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Thrombosis in COVID-19 From a New York City Health System
Quick Takes
- In New York City, rates of thromboembolism among patients hospitalized with COVID-19 were high (16%).
- Rates of thromboembolism were higher among patients with COVID-19 admitted to the ICU than patients managed on the floor.
- Elevated D-dimer was a strong predictor of thrombotic events among hospitalized patients with COVID-19.
Study Questions:
What is the incidence of and risk factors for thrombotic events among patients hospitalized with coronavirus disease 2019 (COVID-19)?
Methods:
The study included all patients admitted to NYU Langone Health system between March 1 and April 17, 2020, who tested positive for COVID-19. Diagnosis of arterial and/or venous thrombotic events was made using routine clinical care. Most patients received prophylactic anticoagulation. Natural language processing was used to identify thrombotic events from the medical record, followed by manual chart review. Outcomes were assessed through June 1, 2020, using death as a competing risk in the model.
Results:
Among 3,334 consecutive hospitalized patients with COVID-19, the median age was 64 (interquartile range, 51-75) and 39.6% were female. Thrombotic events occurred in 533 (16.0%) patients, of which 207 (6.2%) were venous (3.2% pulmonary embolism, 3.9% deep vein thrombosis) and 365 (11.1%) were arterial (1.6% ischemic stroke, 8.9% myocardial infarction, and 1.0% systemic embolism). Thrombotic events were more common in patients at an older age, male sex, current smoking, Hispanic race, with a history of myocardial infarction or coronary artery disease, and with elevated D-dimer on admission. All-cause mortality was 24.5% and was higher among patients with thrombotic events (43.2% vs. 21.0%, adjusted hazard ratio, 1.82; 95% confidence interval, 1.54-2.15). Both venous and arterial thrombotic events were associated with mortality. Among 829 ICU patients, 29.4% experienced a thrombotic event (13.6% venous, 18.6% arterial). Among 2,505 non-ICU patients, 11.5% experienced a thrombotic event (3.6% venous, 8.4% arterial).
Conclusions:
The authors concluded that thrombotic events were common (16.0%) among patients with COVID-19 admitted to a large health system in New York City.
Perspective:
Many studies have explored the risk of thromboembolic events associated with COVID-19. Most from China or Europe have identified a high risk of thrombosis, especially venous thromboembolism (VTE). This analysis from one health system in New York is larger than most prior studies. It demonstrated high overall thrombotic event rates differentiated by type of event and patient location. In particular, rates of VTE were lower than in other reports, while arterial thrombotic events were higher. Two possible explanations exist for the lower VTE rates: 1) the true VTE event rates were overestimated in prior studies using surveillance imaging or without routine prophylactic anticoagulation; or 2) limited access to imaging during the COVID-19 surge in New York City led to fewer confirmed cases of VTE in this analysis. As for the arterial thromboembolism events, they often do not require imaging to diagnose (e.g., use of electrocardiogram and/or troponin for myocardial infarction) or are so severe that imaging is performed (e.g,, ischemic stroke). Prospective studies evaluating the role of prophylactic anticoagulation will also help to explore the incidence of thrombotic events in a systematic manner that should help to address these unanswered questions.
Clinical Topics: Anticoagulation Management, Cardiovascular Care Team, COVID-19 Hub, Noninvasive Imaging, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Anticoagulation Management and Venothromboembolism, Smoking
Keywords: Anticoagulants, Brain Ischemia, Coronary Artery Disease, Coronavirus, COVID-19, Diagnostic Imaging, Intensive Care Units, Myocardial Infarction, Natural Language Processing, Primary Prevention, Pulmonary Embolism, Risk Factors, severe acute respiratory syndrome coronavirus 2, Smoking, Stroke, Thrombosis, Troponin, Vascular Diseases, Venous Thromboembolism
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