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Pharmacologic Thromboprophylaxis and Thrombosis in Hospitalized Patients with COVID-19: A Pooled Analysis
Rushad Patell1, Thita Chiasakul1,2, Ethan Bauer3
1Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States.
Insights
Pharmacologic thromboprophylaxis significantly reduced thrombosis in hospitalized COVID-19 patients. Intermediate-dose or therapeutic anticoagulation showed similar thrombosis and bleeding rates compared to standard-dose prophylaxis.
Area of Science:
- Internal Medicine
- Critical Care Medicine
- Pharmacology
Background:
- Hospitalized patients with COVID-19 face increased thrombosis risk, necessitating varied thromboprophylaxis strategies.
- The safety and efficacy of escalated-dose pharmacologic thromboprophylaxis remain undetermined.
- This study addresses the need for evidence on different anticoagulation intensities for COVID-19 patients.
Purpose of the Study:
- To determine and compare the pooled incidence of thrombosis and bleeding events across different pharmacologic thromboprophylaxis strategies in hospitalized COVID-19 patients.
- To evaluate outcomes for standard-dose, intermediate-dose, and therapeutic anticoagulation versus no pharmacologic prophylaxis.
- To inform clinical decision-making regarding anticoagulation intensity for COVID-19-associated thrombosis.
Main Methods:
- A systematic literature search was conducted in MEDLINE, EMBASE, and Cochrane CENTRAL up to August 29, 2020.
- Included studies reported on pharmacologic thromboprophylaxis, thrombosis, or bleeding in hospitalized COVID-19 patients.
- Pooled event rates for thrombosis and bleeding were calculated using a random-effects model.
Main Results:
- Thirty-five observational studies were analyzed, involving thousands of patients.
- Venous thromboembolism incidence was highest without prophylaxis (41.9%) and lowest with therapeutic anticoagulation (10.5%).
- Arterial thrombosis incidence was also reduced with prophylaxis, ranging from 11.3% (no prophylaxis) to 1.3% (therapeutic anticoagulation).
- Bleeding event rates were nonsignificantly higher with therapeutic anticoagulation (6.3%) compared to standard-dose prophylaxis (1.7%).
Conclusions:
- Pharmacologic thromboprophylaxis is associated with lower thrombosis rates in hospitalized COVID-19 patients.
- Intermediate-dose thromboprophylaxis and therapeutic anticoagulation demonstrated comparable thrombosis and bleeding rates to standard-dose prophylaxis.
- These findings suggest that escalated anticoagulation strategies may be safely employed in select hospitalized COVID-19 patients.
Background:
Coronavirus disease 2019 (COVID-19) increases thrombosis in hospitalized patients prompting adoption of different thromboprophylaxis strategies. Safety and efficacy of escalated-dose pharmacologic thromboprophylaxis are not established.
Objectives:
To determine the pooled incidence of thrombosis/bleeding in hospitalized patients with COVID-19 for standard-dose, intermediate-dose, therapeutic anticoagulation, and no pharmacologic thromboprophylaxis.
Methods:
MEDLINE, EMBASE, and Cochrane CENTRAL were searched up to August 29, 2020 for studies reporting pharmacologic thromboprophylaxis and thrombosis or bleeding. Pooled event rates were calculated using a random-effects model.
Results:
Thirty-five observational studies were included. The pooled incidence rates of total venous thromboembolism (N = 4,685) were: no prophylaxis 41.9% (95% confidence interval [CI]: 28.1-57.2, I 2 = 76%), standard-dose prophylaxis 19.8% (95% CI: 13.2-28.6, I 2 = 95%), intermediate-dose prophylaxis 11.9% (95% CI: 4.3-28.6, I 2 = 91%), and therapeutic-dose anticoagulants 10.5% (95% CI: 4.2-23.8, I 2 = 82%, p = 0.003). The pooled incidence rates of arterial thrombosis (N = 1,464) were: no prophylaxis 11.3% (95% CI: 5.2-23.0, I 2 = 0%), standard-dose prophylaxis 2.5% (95% CI: 1.4-4.3, I 2 = 45%), intermediate-dose prophylaxis 2.1% (95% CI: 0.5-7.7, I 2 = 45%), and therapeutic-dose anticoagulants 1.3% (95% CI: 0.2-8.8, I 2 = 0, p = 0.009). The pooled bleeding event rates (N = 6,393) were nonsignificantly higher in therapeutic-dose anticoagulants compared with standard-dose prophylaxis, (6.3 vs. 1.7%, p = 0.083).
Conclusion:
Thrombosis rates were lower in hospitalized COVID-19 patients who received pharmacologic thromboprophylaxis. Thrombosis and bleeding rates for patients receiving intermediate-dose thromboprophylaxis or therapeutic anticoagulation were similar to those who received standard-dose pharmacologic thromboprophylaxis.
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