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Grand Rounds

Thrombotic Events and COVID-19: How Often do they Occur and What are the Risk Factors?

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BACKGROUND AND PURPOSE:

  • Patients with COVID-19 are at an increased risk of thrombosis although risk factors and incidence remain unclear
  • Bilaloglu et al. (JAMA, 2020) assessed the incidence and risk factors for venous and arterial thrombotic events in all hospitalized patients with COVID-19 at a large health system in New York City

METHODS:

  • Case series
  • Setting
    • Four hospitals between March 1 and April 17, 2020
  • Participants
    • Consecutive patients ≥18 years old
    • Hospitalized with confirmed COVID-19
  • Study design
    • Thrombotic events were identified from clinical notes and radiology reports
    • Venous events:  Deep vein thrombosis (DVT) | Pulmonary embolism (PE)
    • Arterial events: Myocardial infarction (MI) | Ischemic stroke | Other systemic thromboembolism
    • Mortality definition: In-hospital death or discharge to hospice as of June 1, 2020
    • Competing risk survival analyses were conducted
  • Primary outcomes
    • Thrombosis
    • Mortality

RESULTS:

  • Data from 3334 patients were included
    • Median age: 64 (IQR 51 to 75) years | 39.6% female
    • Most patients received low-dose (prophylaxis) anticoagulation
  • Thrombotic event incidence
    • Any thrombotic event: 16.0% (533 patients)
    • Venous: 6.2% (207 patients)
      • PE: 3.2%
      • DVT: 3.9%
    • Arterial: 11.1% (365 patients)
      • Ischemic stroke: 1.6%
      • MI: 8.9%
      • Systemic thromboembolism: 1.0%
  • Risk factors associated with thrombotic event (adjusted for covariates)
    • Age
    • Sex
    • Hispanic ethnicity
    • Coronary artery disease
    • Prior MI
    • Higher D-dimer levels at hospital presentation
  • All-cause mortality
    • All-cause mortality: 24.5%
    • Mortality was higher in those with thrombotic events (P<0.001)
      • With thrombotic events: 43.2%
      • Without: 21.0%
  • A thrombotic event was independently associated with mortality
    • Adjusted hazard ratio (HR) 1.82 (95% CI, 1.54 to 2.15; P < 0.001)
  • Both venous and arterial thrombosis were associated with mortality
    • Venous: adjusted HR 1.37 (95% CI, 1.02 to 1.86; P = 0.04)
    • Arterial: adjusted HR 1.99 (95% CI, 1.65 to 2.40; P < 0.001)
  • ICU patient outcomes  
    • Thrombotic events: 29.4%
      • Venous: 13.6%
      • Arterial: 18.6%
  • Non-ICU patient outcomes
    • Thrombotic events: 11.5%
      • Venous: 3.6%
      • Arterial: 8.4%

CONCLUSION:

  • Thrombotic events occurred in 16.0% of hospitalized COVID-19 patients in a NYC health system
    • Elevated D-dimer levels at presentation were independently associated with thrombotic events, consistent with early coagulopathy
  • Thrombotic events in COVID-19 patients may be the result of
    • Cytokine storm | Hypoxic injury | Endothelial dysfunction | Hypercoagulability | Increased platelet activity
  • Study limitations
    • Thrombosis may have been underestimated due to judicious use of this modality
  • Authors note that awareness for thrombotic events increased over course of the study and that with time, anticoagulation became more common

Learn More – Primary Sources:

Thrombosis in Hospitalized Patients With COVID-19 in a New York City Health System

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Related ObG Topics:

NIH COVID-19 Treatment Guidelines
COVID-19 and Coagulopathy
Is Blood Viscosity Greater in Patients with Severe COVID-19?

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