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1.
Clin Appl Thromb Hemost ; 27: 10760296211051712, 2021.
Article in English | MEDLINE | ID: covidwho-1495925

ABSTRACT

BACKGROUND: Since the beginning of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) pandemic, there have been many reports of increased incidence of venous thromboembolism and arterial events as a complication. OBJECTIVE: To determine the incidence of symptomatic thrombotic events (TEs) in patients hospitalized for SARS-CoV2 disease (coronavirus 19 [Covid-19]). METHODS: A retrospective single-center cohort study with adult patients with a positive reverse transcriptase-polymerase chain reaction (rt-PCR) for SARS-CoV2, included from the date of diagnosis of Covid-19 and followed for 90 days or until death. RESULTS: A total of 1621 patients were included in this study. The median age was 73 years (interquartile range25th-75th [IQR] 53-87 years) and 57% (913) were female. Overall mortality was 21.6% (348). The overall incidence of symptomatic TEs within 90 days of diagnosis was 1.8% (30 of 1621) occurring in 28 patients, including an incidence of pulmonary embolism of 0.9% (15, 95% confidence interval [CI] 0.60%-1.6%), deep venous thrombosis of 0.61% (10, 95% CI 0.2%-1%), ischemic stroke of 0.25% (4, 95% CI 0.09%-0.65%), and ischemic arterial events of 0.06% (1, 95% CI 0.008%-0.43%). No acute coronary syndrome events were recorded. The incidence of symptomatic TEs was significantly lower in the general ward than in intensive care units (1.2% vs 5.7%; p < .001). The median time since positive rt-PCR for SARS-CoV2 to symptomatic TE was 22.5 days (IQR 19-43 days). There was no significant difference in the proportion of patients receiving (53.6%) and not receiving thromboprophylaxis (66.5%) and the development of TEs. CONCLUSION: The overall incidence of symptomatic TEs among these patients was lower than the incidence previously reported.


Subject(s)
Arterial Occlusive Diseases/epidemiology , COVID-19/epidemiology , Pulmonary Embolism/epidemiology , Thromboembolism/epidemiology , Venous Thrombosis/epidemiology , Aged , Aged, 80 and over , Argentina/epidemiology , Arterial Occlusive Diseases/blood , Arterial Occlusive Diseases/diagnosis , COVID-19/blood , COVID-19/diagnosis , Female , Humans , Incidence , Ischemic Stroke/blood , Ischemic Stroke/diagnosis , Ischemic Stroke/epidemiology , Male , Middle Aged , Patient Admission , Pulmonary Embolism/blood , Pulmonary Embolism/diagnosis , Retrospective Studies , Thromboembolism/blood , Thromboembolism/diagnosis , Time Factors , Venous Thrombosis/blood , Venous Thrombosis/diagnosis
2.
Ann Vasc Surg ; 70: 290-294, 2021 Jan.
Article in English | MEDLINE | ID: covidwho-733965

ABSTRACT

BACKGROUND: Coronavirus disease 2019 (COVID-19) predisposes to arterial and venous thromboembolic complications. We describe the clinical presentation, management, and outcomes of acute arterial ischemia and concomitant infection at the epicenter of cases in the United States. METHODS: Patients with confirmed COVID-19 infection between March 1, 2020 and May 15, 2020 with an acute arterial thromboembolic event were reviewed. Data collected included demographics, anatomical location of the thromboembolism, treatments, and outcomes. RESULTS: Over the 11-week period, the Northwell Health System cared for 12,630 hospitalized patients with COVID-19. A total of 49 patients with arterial thromboembolism and confirmed COVID-19 were identified. The median age was 67 years (58-75) and 37 (76%) were men. The most common preexisting conditions were hypertension (53%) and diabetes (35%). The median D-dimer level was 2,673 ng/mL (723-7,139). The distribution of thromboembolic events included upper 7 (14%) and lower 35 (71%) extremity ischemia, bowel ischemia 2 (4%), and cerebral ischemia 5 (10%). Six patients (12%) had thrombus in multiple locations. Concomitant deep vein thrombosis was found in 8 patients (16%). Twenty-two (45%) patients presented with signs of acute arterial ischemia and were subsequently diagnosed with COVID-19. The remaining 27 (55%) developed ischemia during hospitalization. Revascularization was performed in 13 (27%) patients, primary amputation in 5 (10%), administration of systemic tissue- plasminogen activator in 3 (6%), and 28 (57%) were treated with systemic anticoagulation only. The rate of limb loss was 18%. Twenty-one patients (46%) died in the hospital. Twenty-five (51%) were successfully discharged, and 3 patients are still in the hospital. CONCLUSIONS: While the mechanism of thromboembolic events in patients with COVID-19 remains unclear, the occurrence of such complication is associated with acute arterial ischemia which results in a high limb loss and mortality.


Subject(s)
Arterial Occlusive Diseases/epidemiology , COVID-19/epidemiology , Thromboembolism/epidemiology , Acute Disease , Aged , Amputation , Anticoagulants/therapeutic use , Arterial Occlusive Diseases/diagnostic imaging , Arterial Occlusive Diseases/mortality , Arterial Occlusive Diseases/therapy , COVID-19/diagnosis , COVID-19/mortality , COVID-19/therapy , Databases, Factual , Female , Hospital Mortality , Humans , Incidence , Male , Middle Aged , New York City/epidemiology , Retrospective Studies , Thromboembolism/diagnostic imaging , Thromboembolism/mortality , Thromboembolism/therapy , Thrombolytic Therapy , Treatment Outcome , Vascular Surgical Procedures
3.
Stroke ; 51(9): 2656-2663, 2020 09.
Article in English | MEDLINE | ID: covidwho-696177

ABSTRACT

BACKGROUND AND PURPOSE: The 2019 novel coronavirus outbreak and its associated disease (coronavirus disease 2019 [COVID-19]) have created a worldwide pandemic. Early data suggest higher rate of ischemic stroke in severe COVID-19 infection. We evaluated whether a relationship exists between emergent large vessel occlusion (ELVO) and the ongoing COVID-19 outbreak. METHODS: This is a retrospective, observational case series. Data were collected from all patients who presented with ELVO to the Mount Sinai Health System Hospitals across New York City during the peak 3 weeks of hospitalization and death from COVID-19. Patients' demographic, comorbid conditions, cardiovascular risk factors, COVID-19 disease status, and clinical presentation were extracted from the electronic medical record. Comparison was made between COVID-19 positive and negative cohorts. The incidence of ELVO stroke was compared with the pre-COVID period. RESULTS: Forty-five consecutive ELVO patients presented during the observation period. Fifty-three percent of patients tested positive for COVID-19. Total patients' mean (±SD) age was 66 (±17). Patients with COVID-19 were significantly younger than patients without COVID-19, 59±13 versus 74±17 (odds ratio [95% CI], 0.94 [0.81-0.98]; P=0.004). Seventy-five percent of patients with COVID-19 were male compared with 43% of patients without COVID-19 (odds ratio [95% CI], 3.99 [1.12-14.17]; P=0.032). Patients with COVID-19 were less likely to be White (8% versus 38% [odds ratio (95% CI), 0.15 (0.04-0.81); P=0.027]). In comparison to a similar time duration before the COVID-19 outbreak, a 2-fold increase in the total number of ELVO was observed (estimate: 0.78 [95% CI, 0.47-1.08], P≤0.0001). CONCLUSIONS: More than half of the ELVO stroke patients during the peak time of the New York City's COVID-19 outbreak were COVID-19 positive, and those patients with COVID-19 were younger, more likely to be male, and less likely to be White. Our findings also suggest an increase in the incidence of ELVO stroke during the peak of the COVID-19 outbreak.


Subject(s)
Arterial Occlusive Diseases/epidemiology , Brain Ischemia/epidemiology , Coronavirus Infections/epidemiology , Pneumonia, Viral/epidemiology , Stroke/epidemiology , Age Factors , Aged , Aged, 80 and over , Arterial Occlusive Diseases/complications , Brain Ischemia/complications , COVID-19 , Coronavirus Infections/complications , Electronic Health Records , Female , Hospitalization , Humans , Incidence , Male , Middle Aged , New York City , Pandemics , Pneumonia, Viral/complications , Retrospective Studies , Risk Factors , Sex Factors , Stroke/complications , /statistics & numerical data
4.
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 , COVID-19 , 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 , SARS-CoV-2 , 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
5.
Thromb Res ; 191: 148-150, 2020 07.
Article in English | MEDLINE | ID: covidwho-154635

ABSTRACT

INTRODUCTION: We recently reported a high cumulative incidence of thrombotic complications in critically ill patients with COVID-19 admitted to the intensive care units (ICUs) of three Dutch hospitals. In answering questions raised regarding our study, we updated our database and repeated all analyses. METHODS: We re-evaluated the incidence of the composite outcome of symptomatic acute pulmonary embolism (PE), deep-vein thrombosis, ischemic stroke, myocardial infarction and/or systemic arterial embolism in all COVID-19 patients admitted to the ICUs of 2 Dutch university hospitals and 1 Dutch teaching hospital from ICU admission to death, ICU discharge or April 22nd 2020, whichever came first. RESULTS: We studied the same 184 ICU patients as reported on previously, of whom a total of 41 died (22%) and 78 were discharged alive (43%). The median follow-up duration increased from 7 to 14 days. All patients received pharmacological thromboprophylaxis. The cumulative incidence of the composite outcome, adjusted for competing risk of death, was 49% (95% confidence interval [CI] 41-57%). The majority of thrombotic events were PE (65/75; 87%). In the competing risk model, chronic anticoagulation therapy at admission was associated with a lower risk of the composite outcome (Hazard Ratio [HR] 0.29, 95%CI 0.091-0.92). Patients diagnosed with thrombotic complications were at higher risk of all-cause death (HR 5.4; 95%CI 2.4-12). Use of therapeutic anticoagulation was not associated with all-cause death (HR 0.79, 95%CI 0.35-1.8). CONCLUSION: In this updated analysis, we confirm the very high cumulative incidence of thrombotic complications in critically ill patients with COVID-19 pneumonia.


Subject(s)
Arterial Occlusive Diseases/epidemiology , Coronavirus Infections/complications , Pneumonia, Viral/complications , Pulmonary Embolism/epidemiology , Thrombophilia/etiology , Venous Thrombosis/epidemiology , Acute Disease , Anticoagulants/therapeutic use , Arterial Occlusive Diseases/etiology , Brain Ischemia/epidemiology , Brain Ischemia/etiology , COVID-19 , Critical Illness , Embolism/epidemiology , Embolism/etiology , Female , Follow-Up Studies , Hospitals, Teaching/statistics & numerical data , Hospitals, University/statistics & numerical data , Humans , Incidence , Male , Middle Aged , Myocardial Infarction/epidemiology , Myocardial Infarction/etiology , Netherlands/epidemiology , Pandemics , Pulmonary Embolism/etiology , Thrombophilia/drug therapy , Venous Thrombosis/etiology
6.
Thromb Res ; 191: 9-14, 2020 07.
Article in English | MEDLINE | ID: covidwho-153760

ABSTRACT

BACKGROUND: Few data are available on the rate and characteristics of thromboembolic complications in hospitalized patients with COVID-19. METHODS: We studied consecutive symptomatic patients with laboratory-proven COVID-19 admitted to a university hospital in Milan, Italy (13.02.2020-10.04.2020). The primary outcome was any thromboembolic complication, including venous thromboembolism (VTE), ischemic stroke, and acute coronary syndrome (ACS)/myocardial infarction (MI). Secondary outcome was overt disseminated intravascular coagulation (DIC). RESULTS: We included 388 patients (median age 66 years, 68% men, 16% requiring intensive care [ICU]). Thromboprophylaxis was used in 100% of ICU patients and 75% of those on the general ward. Thromboembolic events occurred in 28 (7.7% of closed cases; 95%CI 5.4%-11.0%), corresponding to a cumulative rate of 21% (27.6% ICU, 6.6% general ward). Half of the thromboembolic events were diagnosed within 24 h of hospital admission. Forty-four patients underwent VTE imaging tests and VTE was confirmed in 16 (36%). Computed tomography pulmonary angiography (CTPA) was performed in 30 patients, corresponding to 7.7% of total, and pulmonary embolism was confirmed in 10 (33% of CTPA). The rate of ischemic stroke and ACS/MI was 2.5% and 1.1%, respectively. Overt DIC was present in 8 (2.2%) patients. CONCLUSIONS: The high number of arterial and, in particular, venous thromboembolic events diagnosed within 24 h of admission and the high rate of positive VTE imaging tests among the few COVID-19 patients tested suggest that there is an urgent need to improve specific VTE diagnostic strategies and investigate the efficacy and safety of thromboprophylaxis in ambulatory COVID-19 patients.


Subject(s)
Arterial Occlusive Diseases/etiology , Coronavirus Infections/complications , Pneumonia, Viral/complications , Thrombophilia/etiology , Venous Thromboembolism/etiology , Acute Coronary Syndrome/epidemiology , Acute Coronary Syndrome/etiology , Aged , Aged, 80 and over , Ambulatory Care , Anticoagulants/therapeutic use , Arterial Occlusive Diseases/diagnostic imaging , Arterial Occlusive Diseases/epidemiology , Brain Ischemia/epidemiology , Brain Ischemia/etiology , COVID-19 , Comorbidity , Coronary Thrombosis/diagnostic imaging , Coronary Thrombosis/epidemiology , Coronary Thrombosis/etiology , Critical Care , Disseminated Intravascular Coagulation/epidemiology , Disseminated Intravascular Coagulation/etiology , Female , Hospital Mortality , Hospitals, Teaching/statistics & numerical data , Hospitals, Urban/statistics & numerical data , Humans , Italy/epidemiology , Length of Stay/statistics & numerical data , Male , Middle Aged , Pandemics , Patient Admission , Pulmonary Embolism/diagnostic imaging , Pulmonary Embolism/epidemiology , Pulmonary Embolism/etiology , Retrospective Studies , Risk Factors , Thrombophilia/drug therapy , Venous Thromboembolism/diagnostic imaging , Venous Thromboembolism/epidemiology
7.
Thromb Res ; 191: 145-147, 2020 07.
Article in English | MEDLINE | ID: covidwho-47010

ABSTRACT

INTRODUCTION: COVID-19 may predispose to both venous and arterial thromboembolism due to excessive inflammation, hypoxia, immobilisation and diffuse intravascular coagulation. Reports on the incidence of thrombotic complications are however not available. METHODS: We evaluated the incidence of the composite outcome of symptomatic acute pulmonary embolism (PE), deep-vein thrombosis, ischemic stroke, myocardial infarction or systemic arterial embolism in all COVID-19 patients admitted to the ICU of 2 Dutch university hospitals and 1 Dutch teaching hospital. RESULTS: We studied 184 ICU patients with proven COVID-19 pneumonia of whom 23 died (13%), 22 were discharged alive (12%) and 139 (76%) were still on the ICU on April 5th 2020. All patients received at least standard doses thromboprophylaxis. The cumulative incidence of the composite outcome was 31% (95%CI 20-41), of which CTPA and/or ultrasonography confirmed VTE in 27% (95%CI 17-37%) and arterial thrombotic events in 3.7% (95%CI 0-8.2%). PE was the most frequent thrombotic complication (n = 25, 81%). Age (adjusted hazard ratio (aHR) 1.05/per year, 95%CI 1.004-1.01) and coagulopathy, defined as spontaneous prolongation of the prothrombin time > 3 s or activated partial thromboplastin time > 5 s (aHR 4.1, 95%CI 1.9-9.1), were independent predictors of thrombotic complications. CONCLUSION: The 31% incidence of thrombotic complications in ICU patients with COVID-19 infections is remarkably high. Our findings reinforce the recommendation to strictly apply pharmacological thrombosis prophylaxis in all COVID-19 patients admitted to the ICU, and are strongly suggestive of increasing the prophylaxis towards high-prophylactic doses, even in the absence of randomized evidence.


Subject(s)
Arterial Occlusive Diseases/epidemiology , Coronavirus Infections/complications , Pneumonia, Viral/complications , Pulmonary Embolism/epidemiology , Thrombophilia/etiology , Venous Thrombosis/epidemiology , Acute Disease , Anticoagulants/therapeutic use , Arterial Occlusive Diseases/etiology , Brain Ischemia/epidemiology , Brain Ischemia/etiology , COVID-19 , Critical Illness , Embolism/epidemiology , Embolism/etiology , Female , Hospitals, Teaching/statistics & numerical data , Hospitals, University/statistics & numerical data , Humans , Incidence , Male , Middle Aged , Myocardial Infarction/epidemiology , Myocardial Infarction/etiology , Netherlands/epidemiology , Pandemics , Pulmonary Embolism/etiology , Thrombophilia/drug therapy , Venous Thrombosis/etiology
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