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Published on: November 5, 2021
Coagulopathy of Coronavirus Disease 2019
Toshiaki Iba1, Jerrold H Levy2, Marcel Levi3
1Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.
Insights
Coronavirus disease 2019 (COVID-19) significantly increases the risk of blood clots, leading to serious thromboembolic complications. Monitoring coagulation and using anticoagulants are crucial for managing this hypercoagulable state in hospitalized patients.
Area of Science:
- Medical Science
- Infectious Diseases
- Hematology
Background:
- Coronavirus disease 2019 (COVID-19) is associated with a high incidence of thrombotic events.
- The significance of these thromboembolic complications has been underestimated.
- This review addresses the current understanding of this critical issue.
Purpose of the Study:
- To review the current knowledge on coagulopathy and thrombosis in COVID-19.
- To discuss the role of anticoagulant therapy in managing these complications.
Main Methods:
- A narrative review of the published medical literature.
- Literature search conducted on PubMed using keywords related to COVID-19, SARS, ARDS, coronavirus, coagulopathy, thrombosis, and anticoagulants.
- Articles were selected based on relevance to coagulopathy, thrombosis, and anticoagulant therapy in COVID-19.
Main Results:
- COVID-19 frequently causes hypercoagulability, microangiopathy, local thrombus formation, and systemic coagulation defects.
- Abnormal coagulation tests correlate with adverse outcomes and may require antithrombotic interventions.
- Elevated D-dimer and fibrinogen levels are observed early in infection, with normal or near-normal PT, aPTT, and platelet counts.
- Increased D-dimer levels can prompt venous thromboembolism screening.
- Thromboprophylaxis with low-molecular-weight heparin is recommended for all hospitalized patients.
Conclusions:
- COVID-19 induces a unique coagulopathy distinct from DIC and thrombotic microangiopathy.
- Monitoring D-dimers and fibrinogen is essential.
- All hospitalized patients require thromboembolism prophylaxis, with potential escalation of anticoagulation in specific clinical scenarios.
Objectives:
Recent studies have reported a high prevalence of thrombotic events in coronavirus disease 2019. However, the significance of thromboembolic complications has not been widely appreciated. The purpose of this review is to provide current knowledge of this serious problem.
Design:
Narrative review.
Data Sources:
Online search of published medical literature through PubMed using the term "COVID-19," "SARS," "acute respiratory distress syndrome," "coronavirus," "coagulopathy," "thrombus," and "anticoagulants."
Study Selection And Data Extraction:
Articles were chosen for inclusion based on their relevance to coagulopathy and thrombosis in coronavirus disease 2019, and anticoagulant therapy. Reference lists were reviewed to identify additional relevant articles.
Data Synthesis:
Coronavirus disease 2019 is associated with a strikingly high prevalence of coagulopathy and venous thromboembolism that may contribute to respiratory deterioration. Monitoring coagulation variables is important, as abnormal coagulation tests are related to adverse outcomes and may necessitate adjuvant antithrombotic interventions. In the initial phase of the infection, D-dimer and fibrinogen levels are increased, while activated partial prothrombin time, prothrombin time, and platelet counts are often relatively normal. Increased D-dimer levels three times the upper limit of normal may trigger screening for venous thromboembolism. In all hospitalized patients, thromboprophylaxis using low-molecular-weight heparin is currently recommended. The etiology of the procoagulant responses is complex and thought to be a result of specific interactions between host defense mechanisms and the coagulation system. Although the coagulopathy is reminiscent of disseminated intravascular coagulation and thrombotic microangiopathy, it has features that are markedly distinct from these entities.
Conclusions:
Severe acute respiratory syndrome coronavirus 2/coronavirus disease 2019 frequently induces hypercoagulability with both microangiopathy and local thrombus formation, and a systemic coagulation defect that leads to large vessel thrombosis and major thromboembolic complications, including pulmonary embolism in critically ill hospitalized patients. D-dimers and fibrinogen levels should be monitored, and all hospitalized patients should undergo thromboembolism prophylaxis with an increase in therapeutic anticoagulation in certain clinical situations.
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