The effectiveness and safety of the use of antithrombotic therapy in COVID-19

The article is a non-systematic review of the literature, addressing the effectiveness, safety and appropriateness of antithrombotic drugs for COVID-19 in patients undergoing treatment in different settings: in the hospital phase, including the intensive care unit, in the outpatient phase after discharge from hospital, in primary outpatient treatment. The issues of thrombotic complications during vaccination and the necessity of their prevention are discussed. The studies confirm the importance of prophylactic doses of anticoagulants in all hospitalized patients. The use of increased doses has proven ineffective in patients with a severe course of the disease who are being treated in the intensive care unit. In moderately severe infections, there is a clear benefit of increased doses of anticoagulants in reducing the risk of organ failure, but definitive conclusions can only be drawn after the final results of the studies have been published. Prolonged pharmacological prophylaxis after hospital discharge may be useful in individual patients, but the overall risk of thrombotic complications in the long-term period does not appear to be high. The available data do not support the use of anticoagulants in the treatment of coronavirus disease in the outpatient settings, since the risk of thrombotic complications is not increased in such patients, and the safety of anticoagulant use has not been evaluated. Sulodexide may be useful in selected outpatients at increased risk of disease progression. Vaccination may provoke the development of atypical localized thrombosis by immune mechanisms, but the risk of such complications is lower in the coronavirus disease itself. Anticoagulant prophylaxis during vaccine administration is not indicated.

American Society of Hematology living guidelines on the use of anticoagulation for thromboprophylaxis in patients with COVID-19: July 2021 update on post-discharge thromboprophylaxis

Background: COVID-19 related acute illness is associated with an increased risk of venous thromboembolism (VTE). Objective: These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians and other health care professionals in decisions about the use of anticoagulation for thromboprophylaxis in patients with COVID-19 who do not have confirmed or suspected VTE. Methods: ASH formed a multidisciplinary guideline panel, including three patient representatives, and applied strategies to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including performing systematic evidence reviews (up to March 2021). The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess evidence and make recommendations, which were subject to public comment. Results: The panel agreed on one additional recommendation. The panel issued a conditional recommendation against the use of outpatient anticoagulant prophylaxis in patients with COVID-19 being discharged from the hospital who do not have suspected or confirmed VTE or another indication for anticoagulation. Conclusions: This recommendation was based on very low certainty in the evidence, underscoring the need for high-quality, randomized controlled trials assessing the role of post-discharge thromboprophylaxis. Other key research priorities include better evidence on assessing risk of thrombosis and bleeding outcomes in patients with COVID-19 after hospital discharge.

Mortality and risk factors associated with pulmonary embolism in coronavirus disease 2019 patients: a systematic review and meta-analysis

To determine, in patients with coronavirus disease 2019 (COVID-19) infection, the associations of pulmonary embolism (PE) with mortality and risk factors for PE as well as the therapeutic benefit of anticoagulant prophylaxis. Embase, PubMed, Cochrane controlled trials register, and Web of Science databases were searched from inception to October 10, 2020. We included all published trials on PE in patients diagnosed with COVID-19 with eligibility of the trials assessed following the PRISMA guidelines. Sixteen clinical trials with 5826 patients were eligible. There were significant associations of PE with the male gender [odd ratio (OR) = 1.59, 95% CI 1.28–1.97], mechanical ventilation (OR = 3.71, 95% CI 2.57–5.36), intensive care unit admission (OR = 2.99, 95% CI 2.11–4.23), circulating D-dimer [mean difference (MD) = 5.04 µg/mL, 95% CI 3.67–6.42) and CRP (MD = 1.97 mg/dL, 95% CI 0.58– 3.35) concentrations without significant correlation between PE and mortality (OR = 1.31, 95% CI 0.82–2.08) as well as other parameters or comorbidities. After omitting one trial with strict patient selection criteria for anticoagulant prophylaxis, significant prophylactic benefit was noted (OR = 0.31, 95% CI 0.1–0.91). Our findings identified the risk factors associated with PE in COVID-19 patients and supported the therapeutic benefit of anticoagulant prophylaxis against PE in this patient population.

Thrombosis And Thromboprophylaxis In COVID-19 Patients During Hospitalization And Early Post-discharge Period

While SARS-CoV-2 infection continues to circulate around the world, there are still many uncertainties on how to treat the patients with this potentially deadly virus, and more importantly, for how long! COVID-19 causes many different symptoms, among which coagulopathy seems to play an essential role in the survival prognosis of patients. While medical centers worldwide have developed various algorithms for preventing thrombosis in COVID-19 patients, there are still no clear guidelines on the length of thromboprophylaxis therapy, target groups who should receive suitable anticoagulant prophylaxis, and even the choice of the most appropriate agent for such treatment.

How Well do European Patients Understand Cancer-Associated Thrombosis? A Patient Survey

Ongoing concerns regarding the morbidity and mortality from cancer-associated thrombosis led the European Cancer Patient Coalition (ECPC), the voice of cancer patients across Europe, to create a pan-European cancer-associated awareness patient survey to assess CAT knowledge among a large population of patients with cancer. The ECPC survey represents the largest of its kind amongst patients/caregivers with CAT and identified significant gaps in patient awareness and knowledge of CAT. It also identified a need for educational CAT-related discussions and interventions between healthcare professionals and patients with cancer and their caregivers. The aim of this paper is to highlight these gaps and to provide healthcare professionals with awareness of what information should be shared with patients/caregivers as well as how and when that information should be provided. Notably, the importance of providing information on CAT risk and risk factors, how to reduce their risk of CAT, the role of anticoagulant prophylaxis and treatment (short- and long-term) including possible side-effects, and finally how to early identify CAT symptoms. Here we outline what type of information should be provided, as well as when and how to best discuss CAT with our oncology patients and their caregivers along the cancer care continuum, to reduce the risk of CAT and associated complications with a goal of improving patient outcomes.

Prevalence of thrombotic complications in children with SARS-CoV-2

Knowledge of thrombosis in children with SARS-CoV-2 is scarce. In this multicentre national cohort of children with SARS-CoV-2 involving 49 hospitals, 4 patients out of 537 infected children developed a thrombotic complication (prevalence of 0.7% (95% CI: 0.2% to 1.9%) out of the global cohort and 1.1% (95% CI: 0.3% to 2.8%) out of the hospitalised patients). We describe their characteristics and review other published paediatric cases. Three out of the four patients were adolescent girls, and only two cases had significant thrombotic risk factors. In this paediatric cohort, D-dimer value was not specific enough to predict thrombotic complications. Adolescence and previous thrombotic risk factors may be considered when initiating anticoagulant prophylaxis on children with SARS-CoV-2 disease (COVID-19).

The Predictors of Acute Lower Limb Ischemia on the Background of the Recommended Prophylaxis

Objective: Acute limb ischemia (ALI) manifests as sudden lower limb ischemia that, regardless of the underlying cause, can lead to amputation unless there is an appropriate treatment.The study aims to analyze predictors of the lower limb occlusive thrombosis with the acute ischemia development (ALLI), depending on the localization under specifically recommended prophylaxis. Materials and methods: The researchers performed a retrospective analysis of clinical cases with a confirmed diagnosis of acute lower limb ischemia (ALLI) for 2019. During this period, 20 patients met the study criteria. Results and Discussion: A multivariate analysis (predictors with a p<0.1) established hyperglycemia as a significant predictor of ALLI development under specific prophylaxis (RR 2.2; 95% CI -8.2; 8.4; p = 0.097). It indicates a double risk of ALLI for patients with hyperglycemia. Conclusion: The results indicate the need to correct glycemic parameters to reduce the risk of acute lower limb ischemia, even under antiplatelet or anticoagulant prophylaxis. It is also necessary to analyze the management protocols currently used for such patients to correct the recommended antiplatelet or anticoagulantschemes. Bangladesh Journal of Medical Science Vol.20(3) 2021 p.637-641

Development of a risk-oriented algorithm for the combined use of hemostatics and anticoagulants to prevent thrombosis and bleeding cases after total arthroplasty of knee or hip joints

Introduction: The goal of our study was to develop a risk-oriented algorithm for the combined use of hemostatics and anticoagulants in patients after total arthroplasty of the knee or hip joints to reduce the risk of thrombohemorrhagic complications. Materials and methods: We performed a retrospective study (n=253). In group (Gr.) 1, the time interval (TI) between the administration of hemostatic and anticoagulant prophylaxis was ≤17 hours (n=145; 57.31%), and in Gr. 2 – 18-24 hours (n=108; 42.68%). We analyzed the influence of different factors on the development of thrombosis and bleeding cases after the operation. Results and discussion: Thrombohemorrhagic complications were observed in 27 (10.67%) patients. Thrombosis in Gr. 1 was associated with the use of tranexamic acid, and were recorded 2.2 times more often than in Gr. 2 (p&lt;0.05). The development of thrombosis in Gr. 1 was influenced by: class II obesity, type 2 diabetes mellitus, myocardial infarction, venous pathology, age of patients &gt;75 years, for women – an initially low level of international normalized ratio, and activated partial thromboplastin time (APTT) (p&lt;0.05). The development of bleeding in Gr. 1 was influenced by: age &gt;75 years, among men and women – an increased preoperative level of APTT, for women – a decreased level of fibrinogen and platelets (p&lt;0.05). Conclusion: To prevent thrombosis and bleeding after arthroplasty of large joints, the TI between the use of hemostatics and anticoagulants should be at least 18 hours, especially in patients with the above risk factors, in particular, when using tranexamic acid and low molecular weight heparins.

May-Thurner Syndrome Is Aggravated by Pregnancy

This study aims to emphasize that asymptomatic patients with undiagnosed and asymptomatic May-Thurner syndrome (MTS) may firstly develop severe compression during pregnancy. A 40-year-old woman, G1P0, at 22 weeks of twin gestation presented with left lower extremity edema and pain. One twin was structurally normal while the other had bilateral renal agenesis with oligohydramnios. Magnetic resonance venography (MRV) revealed severe compression of the left iliac vein by the right iliac artery without evidence of deep vein thrombosis (DVT). Conservative treatment with anticoagulant prophylaxis was instituted throughout the rest of pregnancy and postpartum period. She was also complicated with severe pre-eclampsia, a cesarean section was performed due to a prolapsed cord at 27 weeks of gestation, and she gave birth to a surviving baby weighing 1100 g. In conclusion, this case report provides evidence that pregnancy can disclose a subtle May-Thurner anatomy to be symptomatic without DVT. Successful pregnancy outcomes could be achieved with conservative treatment and anticoagulant prophylaxis.