic Factors , Thrombophilia/blood , Thrombophilia/drug therapy , Thrombophilia/etiology , Venous Thromboembolism/blood , Venous Thromboembolism/etiology , Venous Thromboembolism/prevention & control
6.
J Stroke Cerebrovasc Dis ; 29(8): 104974, 2020 Aug.
Article in English | MEDLINE | ID: covidwho-665314

ABSTRACT

Emerging evidence suggests that patients with coronavirus disease 2019 (COVID-19) are at risk of thromboembolic complications, including ischemic strokes. We present a case illustrating the value of CT perfusion to identify acute small subcortical infarcts in a patient with COVID-19 admitted to an intensive care unit for bilateral pneumonia and pulmonary embolism presenting with sudden right limb weakness.


Subject(s)
Betacoronavirus/isolation & purification , Brain Infarction/diagnostic imaging , Clinical Laboratory Techniques , Coronavirus Infections/diagnosis , Perfusion Imaging/methods , Pneumonia, Viral/diagnosis , Thalamic Diseases/diagnostic imaging , Tomography, X-Ray Computed , Anticoagulants/therapeutic use , Antiviral Agents/therapeutic use , Brain Infarction/therapy , Coronavirus Infections/drug therapy , Coronavirus Infections/therapy , Coronavirus Infections/virology , Diffusion Magnetic Resonance Imaging , Host Microbial Interactions , Humans , Male , Middle Aged , Noninvasive Ventilation , Pandemics , Pneumonia, Viral/therapy , Pneumonia, Viral/virology , Predictive Value of Tests , Prosthesis Implantation/instrumentation , Thalamic Diseases/therapy , Treatment Outcome , Vena Cava Filters
8.
Clin Appl Thromb Hemost ; 26: 1076029620936776, 2020.
Article in English | MEDLINE | ID: covidwho-657787

ABSTRACT

COVID-19 has proven to be particularly challenging given the complex pathogenesis of SARS-CoV-2. Early data have demonstrated how the host response to this novel coronavirus leads to the proliferation of pro-inflammatory cytokines, massive endothelial damage, and generalized vascular manifestations. While SARS-CoV-2 primarily targets the upper and lower respiratory tract, other organ systems are also affected. SARS-CoV-2 relies on 2 host cell receptors for successful attachment: angiotensin-converting enzyme 2 and transmembrane protease serine 2. Clinicopathologic reports have demonstrated associations between severe COVID-19 and viral coagulopathy, resulting in pulmonary embolism; venous, arterial, and microvascular thrombosis; lung endothelial injury; and associated thrombotic complications leading to acute respiratory distress syndrome. Viral coagulopathy is not novel given similar observations with SARS classic, including the consumption of platelets, generation of thrombin, and increased fibrin degradation product exhibiting overt disseminated intravascular coagulation-like syndrome. The specific mechanism(s) behind the thrombotic complications in COVID-19 patients has yet to be fully understood. Parenteral anticoagulants, such as heparin and low-molecular-weights heparins, are widely used in the management of COVID-19 patients. Beyond the primary (anticoagulant) effects of these agents, they may exhibit antiviral, anti-inflammatory, and cytoprotective effects. Direct oral anticoagulants and antiplatelet agents are also useful in the management of these patients. Tissue plasminogen activator and other fibrinolytic modalities may also be helpful in the overall management. Catheter-directed thrombolysis can be used in patients developing pulmonary embolism. Further investigations are required to understand the molecular and cellular mechanisms involved in the pathogenesis of COVID-19-associated thrombotic complications.


Subject(s)
Betacoronavirus/pathogenicity , Coronavirus Infections/complications , Pandemics , Pneumonia, Viral/complications , Thrombophilia/etiology , Angiotensin II Type 1 Receptor Blockers/pharmacology , Angiotensin II Type 1 Receptor Blockers/therapeutic use , Angiotensin-Converting Enzyme Inhibitors/pharmacology , Angiotensin-Converting Enzyme Inhibitors/therapeutic use , Anticoagulants/therapeutic use , Arterial Occlusive Diseases/etiology , Arterial Occlusive Diseases/physiopathology , Arterial Occlusive Diseases/virology , Cardiovascular Diseases/etiology , Cardiovascular Diseases/prevention & control , Catheterization, Swan-Ganz , Combined Modality Therapy , Coronavirus Infections/blood , Coronavirus Infections/drug therapy , Endothelium, Vascular/physiopathology , Endothelium, Vascular/virology , Fibrinolytic Agents/therapeutic use , Humans , Hyperbaric Oxygenation , Platelet Aggregation Inhibitors/therapeutic use , Pneumonia, Viral/blood , Pneumonia, Viral/drug therapy , Pulmonary Embolism/etiology , Pulmonary Embolism/therapy , Pulmonary Embolism/virology , Respiratory Distress Syndrome, Adult/etiology , Thrombolytic Therapy/instrumentation , Thrombolytic Therapy/methods , Thrombophilia/physiopathology , Thrombophilia/therapy , Venous Thrombosis/etiology , Venous Thrombosis/physiopathology , Venous Thrombosis/virology , Virus Internalization/drug effects
9.
Clin Appl Thromb Hemost ; 26: 1076029620938149, 2020.
Article in English | MEDLINE | ID: covidwho-651515

ABSTRACT

The novel coronavirus infection (COVID-19) is caused by the new coronavirus SARS-CoV-2 and is characterized by an exaggerated inflammatory response that can lead to severe manifestations such as adult respiratory syndrome, sepsis, coagulopathy, and death in a proportion of patients. Among other factors and direct viral effects, the increase in the vasoconstrictor angiotensin II, the decrease in the vasodilator angiotensin, and the sepsis-induced release of cytokines can trigger a coagulopathy in COVID-19. A coagulopathy has been reported in up to 50% of patients with severe COVID-19 manifestations. An increase in d-dimer is the most significant change in coagulation parameters in severe COVID-19 patients, and progressively increasing values can be used as a prognostic parameter indicating a worse outcome. Limited data suggest a high incidence of deep vein thrombosis and pulmonary embolism in up to 40% of patients, despite the use of a standard dose of low-molecular-weight heparin (LMWH) in most cases. In addition, pulmonary microvascular thrombosis has been reported and may play a role in progressive lung failure. Prophylactic LMWH has been recommended by the International Society on Thrombosis and Haemostasis (ISTH) and the American Society of Hematology (ASH), but the best effective dosage is uncertain. Adapted to the individual risk of thrombosis and the d-dimer value, higher doses can be considered, especially since bleeding events in COVID-19 are rare. Besides the anticoagulant effect of LMWH, nonanticoagulant properties such as the reduction in interleukin 6 release have been shown to improve the complex picture of coagulopathy in patients with COVID-19.


Subject(s)
Anticoagulants/therapeutic use , Betacoronavirus , Coronavirus Infections/complications , Pandemics , Pneumonia, Viral/complications , Thrombophilia/etiology , Thrombosis/prevention & control , Angiotensin II/metabolism , Arterial Occlusive Diseases/blood , Arterial Occlusive Diseases/epidemiology , Arterial Occlusive Diseases/etiology , Coronavirus Infections/blood , Coronavirus Infections/epidemiology , Cytokine Release Syndrome/blood , Cytokine Release Syndrome/etiology , Disease Outbreaks , Disseminated Intravascular Coagulation/etiology , Disseminated Intravascular Coagulation/prevention & control , Fibrin Fibrinogen Degradation Products/analysis , Fibrinolytic Agents/therapeutic use , Heparin, Low-Molecular-Weight/therapeutic use , Humans , Incidence , Inflammation , Pneumonia, Viral/blood , Pneumonia, Viral/epidemiology , Prognosis , Pulmonary Embolism/etiology , Pulmonary Embolism/prevention & control , Risk , Sepsis/blood , Sepsis/complications , Severe Acute Respiratory Syndrome/blood , Severe Acute Respiratory Syndrome/complications , Severe Acute Respiratory Syndrome/epidemiology , Thrombophilia/blood , Thrombophilia/drug therapy , Thrombosis/blood , Thrombosis/epidemiology , Thrombosis/etiology , Thrombotic Microangiopathies/etiology , Thrombotic Microangiopathies/prevention & control , Tissue Plasminogen Activator/therapeutic use
11.
Methodist Debakey Cardiovasc J ; 16(2): 155-157, 2020.
Article in English | MEDLINE | ID: covidwho-646674

ABSTRACT

A COVID-19-positive patient presented with pleuritic chest pain and cough and was found to have acute pulmonary embolisms (APEs). There has been an increase in observational reports of venous thromboembolic events in patients who are positive for COVID-19, especially in the setting of elevated inflammatory markers. The possibility of COVID-19 as an independent risk factor for APEs should be further explored in this novel pandemic.


Subject(s)
Coronavirus Infections/complications , Pneumonia, Viral/complications , Pulmonary Embolism/complications , Pulmonary Embolism/diagnostic imaging , Severe Acute Respiratory Syndrome/complications , Acute Disease , Adult , Anticoagulants/therapeutic use , Chest Pain/diagnosis , Chest Pain/etiology , Computed Tomography Angiography/methods , Coronavirus Infections/diagnosis , Cough/diagnosis , Cough/etiology , Emergency Service, Hospital , Follow-Up Studies , Humans , Male , Pandemics , Pneumonia, Viral/diagnosis , Pulmonary Embolism/drug therapy , Severe Acute Respiratory Syndrome/diagnosis , Severity of Illness Index , Tomography, X-Ray Computed/methods , Treatment Outcome
12.
Front Immunol ; 11: 1439, 2020.
Article in English | MEDLINE | ID: covidwho-644233

ABSTRACT

In December 2019, following a cluster of pneumonia cases in China caused by a novel coronavirus (CoV), named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the infection disseminated worldwide and, on March 11th, 2020, the World Health Organization officially declared the pandemic of the relevant disease named coronavirus disease 2019 (COVID-19). In Europe, Italy was the first country facing a true health policy emergency, and, as at 6.00 p.m. on May 2nd, 2020, there have been more than 209,300 confirmed cases of COVID-19. Due to the increasing number of patients experiencing a severe outcome, global scientific efforts are ongoing to find the most appropriate treatment. The usefulness of specific anti-rheumatic drugs came out as a promising treatment option together with antiviral drugs, anticoagulants, and symptomatic and respiratory support. For this reason, we feel a duty to share our experience and our knowledge on the use of these drugs in the immune-rheumatologic field, providing in this review the rationale for their use in the COVID-19 pandemic.


Subject(s)
Betacoronavirus/metabolism , Cardiovascular Diseases/drug therapy , Cardiovascular Diseases/etiology , Coronavirus Infections/complications , Coronavirus Infections/drug therapy , Pneumonia, Viral/complications , Pneumonia, Viral/drug therapy , Adaptive Immunity/drug effects , Adult , Anticoagulants/therapeutic use , Antirheumatic Agents/therapeutic use , Antiviral Agents/therapeutic use , Betacoronavirus/immunology , Coronavirus Infections/immunology , Coronavirus Infections/virology , Humans , Hydroxychloroquine/therapeutic use , Immunity, Innate/drug effects , Interleukin-1/antagonists & inhibitors , Interleukin-6/antagonists & inhibitors , Janus Kinase Inhibitors/therapeutic use , Pandemics , Pneumonia, Viral/immunology , Pneumonia, Viral/virology , Respiratory Distress Syndrome, Adult/drug therapy , Respiratory Distress Syndrome, Adult/etiology
13.
Clin Appl Thromb Hemost ; 26: 1076029620936350, 2020.
Article in English | MEDLINE | ID: covidwho-639157

ABSTRACT

This practical guidance, endorsed by the Brazilian Society of Thrombosis and Hemostasis and The Brazilian Society of Angiology and Vascular Surgery, the International Union of Angiology and the European Venous Forum, aims to provide physicians with clear guidance, based on current best evidence-based data, on clinical strategies to manage antithrombotic strategies in patients with coronavirus disease 2019.


Subject(s)
Betacoronavirus , Coronavirus Infections/complications , Pandemics , Pneumonia, Viral/complications , Practice Guidelines as Topic , Thrombophilia/therapy , Thrombosis/prevention & control , Anticoagulants/therapeutic use , Biomarkers , Clinical Trials as Topic , Coronavirus Infections/blood , Cytokine Release Syndrome/blood , Cytokine Release Syndrome/etiology , Disease Management , Endothelium, Vascular/physiopathology , Endothelium, Vascular/virology , Evidence-Based Medicine , Fibrin Fibrinogen Degradation Products/analysis , Humans , Lung Diseases/etiology , Lung Diseases/prevention & control , Pneumonia, Viral/blood , Pulmonary Veins , Thrombophilia/etiology , Thrombophlebitis/etiology , Thrombophlebitis/prevention & control , Thrombosis/etiology , Venous Thromboembolism/etiology , Venous Thromboembolism/prevention & control
14.
Swiss Med Wkly ; 150: w20301, 2020 06 15.
Article in English | MEDLINE | ID: covidwho-638143

ABSTRACT

AIMS OF THE STUDY: Many centres have noticed a high number of venous thromboembolism (VTE) events among critically ill inpatients with COVID-19 pneumonia. The aims of this study were (1) to summarise the reported risk of VTE associated with COVID-19 infections and (2) to summarise guidance documents on thromboprophylaxis in COVID-19 patients, in a systematic review. METHODS: We systematically searched for peer-reviewed evidence on the risk of VTE in patients with COVID-19, in PubMed, Embase and Twitter, and for guidelines or guidance documents for thromboprophylaxis, from international or national societies relevant to the field of thrombosis and haemostasis, up to April 30 2020. RESULTS: We found 11 studies (1 clinical trial, 7 retrospective cohorts and 3 prospective cohorts), which included a range of 16 to 388 in patients with COVID-19 (total of 1369 inpatients). The diagnoses of COVID-19 and VTE were of high quality, but the follow-up was often unclear. Most studies reported universal in-hospital thromboprophylaxis. Among all inpatients and among intensive care unit (ICU) inpatients with COVID-19, reported risks of VTE were 4.4–8.2% (three studies) and 0–35.3% (six studies), respectively. Two studies at least partially screened for VTE in ICU inpatients with COVID-19, and found risks of 24.7–53.8%. We found 12 guidelines for thromboprophylaxis of COVID-19 patients. The majority suggested universal pharmacological thromboprophylaxis in all COVID-19 inpatients, but there was heterogeneity in the suggested intensity of thromboprophylaxis: seven advised considering intensified doses of heparin according to the clinical or biological severity of the disease, especially in the ICU setting. CONCLUSIONS: Venous thromboembolism very commonly complicates the clinical course of inpatients with COVID-19, despite thromboprophylaxis. The risk appears highest among critically ill inpatients. We found no estimates of risks among outpatients. Many questions remain unresolved, as delineated by the heterogeneity of national and international guidelines. This situation calls for fast randomised clinical trials, comparing different schemes of thromboprophylaxis in COVID-19 inpatients.


Subject(s)
Coronavirus Infections/epidemiology , Pneumonia, Viral/epidemiology , Pulmonary Embolism/epidemiology , Venous Thromboembolism/epidemiology , Venous Thrombosis/epidemiology , Anticoagulants/therapeutic use , Betacoronavirus , Fondaparinux/therapeutic use , Heparin/therapeutic use , Heparin, Low-Molecular-Weight/therapeutic use , Humans , Pandemics , Practice Guidelines as Topic , Pulmonary Embolism/prevention & control , Risk , Venous Thromboembolism/prevention & control , Venous Thrombosis/prevention & control
15.
Anaesth Crit Care Pain Med ; 39(3): 351-353, 2020 06.
Article in English | MEDLINE | ID: covidwho-636270
17.
J Stroke Cerebrovasc Dis ; 29(8): 104989, 2020 Aug.
Article in English | MEDLINE | ID: covidwho-622312

ABSTRACT

OBJECTIVE: Identify clinical and radiographic features of venous infarct as a presenting feature of COVID-19 in the young. BACKGROUND: SARS-CoV-2 infection causes hypercoagulability and inflammation leading to venous thrombotic events (VTE). Although elderly patients with comorbidities are at higher risk, COVID-19 may also cause VTE in a broader patient population without these risks. Neurologic complications and manifestations of COVID-19, including neuropathies, seizures, strokes and encephalopathy usually occur in severe established cases of COVID-19 infection who primarily present with respiratory distress. CASE DESCRIPTION: Case report of a 29-year-old woman, with no significant past medical history or comorbidities, presenting with new onset seizures. Further questioning revealed a one-week history of headaches, low-grade fever, mild cough and shortness of breath, diagnosed as COVID-19. Imaging revealed a left temporoparietal hemorrhagic venous infarction with left transverse and sigmoid sinus thrombosis treated with full dose anticoagulation and antiepileptics. CONCLUSION: Although elderly patients with comorbidities are considered highest risk for COVID-19 neurologic complications, usually when systemic symptoms are severe, this case report emphasizes that young individuals are at risk for VTE with neurologic complications even when systemic symptoms are mild, likely induced by COVID-19 associated hypercoagulable state.


Subject(s)
Betacoronavirus/pathogenicity , Brain Infarction/virology , Coronavirus Infections/virology , Pneumonia, Viral/virology , Sinus Thrombosis, Intracranial/virology , Venous Thrombosis/virology , Adult , Age Factors , Anticoagulants/therapeutic use , Anticonvulsants/therapeutic use , Brain Infarction/diagnostic imaging , Brain Infarction/drug therapy , Coronavirus Infections/complications , Coronavirus Infections/diagnosis , Coronavirus Infections/drug therapy , Female , Host Microbial Interactions , Humans , Pandemics , Pneumonia, Viral/complications , Pneumonia, Viral/diagnosis , Pneumonia, Viral/drug therapy , Risk Factors , Sinus Thrombosis, Intracranial/diagnostic imaging , Sinus Thrombosis, Intracranial/drug therapy , Treatment Outcome , Venous Thrombosis/diagnostic imaging , Venous Thrombosis/drug therapy
18.
Trials ; 21(1): 574, 2020 Jun 26.
Article in English | MEDLINE | ID: covidwho-617182

ABSTRACT

OBJECTIVES: To assess whether high doses of Low Molecular Weight Heparin (LMWH) (i.e. Enoxaparin 70 IU/kg twice daily) compared to standard prophylactic dose (i.e., Enoxaparin 4000 IU once day), in hospitalized patients with COVID19 not requiring Invasive Mechanical Ventilation [IMV], are: a)more effective in preventing clinical worsening, defined as the occurrence of at least one of the following events, whichever comes first: 1.Death2.Acute Myocardial Infarction [AMI]3.Objectively confirmed, symptomatic arterial or venous thromboembolism [TE]4.Need of either: a.Continuous Positive Airway Pressure (Cpap) or Non-Invasive Ventilation (NIV) orb.IMV in patients who at randomisation were receiving standard oxygen therapy5.IMV in patients who at randomisation were receiving non-invasive mechanical ventilationb)Similar in terms of major bleeding risk TRIAL DESIGN: Multicentre, randomised controlled, superiority, open label, parallel group, two arms (1:1 ratio), in-hospital study. PARTICIPANTS: Inpatients will be recruited from 7 Italian Academic and non-Academic Internal Medicine Units, 2 Infectious Disease Units and 1 Respiratory Disease Unit. INCLUSION CRITERIA (ALL REQUIRED): 1. Age > 18 and < 80 years 2. Positive SARS-CoV-2 diagnostic (on pharyngeal swab of deep airways material) 3. Severe pneumonia defined by the presence of at least one of the following criteria: a.Respiratory Rate ≥25 breaths /minb.Arterial oxygen saturation≤93% at rest on ambient airc.PaO2/FiO2 ≤300 mmHg 4. Coagulopathy, defined by the presence of at least one of the following criteria: a.D-dimer >4 times the upper level of normal reference rangeb.Sepsis-Induced Coagulopathy (SIC) score >4 5. No need of IMV EXCLUSION CRITERIA: 1. Age <18 and >80 years 2. IMV 3. Thrombocytopenia (platelet count < 80.000 mm3) 4. Coagulopathy: INR >1.5, aPTT ratio > 1.4 5. Impaired renal function (eGFR calculated by CKD-EPI Creatinine equation < 30 ml/min) 6. Known hypersensitivity to enoxaparin 7. History of heparin induced thrombocytopenia 8. Presence of an active bleeding or a pathology susceptible of bleeding in presence of anticoagulation (e.g. recent haemorrhagic stroke, peptic ulcer, malignant cancer at high risk of haemorrhage, recent neurosurgery or ophthalmic surgery, vascular aneurysms, arteriovenous malformations) 9. Concomitant anticoagulant treatment for other indications (e.g. atrial fibrillation, venous thromboembolism, prosthetic heart valves) 10. Concomitant double antiplatelet therapy 11. Administration of therapeutic doses of LMWH, fondaparinux, or unfractionated heparin (UFH) for more than 72 hours before randomization; prophylactic doses are allowed 12. Pregnancy or breastfeeding or positive pregnancy test 13. Presence of other severe diseases impairing life expectancy (e.g. patients are not expected to survive 28 days given their pre-existing medical condition) 14. Lack or withdrawal of informed consent INTERVENTION AND COMPARATOR: Control Group (Low-Dose LMWH): patients in this group will be administered Enoxaparin (Inhixa®) at standard prophylactic dose (i.e., 4000 UI subcutaneously once day). Intervention Group (High-Dose LMWH): patients in this group will be administered Enoxaparin (Inhixa®) at dose of 70 IU/kg every 12 hours, as reported in the following table. This dose is commonly used in Italy when a bridging strategy is required for the management of surgery or invasive procedures in patients taking anti-vitamin K oral anticoagulants Body Weight (kg)Enoxaparin dose every 12 hours (IU)<50200050-69400070-89600090-1108000>11010000 The treatment with Enoxaparin will be initiated soon after randomization (maximum allowed starting time 12h after randomization). The treatment will be administered every 12 hours in the intervention group and every 24 hours in the control group. Treatments will be administered in the two arms until hospital discharge or the primary outcomes detailed below occur. MAIN OUTCOMES: Primary Efficacy Endpoint: Clinical worsening, defined as the occurrence of at least one of the following events, whichever comes first: 1.Death2.Acute Myocardial Infarction [AMI]3.Objectively confirmed, symptomatic arterial or venous thromboembolism [TE]4.Need of either: a.Continuous Positive Airway Pressure (Cpap) or Non-Invasive Ventilation (NIV) orb.IMV in patients who at randomisation were in standard oxygen therapy by delivery interfaces5.Need for IMV, in patients who at randomisation were in Cpap or NIV Time to the occurrence of each of these events will be recorded. Clinical worsening will be analysed as a binary outcome as well as a time-to-event one. Secondary Efficacy Endpoints: Any of the following events occurring within the hospital stay 1.Death2.Acute Myocardial Infarction [AMI]3.Objectively confirmed, symptomatic arterial or venous thromboembolism [TE]4.Need of either: a.Continuous Positive Airway Pressure (Cpap) or Non-Invasive Ventilation (NIV) orb.IMV in patients who at randomisation were in standard oxygen therapy by delivery interfaces5.Need for IMV in patients who at randomisation were in Cpap or NIV6.Improvement of laboratory parameters of disease severity, including: o D-dimer levelo Plasma fibrinogen levelso Mean Platelet Volumeo Lymphocyte/Neutrophil ratioo IL-6 plasma levels MORTALITY AT 30 DAYS: Information about patients' status will be sought in those who are discharged before 30 days on Day 30 from randomisation. Time to the occurrence of each of these events will be recorded. Each of these events will be analysed as a binary outcome and as a time-to-event one. Primary safety endpoint: Major bleeding, defined as an acute clinically overt bleeding associated with one or more of the following: Decrease in haemoglobin of 2 g/dl or more;Transfusion of 2 or more units of packed red blood cells;Bleeding that occurs in at least one of the following critical sites [intracranial, intraspinal, intraocular (within the corpus of the eye; thus, a conjunctival bleed is not an intraocular bleed), pericardial, intra-articular, intramuscular with compartment syndrome, or retroperitoneal];Bleeding that is fatal (defined as a bleeding event that was the primary cause of death or contributed directly to death);Bleeding that necessitates surgical intervention Time to the occurrence of each of these events will be recorded. Each of these events will be analysed as a binary outcome and as a time-to-event one. Secondary safety endpoint: Clinically Relevant non-major bleeding, defined as an acute clinically overt bleeding that does not meet the criteria for major and consists of: 1.Any bleeding compromising hemodynamic2.Spontaneous hematoma larger than 25 cm2, or 100 cm2 if there was a traumatic cause3.Intramuscular hematoma documented by ultrasonography4.Epistaxis or gingival bleeding requiring tamponade or other medical intervention5.Bleeding from venipuncture for >5 minutes6.Haematuria that was macroscopic and was spontaneous or lasted for more than 24 hours after invasive procedures7.Haemoptysis, hematemesis or spontaneous rectal bleeding requiring endoscopy or other medical intervention8.Any other bleeding requiring temporary cessation of a study drug. Time to the occurrence of each of these events will be recorded. Each of these events will be analysed as a binary outcome and as a time-to-event one. RANDOMISATION: Randomisation (with a 1:1 randomisation ratio) will be centrally performed by using a secure, web-based system, which will be developed by the Methodological and Statistical Unit at the Azienda Ospedaliero-Universitaria of Modena. Randomisation stratified by 4 factors: 1) Gender (M/F); 2) Age (<75/≥75 years); 3) BMI (<30/≥30); 4) Comorbidities (0-1/>2) with random variable block sizes will be generated by STATA software. The web-based system will guarantee the allocation concealment. Blinding (masking) The study is conceived as open-label: patients and all health-care personnel involved in the study will be aware of the assigned group. NUMBERS TO BE RANDOMISED (SAMPLE SIZE): The target sample size is based on the hypothesis that LMWH administered at high doses versus low doses will significantly reduce the risk of clinical worsening. The overall sample size in this study is expected to be 300 with 150 in the Low-Dose LMWH control group and 150 in the High-Dose LMWH intervention group, recruited over 10-11 months. Assuming an alpha of 5% (two tailed) and a percentage of patients who experience clinical worsening in the control group being between 25% and 30%, the study will have 80% power to detect at least 50% relative reduction in the risk of death between low and high doses of heparin. TRIAL STATUS: Protocol version 1.2 of 11/05/2020. Recruitment start (expected): 08/06/2020 Recruitment finish (expected): 30/04/2021 Trial registration EudraCT 2020-001972-13, registered on April 17th, 2020 Full protocol The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.


Subject(s)
Anticoagulants/therapeutic use , Betacoronavirus , Blood Coagulation Disorders/drug therapy , Coronavirus Infections/drug therapy , Heparin, Low-Molecular-Weight/therapeutic use , Heparin/therapeutic use , Pneumonia, Viral/drug therapy , Randomized Controlled Trials as Topic , Adolescent , Adult , Aged , Heparin/adverse effects , Heparin, Low-Molecular-Weight/adverse effects , Hospitalization , Humans , Middle Aged , Pandemics , Respiration, Artificial , Young Adult
19.
Br J Hosp Med (Lond) ; 81(6): 1-12, 2020 Jun 02.
Article in English | MEDLINE | ID: covidwho-614928

ABSTRACT

Pulmonary embolism remains an important cause of morbidity and mortality in the UK, particularly following the outbreak of the novel coronavirus 2019 (COVID-19), where those infected have an increased prevalence of venous thromboembolic events. The pathophysiology in COVID-19 patients is thought to relate to a thromboinflammatory state within the pulmonary vasculature, triggered by the infection, but other risk factors such as reduced mobility, prolonged immobilisation and dehydration are likely to contribute. Several societies have released comprehensive guidelines emphasising the importance of risk stratification in patients with acute pulmonary embolism. They advocate the use of clinically validated risk scores in conjunction with biochemical and imaging results. Patients with mild disease can now be managed in the outpatient setting and with newly developed therapies, such as catheter-directed thrombolysis, becoming available in more centres, treatment options for those with more severe disease are also expanding. This article presents four theoretical but realistic cases, each diagnosed with acute pulmonary embolism, but differing in levels of severity. These demonstrate how the guidelines can be applied in a clinical setting, with particular focus on risk stratification and management.


Subject(s)
Anticoagulants/therapeutic use , Embolectomy , Fibrinolytic Agents/therapeutic use , Pulmonary Embolism/therapy , Adult , Aged , Ambulatory Care/methods , Betacoronavirus , Computed Tomography Angiography , Coronavirus Infections/epidemiology , Extracorporeal Membrane Oxygenation , Female , Hospitalization , Humans , Male , Middle Aged , Pandemics , Pneumonia, Viral/epidemiology , Practice Guidelines as Topic , Pulmonary Embolism/complications , Pulmonary Embolism/diagnostic imaging , Risk Assessment , Severity of Illness Index , Thrombolytic Therapy/methods , Ventricular Dysfunction, Right/diagnostic imaging , Ventricular Dysfunction, Right/etiology
20.
BMJ Case Rep ; 13(6)2020 Jun 24.
Article in English | MEDLINE | ID: covidwho-614885

ABSTRACT

The presence of rhabdomyolysis secondary to multiple infections has been reported, predominantly viral, but also bacterial and fungal. It is well known that COVID-19 can present a wide variety of complications during the course of infection; however, the presence of rhabdomyolysis as an initial condition has not been reported so far. We report a case of rhabdomyolysis as an initial presentation in a patient diagnosed with SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) infection.


Subject(s)
Betacoronavirus , Coronavirus Infections/complications , Coronavirus Infections/diagnostic imaging , Lung/diagnostic imaging , Pneumonia, Viral/complications , Pneumonia, Viral/diagnostic imaging , Rhabdomyolysis/etiology , Aged , Anti-Bacterial Agents/therapeutic use , Antibodies, Monoclonal, Humanized/therapeutic use , Anticoagulants/therapeutic use , Azithromycin/therapeutic use , Bicarbonates/therapeutic use , Ceftriaxone/therapeutic use , Coronavirus Infections/therapy , Cytochrome P-450 CYP3A Inhibitors/therapeutic use , Enoxaparin/therapeutic use , Enzyme Inhibitors/therapeutic use , Fluid Therapy , Humans , Hydroxychloroquine/therapeutic use , Lopinavir/therapeutic use , Male , Pandemics , Pneumonia, Viral/therapy , Respiration, Artificial , Rhabdomyolysis/diagnosis , Rhabdomyolysis/therapy , Ritonavir/therapeutic use , Tomography, X-Ray Computed/methods , Treatment Outcome
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