Early Anticoagulation in COVID-19

Quick Takes

  • Among critically ill patients with COVID-19, 6.3% developed VTE, while 2.8% developed major bleeding.
  • In a trial emulation model, critically ill patients with COVID-19 did not have a lower rate of death based on the receipt or no receipt of treatment-dose anticoagulation.

Study Questions:

What is the incidence of venous thromboembolism (VTE) and major bleeding in critically ill patients with coronavirus 2019 (COVID-19)?

Methods:

The authors conducted a multicenter cohort study of critically ill patients with COVID-19 between March 4–April 11, 2020. The incidence of VTE and major bleeding within 14 days of intensive care unit (ICU) admission was evaluated. The authors also conducted a trial emulation based on receipt or no receipt of therapeutic anticoagulation using a Cox model with inverse probability weighting to predict mortality.

Results:

Among the 3,239 critically ill patients, whose mean age was 61 years and 64.5% were men, 204 (6.3%) developed VTE and 90 (2.8%) developed a major bleeding event. Independent predictors of VTE were male sex and higher D-dimer level on ICU admission. Among the 2,809 patients in the trial emulation, 384 (11.9%) received early therapeutic anticoagulation. During a median follow-up of 27 days, patients who did and did not receive early therapeutic anticoagulation had a similar risk for death (hazard ratio, 1.12; 95% confidence interval, 0.92-1.35).

Conclusions:

The authors concluded that critically ill patients with COVID-19 did not experience a survival benefit when treated with therapeutic anticoagulation.

Perspective:

This multicenter, US-based analysis of >3,000 critically ill patients demonstrated a lower rate of VTE (6.3%) than has been reported in a recent meta-analysis (27.9%). Notably, the rate of major bleeding was lower (2.8%) than the rate of VTE (6.3%). However, it should be noted that this study enrolled patients from the first “wave” of COVID-19 in the United States (March–April 2020) and that subsequent waves have included different populations and treatments that may have impacted mortality. Furthermore, this study did not clarify how long patients had been hospitalized prior to ICU admission. Nonetheless, the data presented in this retrospective study largely mirror those that have been reported from the multi-platform randomized trial—no benefit with treatment dose anticoagulation for critically ill patients with COVID-19. They also mirror the results of the INSPIRATION randomized trial, which found no benefit with intermediate-dose over standard-dose prophylactic anticoagulation in critically ill patients. At this time, most patients with COVID-19 who are admitted to the ICU for organ support should receive standard VTE prophylaxis.

Clinical Topics: Anticoagulation Management, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Anticoagulation Management and Venothromboembolism

Keywords: Anticoagulants, Blood Coagulation, Coronavirus, COVID-19, Critical Illness, Hemorrhage, Intensive Care Units, Secondary Prevention, Thrombosis, Venous Thromboembolism, Vascular Diseases


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