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High-Dose Prophylactic Anticoagulation in Critically Ill Patients With COVID-19
TAKE-HOME MESSAGE
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In this prospective cohort study, the incidence of thrombotic complications in patients with COVID-19 infection admitted to the ICU was 22.7%. Cumulative exposure to a higher prophylactic anticoagulation dosage was associated with a reduction in the risk of thrombotic complications without an increased risk of bleeding.
- Higher doses of anticoagulation can be beneficial in patients with severe COVID-19 infection without increasing the risk of bleeding. Further randomized studies are warranted.
abstract
This abstract is available on the publisher's site.
Access this abstract nowBACKGROUND
Due to the high risk of thrombotic complications (TC) during SARS-CoV-2 infection, several scientific societies have proposed to increase the dose of preventive anticoagulation, although arguments in favor of this strategy are inconsistent.
RESEARCH QUESTION
What is the incidence of TC in critically ill patients with COVID-19 and what is the relationship between the dose of anticoagulant therapy and the incidence of TC?
STUDY DESIGN AND METHODS
All consecutive patients referred to eight French intensive care units (ICU) for COVID-19 were included in our observational study. Clinical and laboratory data were collected from ICU admission to day 14, including anticoagulation status and thrombotic and hemorrhagic events. The effect of high dose prophylactic anticoagulation (either at intermediate or equivalent to therapeutic dose), defined using a standardized protocol of classification, was assessed using a time-varying exposure model using inverse probability of treatment weight.
RESULTS
Out of 538 patients included, 104 patients developed a total of 122 TC with an incidence of 22.7 % (19.2-26.3). Pulmonary embolism accounted for 52 % of the recorded TC. High dose prophylactic anticoagulation was associated with a significant reduced risk of TC (HR 0.81 [0.66-0.99]) without increasing the risk of bleeding (HR 1.11 [0.70-1.75]).
INTERPRETATION
High dose prophylactic anticoagulation is associated with a reduction in thrombotic complications in critically ill COVID-19 patients without an increased risk of hemorrhage. Randomized controlled trials comparing prophylaxis with higher doses of anticoagulants are needed to confirm these results.
Additional Info
Disclosure statements are available on the authors' profiles:
Impact of High Dose Prophylactic Anticoagulation in Critically Ill Patients With COVID-19 Pneumonia
Chest 2021 Jan 16;[EPub Ahead of Print], C Tacquard, A Mansour, A Godon, J Godet, J Poissy, D Garrigue, E Kipnis, SR Hamada, PM Mertes, A Steib, M Ulliel-Roche, B Bouhemad, M Nguyen, F Reizine, I Gouin-Thibault, MC Besse, N Collercandy, S Mankikian, JH Levy, Y Gruel, P Albaladejo, S Susen, A Godier, GIHP groupFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Benign Hematology
There have been many descriptions of the use of anticoagulant therapy for patients with COVID-19. Anticoagulation is alleged to improve outcomes through its expected target—preventing or treating venous thromboembolism (VTE)—and through its theoretical target—preventing microvascular thrombosis leading to ARDS and multi-organ failure. Tacquard et al present retrospective data aimed at the first and most familiar of these clinical outcomes: preventing VTE. Their data support the hypothesis that higher than typical doses of pharmacological thromboprophylaxis are safe and will prevent more VTEs during the first 14 days of ICU management. This conclusion is consistent with some expert opinion1 but inconsistent with clinical guidelines, such as those of the American Society of Hematology (ASH). The ASH guideline panel suggests using prophylactic-intensity over intermediate-intensity or therapeutic-intensity anticoagulation in patients with COVID-19–related critical illness who do not have suspected or confirmed VTE. When I confront this ambiguity, I choose to advocate sticking to the ASH guidelines unless the beneficial effect of intermediate- or higher-dose anticoagulation to prevent VTE in acutely ill COVID-19 patients is corroborated through randomized controlled clinical trials, of which there are several ongoing. COVID-19 has now been with us long enough to have taught the hard lessons of jumping to premature and possibly erroneous conclusions.2
References