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Trends in VTE Anticoagulation in Hospitalized COVID-19 Patients
Quick Takes
- Use of treatment-dose anticoagulation was common in patients hospitalized with COVID-19, varied widely between hospitals, and increased over time.
- While both prophylactic- and treatment-dose anticoagulation were associated with lower in-hospital mortality compared with no anticoagulation, only prophylactic anticoagulation was associated with lower 60-day mortality.
- These data suggest prophylactic-dose rather than treatment-dose anticoagulation may be the optimal therapy for patients hospitalized with COVID-19.
Study Questions:
What is the frequency with which patients hospitalized with coronavirus disease 2019 (COVID-19) are treated with venous thromboembolism (VTE) prophylactic- and treatment-dose anticoagulation, and what is the association of anticoagulation with in-hospital and 60-day mortality?
Methods:
The investigators conducted a cohort study of adults hospitalized with COVID-19 and used a pseudorandom sample from 30 US hospitals in the state of Michigan participating in a collaborative quality initiative. Data analyzed were from patients hospitalized between March 7, 2020, and June 17, 2020. Data were analyzed through March 2021. Data on nonadherence to VTE prophylaxis (defined as missing ≥2 days of VTE prophylaxis) and receipt of treatment-dose or prophylactic-dose anticoagulants versus no anticoagulation during hospitalization were collected. The effect of nonadherence and anticoagulation strategies on in-hospital and 60-day mortality was assessed using multinomial logit models with inverse probability of treatment weighting.
Results:
Of a total 1,351 patients with COVID-19 included (median [interquartile range] age, 64 [52-75] years; 47.7% women, 48.9% Black patients), only 18 (1.3%) had a confirmed VTE, and 219 (16.2%) received treatment-dose anticoagulation. Use of treatment-dose anticoagulation without imaging ranged from 0%-29% across hospitals and increased over time (adjusted odds ratio [aOR], 1.46; 95% confidence interval [CI], 1.31-1.61 per week). Of 1,127 patients who ever received anticoagulation, 392 (34.8%) missed ≥2 days of prophylaxis. Missed prophylaxis varied from 11%-61% across hospitals and decreased markedly over time (aOR, 0.89; 95% CI, 0.82-0.97 per week). VTE nonadherence was associated with higher 60-day (adjusted hazard ratio [aHR], 1.31; 95% CI, 1.03-1.67) but not in-hospital mortality (aHR, 0.97; 95% CI, 0.91-1.03). Receiving any dose of anticoagulation (vs. no anticoagulation) was associated with lower in-hospital mortality (only prophylactic dose: aHR, 0.36; 95% CI, 0.26-0.52; any treatment dose: aHR, 0.38; 95% CI, 0.25-0.58). However, only the prophylactic dose of anticoagulation remained associated with lower mortality at 60 days (prophylactic dose: aHR, 0.71; 95% CI, 0.51-0.90; treatment dose: aHR, 0.92; 95% CI, 0.63-1.35).
Conclusions:
The authors concluded that prophylactic-dose anticoagulation was associated with lower 60-day mortality.
Perspective:
This large, multicenter cohort of patients hospitalized with COVID-19 reports that use of treatment-dose anticoagulation was common, varied widely between hospitals, and increased over time. While both prophylactic- and treatment-dose anticoagulation were associated with lower in-hospital mortality compared with no anticoagulation, only prophylactic anticoagulation was associated with lower 60-day mortality. This study, pending additional data, suggests prophylactic-dose rather than treatment-dose anticoagulation may be the optimal therapy for patients hospitalized with COVID-19. Overall, there is need for better methods to risk stratify and diagnose patients with VTE and a stronger evidence-base to decide when to employ prophylactic versus therapeutic doses of anticoagulation for patients hospitalized with COVID-19.
Clinical Topics: Anticoagulation Management, COVID-19 Hub, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Anticoagulation Management and Venothromboembolism
Keywords: Anticoagulants, Coronavirus, COVID-19, Post-Exposure Prophylaxis, Primary Prevention, Hospital Mortality, Treatment Outcome, Venous Thromboembolism
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