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Thromboprophylaxis in COVID-19: Weight and severity adjusted intensified dosing
Matthias M Engelen1,2, Christophe Vandenbriele1,2, Valérie Spalart1,2
1Department of Cardiovascular Diseases University Hospitals Leuven Leuven Belgium.
Insights
Intensified anticoagulation for hospitalized COVID-19 patients reduced venous thromboembolism (VTE) and bleeding events. Weight-adjusted prophylactic doses, not therapeutic, proved effective and safer than standard care.
Area of Science:
- Internal Medicine
- Critical Care Medicine
- Hematology
Background:
- Hospitalized patients with coronavirus disease 2019 (COVID-19) have a high incidence of venous thromboembolism (VTE).
- The optimal anticoagulation dose for VTE prophylaxis in COVID-19 remains undetermined.
Purpose of the Study:
- To evaluate the impact of an intensified thromboprophylaxis protocol on VTE incidence and bleeding in COVID-19 patients.
- To compare VTE rates and bleeding complications before and after protocol implementation.
Main Methods:
- Implementation of a hospital-wide intensified thromboprophylaxis protocol using weight-adjusted low molecular weight heparin (LMWH).
- Inclusion of all hospitalized symptomatic COVID-19 patients, with VTE screening via ultrasound.
- Primary outcome assessment included symptomatic/subclinical VTE and major bleeding during admission.
Main Results:
- A total of 412 patients were included; 219 received standard LMWH prophylaxis and 193 received intensified prophylaxis.
- The intensified protocol group showed no symptomatic VTE, with only three incidental deep vein thrombosis (1.6%) and one incidental pulmonary embolism (0.5%) cases.
- Major bleeding rates were 1.2% with intensified prophylaxis versus 7.7% when therapeutic anticoagulation was required.
Conclusions:
- Systematic, weight-adjusted prophylactic anticoagulation (intermediate dosing in ICU) significantly reduced VTE incidence in hospitalized COVID-19 patients.
- The intensified thromboprophylaxis strategy was associated with a lower risk of major bleeding compared to therapeutic anticoagulation.
Background:
Venous thromboembolism (VTE) frequently occurs in hospitalized patients with coronavirus disease 2019 (COVID-19). The optimal dose of anticoagulation for thromboprophylaxis in COVID-19 is unknown.
Aims:
To report VTE incidence and bleeding before and after implementing a hospital-wide intensified thromboprophylactic protocol in patients with COVID-19.
Methods:
On March 31, 2020, we implemented an intensified thromboprophylactic protocol consisting of 50 IU anti-Xa low molecular weight heparin (LMWH)/kg once daily at the ward, twice daily at the intensive care unit (ICU). We included all patients hospitalized in a tertiary care hospital with symptomatic COVID-19 between March 7 and July 1, 2020. The primary outcome was the incidence of symptomatic or subclinical VTE and major bleeding during admission. Routine ultrasound screening for VTE was performed whenever logistically possible.
Results:
We included 412 patients, of which 116 were admitted to the ICU. Of 219 patients with standard a prophylactic dose of LMWH, 16 (7.3%) had VTE, 10 of which were symptomatic (4.6%). Of 193 patients with intensified thromboprophylaxis, there were no symptomatic VTE cases, three incidental deep venous thrombosis cases (1.6%), and one incidental pulmonary embolism (0.5%). The major bleeding rate was 1.2% in patients with intensified thromboprophylaxis and 7.7% when therapeutic anticoagulation was needed.
Conclusion:
In hospitalized patients with COVID-19, there were no additional symptomatic VTEs and a reduction in incidental deep vein thrombosis after implementing systematic thromboprophylaxis with weight-adjusted prophylactic (ward) to intermediate (ICU), but not therapeutic dosed anticoagulation. This intensified thromboprophylaxis was associated with a lower risk of major bleeding compared with therapeutic dosed anticoagulation.
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