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1.
Am Heart J ; 231: 93-95, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33181067

RESUMO

We evaluated the incidence of thrombosis in patients hospitalized with non-COVID-19 acute viral respiratory illnesses nationwide from 2012 to 2014 and compared this to the incidence among patients hospitalized with COVID-19 at a large health system in New York. Non-COVID-19 viral respiratory illness was complicated by acute MI in 2.8% of hospitalizations, VTE in 1.6%, ischemic stroke in 0.7%, and other systemic embolism in 0.1%. The proportion of hospitalizations complicated by thrombosis was lower in patients with viral respiratory illness in 2002-2014 than in COVID-19 (5% vs 16%; P< .001). BACKGROUND: Thrombosis is a prominent feature of the novel Coronavirus disease 2019 (COVID-19). The incidence of thrombosis during hospitalization for non-COVID-19 viral respiratory infections is uncertain. We evaluated the incidence of thrombosis in patients hospitalized with non-COVID-19 acute viral respiratory illnesses compared to COVID-19. METHODS: Adults age >18 years hospitalized with a non-COVID-19 viral respiratory illness between 2002 and 2014 were identified. The primary study outcome was a composite of venous and arterial thrombotic events, including myocardial infarction (MI), acute ischemic stroke, and venous thromboembolism (VTE), as defined by ICD-9 codes. The incidence of thrombosis in non-COVID-19 viral respiratory illnesses was compared to the recently published incidence of thrombosis in COVID-19 from 3,334 patients hospitalized in New York in 2020. RESULTS: Among 954,521 hospitalizations with viral pneumonia from 2002 to 2014 (mean age 62.3 years, 57.1% female), the combined incidence of arterial and venous thrombosis was 5.0%. Acute MI occurred in 2.8% of hospitalizations, VTE in 1.6%, ischemic stroke in 0.7%, and other systemic embolism in 0.1%. Patients with thrombosis had higher in-hospital mortality (14.9% vs 3.3%, P< .001) than those without thrombosis. The proportion of hospitalizations complicated by thrombosis was lower in patients with viral respiratory illness in 2002-2014 than in COVID-19 (median age 64; 39.6% female) in 2020 (5% vs 16%; P< .001) CONCLUSION: In a nationwide analysis of hospitalizations for viral pneumonias, thrombosis risk was lower than that observed in patients with COVID-19. Investigations into mechanisms of thrombosis and risk reduction strategies in COVID-19 and other viral respiratory infections are necessary.


Assuntos
Infarto do Miocárdio , Pneumonia Viral , Infecções Respiratórias , Trombose , Tromboembolia Venosa , /diagnóstico , Feminino , Hospitalização/estatística & dados numéricos , Humanos , /epidemiologia , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/etiologia , Pneumonia Viral/complicações , Pneumonia Viral/diagnóstico , Infecções Respiratórias/complicações , Infecções Respiratórias/diagnóstico , Infecções Respiratórias/virologia , Medição de Risco , Trombose/epidemiologia , Trombose/virologia , Estados Unidos/epidemiologia , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/epidemiologia , Tromboembolia Venosa/etiologia
2.
J Stroke Cerebrovasc Dis ; 30(1): 105427, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33137615

RESUMO

COVID-19, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been shown to cause multisystemic damage. We undertook a systematic literature review and comprehensive analysis of a total of 55 articles on arterial and venous thromboembolism in COVID-19 and articles on previous pandemics with respect to thromboembolism and compared the similarities and differences between them. The presence of thrombosis in multiple organ systems points to thromboembolism being an integral component in the pathogenesis of this disease. Thromboembolism is likely to be the main player in the morbidity and mortality of COVID -19 in which the pulmonary system is most severely affected. We also hypothesize that D-dimer values could be used as an early marker for prognostication of disease as it has been seen to be raised even in the pre-symptomatic stage. This further strengthens the notion that thromboembolism prevention is necessary. We also examined literature on the neurovascular and cardiovascular systems, as the manifestation of thromboembolic phenomenon in these two systems varied, suggesting different pathophysiology of damage. Further research into the role of thromboembolism in COVID-19 is important to advance the understanding of the virus, its effects and to tailor treatment accordingly to prevent further casualties from this pandemic.


Assuntos
Arteriopatias Oclusivas/etiologia , Transtornos Cerebrovasculares/etiologia , Embolia Pulmonar/etiologia , Tromboembolia Venosa/etiologia , Trombose Venosa/etiologia , Arteriopatias Oclusivas/diagnóstico , Arteriopatias Oclusivas/mortalidade , Arteriopatias Oclusivas/prevenção & controle , /tratamento farmacológico , Transtornos Cerebrovasculares/diagnóstico , Transtornos Cerebrovasculares/mortalidade , Transtornos Cerebrovasculares/prevenção & controle , Fibrinolíticos/uso terapêutico , Humanos , Prognóstico , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/mortalidade , Embolia Pulmonar/prevenção & controle , Medição de Risco , Fatores de Risco , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/mortalidade , Tromboembolia Venosa/prevenção & controle , Trombose Venosa/diagnóstico , Trombose Venosa/mortalidade , Trombose Venosa/prevenção & controle
3.
Blood Adv ; 4(24): 6230-6239, 2020 12 22.
Artigo em Inglês | MEDLINE | ID: mdl-33351117

RESUMO

Although COVID-19 has been reported to be associated with high rates of venous thromboembolism (VTE), the risk of VTE and bleeding after hospitalization for COVID-19 remains unclear, and the optimal hospital VTE prevention strategy is not known. We collected retrospective observational data on thrombosis and bleeding in 303 consecutive adult patients admitted to the hospital for at least 24 hours for COVID-19. Patients presenting with VTE on admission were excluded. Data were collected until 90 days after admission or known death by using medical records and an established national VTE network. Maximal level of care was ward based in 78% of patients, with 22% requiring higher dependency care (12% noninvasive ventilation, 10% invasive ventilation). Almost all patients (97.0%) received standard thromboprophylaxis or were already receiving therapeutic anticoagulation (17.5%). Symptomatic image-confirmed VTE occurred in 5.9% of patients during index hospitalization, and in 7.2% at 90 days after admission (23.9% in patients requiring higher dependency care); half the events were isolated segmental or subsegmental defects on lung imaging. Bleeding occurred in 13 patients (4.3%) during index hospitalization (1.3% had major bleeding). The majority of bleeds occurred in patients on the general ward, and 6 patients were receiving treatment-dose anticoagulation, highlighting the need for caution in intensifying standard thromboprophylaxis strategies. Of 152 patients discharged from the hospital without an indication for anticoagulation, 97% did not receive thromboprophylaxis after discharge, and 3% received 7 days of treatment with low molecular weight heparin after discharge. The rate of symptomatic VTE in this group at 42 days after discharge was 2.6%, highlighting the need for large prospective randomized controlled trials of extended thromboprophylaxis after discharge in COVID-19.


Assuntos
/complicações , Tromboembolia Venosa/epidemiologia , Tromboembolia Venosa/etiologia , Idoso , Idoso de 80 Anos ou mais , Biomarcadores , Testes de Coagulação Sanguínea , Diagnóstico por Imagem/métodos , Gerenciamento Clínico , Suscetibilidade a Doenças , Inglaterra/epidemiologia , Feminino , Seguimentos , Hospitalização , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Avaliação de Sintomas , Fatores de Tempo , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/prevenção & controle
5.
JAMA ; 324(17): 1765-1776, 2020 Nov 03.
Artigo em Inglês | MEDLINE | ID: mdl-33141212

RESUMO

Importance: Incidence rates for lower extremity deep vein thrombosis (DVT) range from 88 to 112 per 100 000 person-years and increase with age. Rates of recurrent VTE range from 20% to 36% during the 10 years after an initial event. Observations: PubMed and Cochrane databases were searched for English-language studies published from January 2015 through June 2020 for randomized clinical trials, meta-analyses, systematic reviews, and observational studies. Risk factors for venous thromboembolism (VTE), such as older age, malignancy (cumulative incidence of 7.4% after a median of 19 months), inflammatory disorders (VTE risk is 4.7% in patients with rheumatoid arthritis and 2.5% in those without), and inherited thrombophilia (factor V Leiden carriers with a 10-year cumulative incidence of 10.9%), are associated with higher risk of VTE. Patients with signs or symptoms of lower extremity DVT, such as swelling (71%) or a cramping or pulling discomfort in the thigh or calf (53%), should undergo assessment of pretest probability followed by D-dimer testing and imaging with venous ultrasonography. A normal D-dimer level (ie, D-dimer <500 ng/mL) excludes acute VTE when combined with a low pretest probability (ie, Wells DVT score ≤1). In patients with a high pretest probability, the negative predictive value of a D-dimer less than 500 ng/mL is 92%. Consequently, D-dimer cannot be used to exclude DVT without an assessment of pretest probability. Postthrombotic syndrome, defined as persistent symptoms, signs of chronic venous insufficiency, or both, occurs in 25% to 50% of patients 3 to 6 months after DVT diagnosis. Catheter-directed fibrinolysis with or without mechanical thrombectomy is appropriate in those with iliofemoral obstruction, severe symptoms, and a low risk of bleeding. The efficacy of direct oral anticoagulants-rivaroxaban, apixaban, dabigatran, and edoxaban-is noninferior to warfarin (absolute rate of recurrent VTE or VTE-related death, 2.0% vs 2.2%). Major bleeding occurs in 1.1% of patients treated with direct oral anticoagulants vs 1.8% treated with warfarin. Conclusions and Relevance: Greater recognition of VTE risk factors and advances in anticoagulation have facilitated the clinical evaluation and treatment of patients with DVT. Direct oral anticoagulants are noninferior to warfarin with regard to efficacy and are associated with lower rates of bleeding, but costs limit use for some patients.


Assuntos
Extremidade Inferior/irrigação sanguínea , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/terapia , Fatores Etários , Biomarcadores/sangue , Inibidores do Fator Xa/efeitos adversos , Inibidores do Fator Xa/uso terapêutico , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Humanos , Estilo de Vida , Ilustração Médica , Síndrome Pós-Trombótica/etiologia , Valor Preditivo dos Testes , Fatores de Risco , Fatores Sexuais , Avaliação de Sintomas , Trombectomia/métodos , Trombofilia/complicações , Trombofilia/genética , Ultrassonografia , Filtros de Veia Cava , Tromboembolia Venosa/sangue , Tromboembolia Venosa/etiologia , Varfarina/uso terapêutico
6.
Blood Adv ; 4(21): 5373-5377, 2020 11 10.
Artigo em Inglês | MEDLINE | ID: mdl-33137202

RESUMO

Patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) appear to be at increased risk for venous thromboembolism (VTE), especially if they become critically ill with COVID-19. Some centers have reported very high rates of thrombosis despite anticoagulant prophylaxis. The electronic health record (EHR) of a New Orleans-based health system was searched for all patients with polymerase chain reaction-confirmed SARS-CoV-2 infection who were either admitted to hospital or treated and discharged from an emergency department between 1 March 2020 and 1 May 2020. From this cohort, patients with confirmed VTE (either during or after their hospital encounter) were identified by administrative query of the EHR.: Between 1 March 2020 and 1 May 2020, 6153 patients with COVID-19 were identified; 2748 of these patients were admitted, while 3405 received care exclusively through the emergency department. In total, 637 patients required mechanical ventilation and 206 required renal replacement therapy. Within the hospitalized cohort, the overall mortality rate was 24.5% and VTE occurred in 86 patients (3.1%). In the 637 patients who required mechanical ventilation at some point during their hospital stay, 45 developed VTE (7.2%). After a median follow-up of 14.6 days, VTE had been diagnosed in 3 of the 2075 admitted who were discharged alive (0.14%). Among 6153 patients with COVID-19 who were hospitalized or treated in emergency departments, we did not find evidence of unusually high VTE risk. Pending further evidence from prospective, controlled trials, our findings support a traditional approach to primary VTE prevention in patients with COVID-19.


Assuntos
/patologia , Tromboembolia Venosa/diagnóstico , Adulto , Idoso , Anticoagulantes/uso terapêutico , /virologia , Feminino , Humanos , Coeficiente Internacional Normatizado , Tempo de Internação , Louisiana/epidemiologia , Masculino , Pessoa de Meia-Idade , Terapia de Substituição Renal , Respiração Artificial , Estudos Retrospectivos , Tromboembolia Venosa/complicações , Tromboembolia Venosa/tratamento farmacológico , Tromboembolia Venosa/epidemiologia
7.
Vasc Health Risk Manag ; 16: 455-462, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33223833

RESUMO

Coronavirus disease 2019 (COVID-19) emerged from the West District of Southern China Seafood Wholesale Market in late December 2019 and has been declared a global pandemic by the World Health Organization (WHO). Infection with severe acute respiratory syndrome coronavirus (SARS-CoV-2) presents with upper respiratory symptoms like cough, fever, and lethargy. At the same time, in later stages, critical COVID-19 patients develop acute respiratory distress syndrome (ARDS), venous thromboembolism (VTE), and multiple organ failure from cytokine storm and coagulation hyperactivity. Primary manifestations of thrombotic events include deep vein thrombosis (DVT), disseminated intravascular coagulation (DIC) and pulmonary embolism (PE). Initial coagulopathy in COVID-19 patients presents with elevated fibrin degradation products, especially D-dimers. In contrast, late presentations show evidence of prolonged prothrombin time (PT) and activated partial thromboplastin (aPTT), increased platelets, and fibrinogen levels. Diagnosis and monitoring of disease progression are done by regular screening of laboratory parameters, including D-dimer and fibrinogen. Management of coagulopathy in COVID-19 patients is like that of critically ill patients, including thromboprophylaxis. Coagulopathy is a poor prognostic factor, and optimum strategies should be developed for early diagnosis, prevention, and prompt treatment of VTE in COVID-19 patients. Thrombosis prophylaxis with low molecular weight heparin (LMWH) has shown beneficial results in preventing coagulopathy a reducing risk of mortality due to thrombotic events. We will discuss VTE in COVID-19 patients highlighting the role of D-dimer, fibrinogen, and interleukin-6 (IL-6).


Assuntos
/sangue , Produtos de Degradação da Fibrina e do Fibrinogênio/metabolismo , Fibrinogênio/metabolismo , Mediadores da Inflamação/sangue , Interleucina-6/sangue , Tromboembolia Venosa/sangue , Anticoagulantes/uso terapêutico , Biomarcadores/sangue , /mortalidade , Heparina de Baixo Peso Molecular/uso terapêutico , Humanos , Incidência , Prevalência , Prognóstico , Medição de Risco , Fatores de Risco , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/mortalidade , Tromboembolia Venosa/prevenção & controle
8.
J Nutr Health Aging ; 24(10): 1116-1119, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33244570

RESUMO

D-dimer is routinely measured to exclude the diagnosis of venous thromboembolism and is its main biomarker. Appropriate age-adjusted D-dimer testing improves D-dimer specificity, could decrease inappropriate CT pulmonary angiograms in the older person, and prevent unnecessary radiation exposure. A "COVID-19 blood battery", designed to increase the efficiency of evaluation of COVID-19 suspected patients is used in our institution. It includes D-dimers which are elevated in COVID-19 infections and potentially an index of severe infection. These 3 very frail patients presented late to the emergency department, all acutely and non-specifically unwell, with high prevalence of comorbidities and were transferred in by ambulance. They were triaged to the COVID-19 pathway of our hospital, and subsequently had negative COVID-19 swabs. All had an incidental finding of markedly elevated D-dimers, with potential causes of their symptoms other than pulmonary embolus. They were transferred to an acute geriatric ward specifically designated to manage older patients (>75years) who had negative nasopharyngeal swab results. They were all ultimately diagnosed with extensive pulmonary emboli with evidence of raised pulmonary pressures on CTPA and/or echocardiogram. It is possible that these patients had false negative COVID-19 swabs. Allowing for the novel nature of COVID-19, prospective evaluation for new symptoms and complications such as thromboembolic disease in those affected by milder symptoms should be considered. In the absence of clinical improvement following treatment of other conditions in frail older patients, D-dimer testing could be indicated with pursuit of specific diagnostic evaluation for venous thromboembolism when significantly elevated.


Assuntos
/sangue , Idoso Fragilizado , Embolia Pulmonar/diagnóstico , Tromboembolia Venosa/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Serviço Hospitalar de Emergência , Feminino , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Humanos , Pulmão/patologia , Pandemias , Prevalência , Estudos Prospectivos , Embolia Pulmonar/sangue , Embolia Pulmonar/complicações , Embolia Pulmonar/epidemiologia , Sensibilidade e Especificidade , Tromboembolia Venosa/sangue , Tromboembolia Venosa/complicações , Tromboembolia Venosa/epidemiologia
9.
J Med Case Rep ; 14(1): 188, 2020 Oct 15.
Artigo em Inglês | MEDLINE | ID: mdl-33054805

RESUMO

BACKGROUND: Currently, there is minimal data available highlighting the prevalence of venous thromboembolism in patients infected with coronavirus disease 2019 (COVID-19). This case report with a literature review emphasizes a unique presentation of COVID-19 that is highly important for health care providers to consider when treating their patients. CASE REPORT: A 65-year-old Caucasian male patient presented to the emergency department with a 2-day history of dyspnea on exertion after his wife's recent diagnosis of COVID-19. He additionally had experienced a couple of episodes of self-resolving diarrhea a few days before presentation. Based on the patient's clinical presentation and the laboratory workup identifying an elevated D-dimer, a computed tomography angiogram of the chest was obtained, which was significant for moderately large, bilateral pulmonary emboli with a saddle embolus, and an associated small, left lower lobe, pulmonary infarct. Ultrasound of the lower extremity showed non-occlusive deep vein thrombosis at the distal left femoral vein to the left popliteal vein. The patient was additionally diagnosed with COVID-19 when the results of the COVID-19 polymerase chain reaction test returned as positive. The patient was admitted to the COVID unit, and he was started on an intravenously administered, unfractionated heparin drip for management of his bilateral pulmonary emboli and deep vein thrombosis. The patient's clinical condition improved significantly with anticoagulation, and he was observed in the hospital for 3 days, after which he was discharged home on the enoxaparin bridge with warfarin. Post-discharge telephone calls at day 10 and week 4 revealed that the patient was appropriately responding to anticoagulation treatment and had no recurrence of his symptoms related to venous thromboembolism and COVID-19. CONCLUSION: As COVID-19 continues to lead to significant mortality, more data is emerging that is exposing its perplexing pathogenicity. Meanwhile, the presentation of venous thromboembolism in patients with COVID-19 remains an unusual finding. It is imperative for health care providers to be mindful of this unique association to make necessary diagnostic evaluations and provide appropriate treatment for the patients.


Assuntos
Infecções por Coronavirus , Enoxaparina/administração & dosagem , Veia Femoral/diagnóstico por imagem , Heparina/administração & dosagem , Pandemias , Pneumonia Viral , Embolia Pulmonar , Tromboembolia Venosa , Varfarina/administração & dosagem , Idoso , Anticoagulantes/administração & dosagem , Betacoronavirus/isolamento & purificação , Angiografia por Tomografia Computadorizada/métodos , Infecções por Coronavirus/sangue , Infecções por Coronavirus/complicações , Infecções por Coronavirus/diagnóstico , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Hospitalização , Humanos , Pulmão/diagnóstico por imagem , Masculino , Pneumonia Viral/sangue , Pneumonia Viral/complicações , Pneumonia Viral/diagnóstico , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/etiologia , Embolia Pulmonar/terapia , Resultado do Tratamento , Ultrassonografia/métodos , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/etiologia , Tromboembolia Venosa/terapia
14.
J Thromb Haemost ; 18(11): 2942-2953, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32881304

RESUMO

BACKGROUND: Hypercoagulability seems to contribute to SARS-CoV-2 pneumonia pathogenesis. However, age and metabolic syndrome are potential confounders when assessing the value of coagulation biomarkers' prediction of COVID-19 outcomes. We assessed whether coagulation biomarkers, including factor VIII (FVIII) and von Willebrand factor (VWF) levels, measured at time of admission, were predictive of COVID-19 adverse outcomes irrespective of age and major comorbidities associated with metabolic syndrome. METHODS: Blood was sampled at admission in 243 adult COVID-19 patients for analysis of coagulation biomarkers including FVIII and VWF on platelet-poor plasma. The association between baseline C-reactive protein (CRP), activated partial thromboplastin time ratio, prothrombin time ratio, D-dimers, fibrinogen, FVIII, VWF antigen (VWF:Ag), and FVIII/VWF:Ag ratio levels and adverse outcomes (increased oxygen requirements, thrombosis, and death at day 30) was assessed by regression analysis after adjustment on age, sex, body mass index (BMI), diabetes, and hypertension. RESULTS: In univariable regression analysis increased CRP (subdistribution hazard ratio [SHR], 1.68; 95% confidence interval [CI], 1.26-2.23), increased fibrinogen (SHR, 1.32; 95% CI, 1.04-1.68), and decreased FVIII/VWF:Ag ratio (SHR, 0.70; 95% CI, 0.52-0.96) levels at admission were significantly associated with the risk of increased oxygen requirement during follow-up. Leucocytes (SHR, 1.36; 95% CI, 1.04-1.76), platelets (SHR,1.71; 95% CI, 1.11-2.62), D-dimers (SHR, 2.48; 95% CI, 1.66-3.78), and FVIII (SHR, 1.78; 95% CI, 1.17-2.68) were associated with early onset of thrombosis after admission. After adjustment for age, sex, BMI, hypertension, and diabetes, these associations were not modified. CONCLUSION: Coagulation biomarkers are early and independent predictors of increased oxygen requirement in COVID-19 patients.


Assuntos
Coagulação Sanguínea , Fator VIII/análise , Oxigenoterapia , Trombose/sangue , Tromboembolia Venosa/sangue , Fator de von Willebrand/análise , Fatores Etários , Anticoagulantes/uso terapêutico , Biomarcadores/sangue , Coagulação Sanguínea/efeitos dos fármacos , /diagnóstico , Comorbidade , Feminino , França/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Admissão do Paciente , Prevalência , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Fatores Sexuais , Trombose/diagnóstico , Trombose/epidemiologia , Trombose/prevenção & controle , Resultado do Tratamento , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/epidemiologia , Tromboembolia Venosa/prevenção & controle
15.
J Thromb Haemost ; 18(11): 2958-2967, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32888372

RESUMO

INTRODUCTION: Coronavirus disease (COVID-19) is associated with a high incidence of thrombosis and mortality despite standard anticoagulant thromboprophylaxis. There is equipoise regarding the optimal dose of anticoagulant intervention in hospitalized patients with COVID-19 and consequently, immediate answers from high-quality randomized trials are needed. METHODS: The World Health Organization's International Clinical Trials Registry Platform was searched on June 17, 2020 for randomized controlled trials comparing increased dose to standard dose anticoagulant interventions in hospitalized COVID-19 patients. Two authors independently screened the full records for eligibility and extracted data in duplicate. RESULTS: A total of 20 trials were included in the review. All trials are open label, 5 trials use an adaptive design, 1 trial uses a factorial design, 2 trials combine multi-arm parallel group and factorial designs in flexible platform trials, and at least 15 trials have multiple study sites. With individual target sample sizes ranging from 30 to 3000 participants, the pooled sample size of all included trials is 12 568 participants. Two trials include only intensive care unit patients, and 10 trials base patient eligibility on elevated D-dimer levels. Therapeutic intensity anticoagulation is evaluated in 14 trials. All-cause mortality is part of the primary outcome in 14 trials. DISCUSSION: Several trials evaluate different dose regimens of anticoagulant interventions in hospitalized patients with COVID-19. Because these trials compete for sites and study participants, a collaborative effort is needed to complete trials faster, conduct pooled analyses and bring effective interventions to patients more quickly.


Assuntos
Anticoagulantes/administração & dosagem , Hospitalização , Cooperação Internacional , Trombose/prevenção & controle , Tromboembolia Venosa/prevenção & controle , Anticoagulantes/efeitos adversos , /diagnóstico , Comportamento Cooperativo , Humanos , Estudos Multicêntricos como Assunto , Seleção de Pacientes , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Fatores de Risco , Trombose/sangue , Trombose/diagnóstico , Trombose/mortalidade , Resultado do Tratamento , Tromboembolia Venosa/sangue , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/mortalidade
16.
Thromb Res ; 196: 209-212, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-32911392

RESUMO

BACKGROUND: In the recent outbreak of COVID-19 pandemic, increased D-dimer levels and high rates of venous thromboembolic events were reported. We aimed to compare coagulation parameters on admission between COVID-19 patients and non-COVID-19 patients with acute respiratory insufficiency and to describe VTE diagnosed at entry. METHODS: In this single-centre, observational retrospective study consecutive patients admitted for fever and acute respiratory failure were included. Patients underwent laboratory tests, arterial blood gas, chest X-ray, point of care ultrasound (POCUS), limited compression ultrasonography of the lower limbs (L-CUS), chest CT-scan if necessary, and swab test for COVID-19. RESULTS: Of 324 patients, 50% had COVID-19. COVID19 patients had significantly lower mean white blood cells, neutrophils, platelet count, and pCT values, and significantly higher CRP, LDH, and ferritin levels than non-COVID19 patients. D-dimer was increased in 86.5% COVID19 patients and in 84.9% non-COVID19 patients; mean values were similar (2185 ng/mL and 2814 ng/mL, respectively, p = n.s.). After multivariate analysis, results were unchanged (Odds Ratio 1.00 95%CI: 0.99-1.00, p = 0.21). PT and aPTT values were also similar between the two groups, fibrinogen levels were higher in COVID19 than in non-COVID19 patients (684 and 496 mg/dL, respectively, p < 0.0001). Five patients had asymptomatic proximal deep vein thrombosis detected by L-CUS (3 COVID19) and 2 patients had symptomatic pulmonary embolism (both non-COVID19). CONCLUSIONS: D-dimer levels were similarly increased in patients with and without SARS-CoV 2 related disease. There were few cases of asymptomatic deep vein thrombosis or symptomatic pulmonary embolism at first day of admission, similarly distributed between COVID19 patients and non-COVID19 patients.


Assuntos
Coagulação Sanguínea , Serviço Hospitalar de Emergência , Admissão do Paciente , Embolia Pulmonar/etiologia , Insuficiência Respiratória/etiologia , Tromboembolia Venosa/etiologia , Trombose Venosa/etiologia , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , /diagnóstico , Feminino , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Embolia Pulmonar/sangue , Embolia Pulmonar/diagnóstico , Insuficiência Respiratória/diagnóstico , Estudos Retrospectivos , Fatores de Risco , Regulação para Cima , Tromboembolia Venosa/sangue , Tromboembolia Venosa/diagnóstico , Trombose Venosa/sangue , Trombose Venosa/diagnóstico
17.
Thromb Res ; 196: 308-312, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-32977128

RESUMO

BACKGROUND: Venous thromboembolism (VTE) is a frequent complication in critically ill patients with coronavirus disease 2019 (COVID-19) and is associated with mortality. Early diagnosis and treatment of VTE is warranted. OBJECTIVE: To develop a prediction model for VTE in critically ill COVID-19 patients. PATIENTS AND METHODS: In this retrospective cohort study, 127 adult patients with confirmed COVID-19 infection admitted to the intensive care unit of two teaching hospitals were included. VTE was diagnosed with either ultrasound or computed tomography scan. Univariate receiver operating characteristic (ROC) curves were constructed for Positive End Expiratory Pressure, PaO2/FiO2 ratio, platelet count, international normalized ratio, activated partial thromboplastin time as well as levels of fibrinogen, antithrombin, D-dimer and C-reactive protein (CRP). Multivariate analysis was done using binary linear regression. RESULTS: Variables associated with VTE in both univariate and multivariate analysis were D-dimer and CRP with an area under the curve (AUC) of 0.64, P = 0.023 and 0.75, P = 0.045, respectively. Variables indicating hypoxemia were not predictive. The ROC curve of D-dimer and CRP combined had an AUC of 0.83, P < 0.05. Categorized values of D-dimer and CRP were used to compute a mean absolute risk for the combination of these variables with a high positive predictive value. The predicted probability of VTE with a D-dimer > 15 in combination with a CRP > 280 was 98%. The negative predictive value of D-dimer was low. CONCLUSION: Elevated CRP and D-dimer have a high positive predictive value for VTE in critically ill COVID-19 patients. We developed a prediction table with these biomarkers that can aid clinicians in the timing of imaging in patients with suspected VTE.


Assuntos
Proteína C-Reativa/análise , Estado Terminal , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Tromboembolia Venosa/etiologia , Idoso , Biomarcadores/sangue , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Tromboembolia Venosa/diagnóstico
19.
Thromb Res ; 196: 355-358, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-32977136

RESUMO

As the Coronavirus disease 2019 (COVID-19) pandemic spread to the US, so too did descriptions of an associated coagulopathy and thrombotic complications. Hospitals created institutional protocols for inpatient management of COVID-19 coagulopathy and thrombosis in response to this developing data. We collected and analyzed protocols from 21 US academic medical centers developed between January and May 2020. We found greatest consensus on recommendations for heparin-based pharmacologic venous thromboembolism (VTE) prophylaxis in COVID-19 patients without contraindications. Protocols differed regarding incorporation of D-dimer tests, dosing of VTE prophylaxis, indications for post-discharge pharmacologic VTE prophylaxis, how to evaluate for VTE, and the use of empiric therapeutic anticoagulation. These findings support ongoing efforts to establish international, evidence-based guidelines.


Assuntos
Anticoagulantes/administração & dosagem , Coagulação Sanguínea/efeitos dos fármacos , Protocolos Clínicos , Embolia Pulmonar/prevenção & controle , Trombofilia/prevenção & controle , Tromboembolia Venosa/prevenção & controle , Trombose Venosa/prevenção & controle , Centros Médicos Acadêmicos , Anticoagulantes/efeitos adversos , /complicações , Consenso , Disparidades em Assistência à Saúde/tendências , Humanos , Padrões de Prática Médica/tendências , Embolia Pulmonar/sangue , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/etiologia , Medição de Risco , Fatores de Risco , Trombofilia/sangue , Trombofilia/diagnóstico , Trombofilia/etiologia , Resultado do Tratamento , Estados Unidos , Tromboembolia Venosa/sangue , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/etiologia , Trombose Venosa/sangue , Trombose Venosa/diagnóstico , Trombose Venosa/etiologia
20.
J Atheroscler Thromb ; 27(10): 1123-1137, 2020 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-32863290

RESUMO

AIM: Patients with acute infectious diseases are at an increased risk of venous thromboembolism (VTE). Clinicians should be aware of the VTE risk in patients with COVID-19, many of whom present with severe coagulation disorders. METHOD: We used an online platform to conduct a cross-sectional questionnaire survey among doctors in mainland China in March 2020. The questionnaire was designed to figure out the clinician's current awareness of VTE prevention and detection rates, as well as the current status of VTE prophylaxis in patients with COVID-19. RESULTS: We collected 1,636 replies, of which 1,579 were valid. Among these, 991 (63%) clinicians were involved directly in frontline treatment. Most of the clinicians (1,492, or 94%) thought it was necessary to assess the VTE risk in patients with COVID-19. However, only 234 (24%) clinicians performed appropriate assessment during the COVID-19 outbreak. For patients with mild/moderate COVID-19, 752 (76%) clinicians would prescribe exercise and water to prevent VTE. For patients with severe COVID-19, 448 (45%) clinicians would prescribe mechanical devices if the patient had a high bleeding risk, and 648 (65%) clinicians would choose LMWH as prophylaxis if the patient had a low bleeding risk. The VTE detection rate was not that high in both mild/moderate and severe patients. CONCLUSION: Although most clinicians recommended prescribing VTE prophylaxis to patients with COVID-19, the practice still needs to be improved. A real-world registry to investigate the true incidence of VTE, and the effect of prescribing appropriate prophylaxis for patients with COVID-19, is necessary in the future.


Assuntos
Betacoronavirus , Infecções por Coronavirus/complicações , Pneumonia Viral/complicações , Padrões de Prática Médica , Tromboembolia Venosa/prevenção & controle , Tromboembolia Venosa/virologia , Adulto , Anticoagulantes/uso terapêutico , China , Competência Clínica , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/terapia , Estudos Transversais , Feminino , Heparina de Baixo Peso Molecular/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/diagnóstico , Pneumonia Viral/terapia , Inquéritos e Questionários , Tromboembolia Venosa/diagnóstico
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