Although the clinical features of SARS-CoV-2 infection were first reported in 2019, it was also established that patients hospitalized with COVID-19, especially those admitted to the intensive care unit (ICU), had an additional risk for venous thromboembolism (VTE) despite prophylactic dose anticoagulation.1-4 As a result, some experts have suggested that higher anticoagulation targets may be necessary for patients with chronic pain with COVID-19 pneumonia.5 An ongoing challenge in the treatment of these patients is the lack of quality evidence to guide clinical decision-making.
In a review published in International Journal of Environmental Research and Public Health, Christian Zanza, MD, PhD, of the department of emergency medicine at the Catholic University of Rome in Italy, and colleagues, summarizes the current literature surrounding the treatment of coagulation abnormalities in patients with COVID-19.5
Coagulation abnormalities of COVID-19
Infection with COVID-19 may precede patients with both venous and arterial thrombotic events, thought to be the result of platelet activation, endothelial dysfunction, and hyperinflammation. Even if bleeding is not commonly observed in patients, it can occur with other factors, such as anticoagulation therapy or trauma, and if present, treatment consists of anticoagulant reversal or cessation, transfer, or hemoderivatives for concomitant medications. bleeding disorders. The presence of specific laboratory findings of COVID-19 may indicate a hypercoagulative condition is on the table (Table 1).
|Table 1. List of laboratory findings identifying a hypercoagulative condition with COVID-195|
|D-dimer is elevated|
|aPTT and PT normal or somewhat delayed|
|Platelet count is normal or increased|
|Increased Factor VIII activity|
|VWF antigen is further increased|
|Slight decrease in antithrombin and slight increase in protein C|
|Decreases: aPTT, part -time thromboplastin activated; PT, prothrombin time; VWF, von Willebrand cause|
Other laboratory findings include the presence of a lupus anticoagulant, which is common in those with chronic aPTT. In addition, marked D-dimer levels may be associated with disease severity, especially if the level is increased several times.
Current evidence suggests that the presence of a hypercoagulative state is different from disseminated intravascular coagulation (DIC); however, some patients with COVID-19 may also meet the criteria for likely DIC. Evidence of acute DIC includes increased plasma D-dimers, bleeding, thrombocytopenia, low plasma fibrinogen, prolonged aPTT and PT, and microangiopathic changes in peripheral blood smears.
The 2009 International Society of Thrombosis and Haemostasis (ISTH) scoring system may assist in the diagnosis of DIC in patients with COVID-19 infection. For full details of the scoring system, readers should refer to the entire publication of International Journal of Environmental Research and Public Health.5
VTE in Patients With COVID-19
Critically ill and hospitalized patients with COVID-19 are at high risk for VTE primarily due to mobility, with pulmonary embolism (PE) being the most serious clinical manifestation of VTE. Clinical screening for PE in these patients is challenging because symptoms often overlap with COVID-19, and imaging studies may not be feasible in all cases. The authors of this review recommended that the criteria for the diagnosis of VTE should be short in patients with COVID-19.
Regarding anticoagulation, most medical societies still recommend the use of standard prophylactic dosing for hospitalized patients, but some physicians advocate for the empiric use of therapeutic anticoagulation, even in undocumented ones. . request to VTE. Given the current state of evidence, the authors conclude that VTE prophylaxis with a minimum prophylactic dosing is appropriate for all hospitalized, medically, and medically treated patients with COVID-19, unless there is a contraindication to anticoagulation, such as active or severe bleeding the first 24 to 48 hours.
As for the agent, the lowest weight loss heparin is preferred, but non-supplemental heparin can also be used in patients with severe kidney damage. In cases of heparin -induced thrombocytopenia, an alternative therapy, such as fondaparinux, may be prescribed. In addition, therapeutic (full-dose) anticoagulation for a minimum of three months is appropriate to treat VTE, and tissue plasminogen activator is appropriate for multiple PEs, unless there is a contraindication.
Expert Perspective: The Importance of the COVID-19 Vaccine
“It is very clear that COVID-19-related disease is important for patients with a variety of malignant diseases, especially those with hematological diseases,” commented Balazs Halmos, MD, of Albert Einstein’s medical department. College of Medicine of New York. .
“Encouraging COVID-19 vaccination among patients is of paramount importance, and is strongly endorsed by all concerned agencies,” Dr Halmos further explained.
- Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020; 395 (10223): 507-513. doi: 10.1016 / S0140-6736 (20) 30211-7
- Tang N, Bai H, Chen X, Gong J, Li D, Sun Z. Anticoagulant treatment is associated with reduced mortality of acute coronavirus disease in 2019 patients with coagulopathy.. J Thromb Haemost. 2020; 18 (5): 1094-1099. doi: 10.1111 / jth.14817
- Longhitano Y, Racca F, Zanza C, et al. Venous thrombo-embolism in hospitalized SARS-CoV-2 patients treated with three different anticoagulation protocols: a future case study. Biology. 2020; 9 (10): 310. doi: 10.3390 / biology9100310
- Demelo-Rodríguez P, Cervilla-Muñoz E, Ordieres-Ortega L, et al. Incidence of asymptomatic deep vein thrombosis in patients with COVID-19 pneumonia and elevated D-dimer levels. The Thromb Res. 2020; 192: 23-26. doi: 10.1016 / j.thromres.2020.05.018
- Zanza C, Racca F, Longhitano Y, et al. Risk management and treatment of coagulation diseases associated with COVID-19 infection. Int J En environment Res Public Health. 2021; 18 (3): 1268. doi: 10.3390 / ijerph18031268.
This article originally appeared Rheumatology Advisor