A Dynamic, D-dimer-based Thromboprophylaxis Strategy in Patients with COVID-19
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Published on: February 16, 2022
Lantarima Bhoopat1,2, Anastasia Martynova1, April Choi3
1Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, 90089, USA.
Insights
Adjusting anticoagulant doses based on D-dimer levels in hospitalized COVID-19 patients improved survival. This dynamic approach showed better outcomes than fixed dosing, with manageable bleeding risks.
Area of Science:
- Internal Medicine
- Hematology
- Infectious Diseases
Background:
- COVID-19 infection is associated with an increased risk of venous thromboembolism (VTE) during hospitalization.
- Standard prophylactic anticoagulation may be insufficient to mitigate VTE risk in these patients.
- Limited diagnostic imaging during the pandemic necessitates optimized anticoagulant management protocols.
Purpose of the Study:
- To evaluate the efficacy and safety of a dynamic anticoagulation dosing protocol based on D-dimer levels in hospitalized COVID-19 patients.
- To compare in-hospital survival rates between patients receiving fixed versus dynamically adjusted anticoagulant doses.
- To assess secondary outcomes including bleeding events, thrombosis incidence, and hospitalization duration.
Main Methods:
- Retrospective cohort study involving 260 hospitalized COVID-19 patients.
- Implementation of a quality improvement program with a D-dimer-guided anticoagulation dosing protocol.
- Patients were divided into fixed-dose and dynamic (up-titrated) anticoagulation groups.
Main Results:
- In-hospital survival at 30 days was significantly higher in the up-titrated group (80.2%) compared to the fixed-dose group (51.3%) (p=0.01).
- Bleeding events were more frequent in the up-titrated group (12.5%) versus the fixed-dose group (2.13%), primarily consisting of clinically relevant non-major bleeding (CRNMB).
- The study included assessment of breakthrough thrombosis, length of stay, and mechanical ventilation days.
Conclusions:
- Dynamic, D-dimer-based anticoagulation dose escalation shows promise for improving survival in hospitalized COVID-19 patients.
- This approach may reduce in-hospital mortality without a significant increase in fatal bleeding events.
- Optimized anticoagulation strategies are crucial for managing VTE risk in COVID-19 patients.
Background:
COVID-19 pandemics increases venous thromboembolism (VTE) risk during hospitalization, despite prophylactic anticoagulation. Limited radiological diagnosis in pandemic requires a guided protocol for anticoagulant adjustment.
Methods:
This retrospective cohort study was conducted at a single center as part of a quality improvement program evaluating the efficacy and safety of anticoagulation protocols. The study focused on implementing a guideline for anticoagulant dosing protocol based on dynamic changes in D-dimer levels in COVID-19 hospitalized patients. The dosing guideline allowed for dose escalation from standard prophylactic levels to escalated prophylactic or therapeutic levels, depending on the patient's risk profile for VTE. The primary endpoints included in-hospital survival comparing between fix and dynamic adjustment treatment groups. Secondary endpoints encompassed major and clinically relevant non-major bleeding (CRNMB) events, incidence of breakthrough thrombosis, length of hospitalization and ICU stay, days of mechanical ventilator use, and survival duration.
Findings:
Among the 260 COVID-19-infected patients hospitalized between March 15th and June 15th, 2020. The patients received fixed anticoagulant dosage in 188, 72.3%) patients, while 72 (27.7%) were up-titrated according to the protocol. In-hospital survival at 30 days demonstrated superiority among patients whose anticoagulation was up-titrated to either escalated prophylactic or therapeutic (80.2%) compared to receiving fixed anticoagulant dosage (51.3%) (p=0.01). Bleeding events were significantly higher in up-titrate group (12.5%) compared to fixed anticoagulant dosage group (2.13%). Most of them are CRNMB.
Conclusion:
A dynamic, D-dimer-based dose escalation of anticoagulation for hospitalized patients with COVID-19 holds promise in improving in-hospital mortality rates without a significant increase in fatal bleeding events.
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