No abstract

Introduction The outcomes related to different anticoagulation doses in Coronavirus disease 2019 (COVID-19) patients are not well established. COVID-19 is associated with increased thrombotic events and early coagulopathy as reported by a large New York City health system. Initial studies on patients in Wuhan, China showed anticoagulant therapy mainly with low molecular weight heparin was reported to be associated with better prognosis in severe COVID-19 patients meeting sepsis-induced coagulopathy criteria or with markedly elevated D-dimer. These studies fueled the need for anticoagulation protocols to be institutionalized broadly. Here we report the outcomes of patients on prophylactic compared to treatment dose anticoagulation early in the COVID-19 pandemic. This data reflects results before broad institutionalization of anticoagulation protocols for this novel disease in a Brooklyn, New York population. Methods This is a retrospective chart review of all laboratory confirmed COVID-19 patients who were admitted to New York-Presbyterian Brooklyn Methodist Hospital between March and April, 2020. Patient clinical characteristics were manually extracted from electronic medical records. Patients were divided into 2 groups: patients on treatment dose anticoagulation and patients on prophylactic dose anticoagulation. Primary outcome of this study was inpatient mortality among the two groups. Secondary outcomes were thromboembolisms (both arterial and venous), myocardial infarction (MI), major bleeding, ICU admission, ICU length of stay, invasive mechanical ventilation and initiation of dialysis. Odds ratio and p-values were obtained using univariate analysis. Results We analyzed 580 hospitalized patients with confirmed nasopharyngeal COVID19 infection. Of these, 82 patients were on treatment dose anticoagulation 498 patients were on prophylactic dose. Median age was 70 years in treatment dose group and 66 years in prophylactic dose group. Percentage of males were similar between both groups (53%). African American race(56% vs 46%) was the predominant race in both groups. Median BMI was 28.1 in both groups. Percentage of smokers was higher in the treatment dose group (34% compared to 21%). Patients in the treatment dose group had a higher rate of all the comorbidities. Median D-Dimer (630 vs 590) was higher in the treatment dose group. Rates of ICU admission in treatment dose group and prophylactic dose group was 44% and 22% respectively. Patients requiring intubation (43% vs 24%) and transfusion (24% and 7%) were higher in the treatment dose group. There was an increased incidence of thromboembolic events in the treatment dose group as compared to prophylactic dose group with DVT (15.6% vs 1.6%) PE (3.7% vs 0.2%), arterial thrombosis (1.2% vs 0%) and MI (6.1% vs 1.6%). Incidence of major bleeding was higher in the treatment group (10% vs3.5%) Discussion Our study found increased inpatient mortality with treatment dose anticoagulation and increased risk of bleeding when compared with prophylactic dose anticoagulation. These findings may be due to higher rates of comorbidities, smoking and older age when compared to the prophylactic anticoagulation group. Higher rates of bleeding raises concern for the safety of treatment dose anticoagulation in these populations. Some limitations of this study include: uneven sample size between the two groups and data was collected from patients before anticoagulation dose recommendations were standardized and officially implemented. Further randomized control trials are needed to evaluate the dose- dependent relationship between anticoagulation and mortality. Our study suggests that the treatment dose anticoagulation may adversely affect the outcomes in COVID-19 patients who are older and have multiple comorbidities. Therefore, the anticoagulation dose must be chosen carefully given the overall clinical picture. Disclosures No relevant conflicts of interest to declare.

Background Hypercoagulability is a well-known mechanism of injury in patients with COVID-19 (Rico-Mesa et al Cardiology 2020). There are several clinical reports suggesting higher incidence of venous as well as arterial thromboembolism in the infected individuals. Patients with evidence of thromboembolism are at higher risk of poor outcomes as well (Bilaloglu et al JAMA 2020). The underlying mechanism is thought to be due to increased platelet aggregation and activation (Manne et al Blood 2020) along with inflammatory activation of the coagulation cascade that can lead to a hypercoagulable state (McGonagle et al Lancet Rheumatology 2020). There is a suggestion that anticoagulation is associated with reduction in mortality in COVID-19 infections (Paranjpe et al Cardiology 2020). However, the role of antiplatelet therapy has not been very well described or studied. In this study we investigated the outcomes for patients who were on antiplatelet therapy or full dose anticoagulation at baseline who developed COVID-19 infections. Methods This is a retrospective electronic chart review of patients admitted to New York-Presbyterian Brooklyn Methodist Hospital (NYP BMH), a Weill Cornell Medicine-affiliated hospital in Brooklyn, NY. Patients who were diagnosed and hospitalized for COVID-19 between March to April 2020 were included. Clinical data was extracted manually from electronic medical record (EMR). Patients were divided into 3 cohorts, considered "high risk" due to chronic comorbidities which required therapeutic anticoagulation and/or antiplatelet therapy. The first cohort included patients on single or dual antiplatelet therapy (Aspirin, Clopidogrel, Ticagrelor, Prasugrel, Aspirin-Dipyridamole or dual antiplatelet therapy) prior to admission and continued on admission (AP only). The second cohort included patients on anticoagulation (therapeutic Coumadin, Apixaban, Rivaroxaban, Enoxaparin) without antiplatelet therapy prior to admission, and continued on equivalent anticoagulation inpatient (AC only). The third included patients who were on both antiplatelet therapy and therapeutic anticoagulation (AP + AC). Additionally, we collected data on baseline characteristics, demographics, and outcomes. The primary outcome of the study was inpatient mortality. Secondary outcomes were median length of stay, ICU admission, Intubation requirement, bleeding, transfusions of blood products, development of venous thromboembolism and myocardial infarction. Chi-squared analyses were performed to determine statistical significance. Results We analysed 684 hospitalized patients who were diagnosed with COVID-19. Ages ranged from 18 to 101 years old, 52% were male, and 48% were black, with a median age of 70. There were 146 patients in the AP group, 34 patients in the AC group, 24 patients in the AP + AC group, and 480 patients were on neither. Our data was significant for mortality of 82% in the AC group, 36% in the AP group, and 38% in the AP + AC group (p value <0.00001). 37% of AP patients required ICU admission, 44% of AC patients, and 46% for AP + AC patients. 31% of AP patients required intubation, 32% of AC patients, and 21% of AP + AC patients. 24% of AC patients required at least 1 unit packed red blood cell transfusion, and 25% of AP + AC patients (Table 1). Conclusion We determined our patients to be those at high risk of thrombosis at baseline due to their requirement of antiplatelets or anticoagulation prior to hospitalization for COVID-19 infection. Our study suggests that mortality is higher for these patients who already required anticoagulation prior to COVID infection. Significantly, we demonstrated that patients on both therapeutic anticoagulation and antiplatelet therapy had less mortality than patients on anticoagulation alone, suggesting that antiplatelets in addition to anticoagulation might be protective against mortality in COVID-19 infection. Additionally, patients on antiplatelets and anticoagulation had less development of respiratory failure requiring intubation than either alone. This study provides proof of concept for prospective clinical trials for assessing the role of combination of antiplatelet therapy and therapeutic anticoagulation in high risk patients. Disclosures No relevant conflicts of interest to declare.

Introduction: There is conflicting data on the association of blood type with COVID-19 infection. Recent studies have shown an association of blood type in acquisition of COVID-19 infection (Zhao et al., medRxiv 2020), but no association in terms of disease mortality (Latz, Ann Hematol 2020). Prior studies are limited due to lack of diversity. One of the largest studies conducted in China found blood type A conferred highest risk of acquiring COVID-19 infection (Zhao et al., medRxiv 2020). Similar results were found in which the odds of COVID-19 positive infection compared to negative test results were increased in blood group A and decreased in blood group O (Zietz et al., medRxiv 2020). There was no significant association between blood group and intubation or death. Neither of these studies addressed the association of blood groups with thromboembolism. This study aimed to evaluate the impact of blood types on outcomes of COVID-19 infection in a multiracial population. Methods: This is a retrospective electronic chart review of all patients admitted to New York-Presbyterian Brooklyn Methodist Hospital in Brooklyn, NY. All patients admitted from March 2020 to April 2020 who tested positive for SARS-CoV-2 nasopharyngeal swab were analyzed. Baseline patient characteristics and outcomes were entered manually by medical professionals via chart review using the electronic medical record (EMR). Baseline characteristics include blood group type, rhesus antigen status, age, gender, race, comorbid conditions, median initial and peak D-dimer. The primary endpoint was inpatient mortality. The secondary endpoints included thromboembolism (pulmonary embolism, deep venous thrombosis, arterial thrombosis), myocardial infarction, bleeding event, length of stay, intensive care unit admission, and intubation. Chi-square test for categorical variables was used to calculate statistical significance defined as p value ≤ .05 when comparing ABO blood group and rhesus antigen with mortality and development of thromboembolism. Results: Our study consisted of 249 patients that were COVID-19 positive with a documented blood group. Our population consisted of 51% of patients that identified as black, 35.7% that identified as white, and 17.7% that identified as Hispanic. Blood type B had the highest rate of patients that identified as black at 58.1% and blood type O had the highest rate that identified as Hispanic at 23.6%. When comparing blood groups A, AB, B and O to the rate of mortality the result was 46%, 44.4%, 41.9% and 50.9% respectively which was found to be not statistically significant (p=0.759). Rh positive patients had a 47.2% mortality rate while Rh negative patients had a 46.9% mortality rate however this was also found to be not statistically significant (p=0.954). Next, we compared development of thromboembolism during hospital stay in the A, AB, B, and O blood type groups and the rate was 8%, 11.1%, 9.3%, and 10.9% respectively with the results not being statistically significant when accounted for blood type (p=0.991). Rate of development of thromboembolism in Rh positive and negative patients was 9.3% and 9.4% respectively which was found to not be statistically significant as well (p=0.998). When looking at comorbidities, 70.2% of our patient population had hypertension and the second prevalent comorbidity was diabetes at 38.2% (Table 1). Discussion: In a diverse population, no association between ABO blood group, Rh status, and mortality was found which is similar to the conclusion found in prior studies done by Zhao et al. and Latz et al. in which the majority of the population was either Caucasian or Asian. Additionally, there is no association found between ABO blood group, Rh status and development of thromboembolism. Our patient population consisted mostly of minority groups. Prior studies have shown that blood type A has the highest risk of positive SARS-CoV-2 test whereas type O has the lowest risk of positive SARS-CoV-2 test. Our study further supplements this discovery by the conclusion that while blood type A conferred highest risk of acquiring COVID-19 infection, blood type had no significant association with mortality. Investigation on a larger scale is necessary to address the susceptibility of ABO blood group and COVID-19 infection severity in a multiracial population to address racial disparities. Disclosures No relevant conflicts of interest to declare.

Introduction COVID-19 is an ongoing pandemic that has impacted millions of individuals throughout the world. The spectrum of clinical features of COVID-19 can vary from asymptomatic infection to severe multiorgan failure leading to death. There is no single biomarker available that can predict the trajectory of the infected patient. Few clinical reports suggest a correlation between the severity of COVID-19 and elevation of certain hematological and inflammatory markers. We used a novel COVID-19 Prognostic Score (CPS) which included lymphocyte count, elevated lactate dehydrogenase (LDH), C-reactive protein (CRP) and ferritin levels to predict the outcomes of COVID-19 patients. Methods We performed a retrospective chart review of COVID-19 patients admitted to New York Presbyterian Brooklyn Methodist Hospital between March and April of 2020. Clinical data was extracted manually from electronic medical records. Patients were divided into 2 cohorts. The first cohort included a combination of low lymphocyte count, elevated LDH, CRP and ferritin. The second cohort included normal lymphocyte count, low LDH, CRP and ferritin. Low lymphocyte count was defined as < 20% of white blood cell count (WBC), high LDH as ≥ 300 U/L, high CRP as ≥50mg/L and high ferritin as ≥600 ng/mL. Statistical analysis was performed by computing odds ratio using a p-value of < 0.05 as statistically significant. Results We analyzed 683 hospitalized patients who were diagnosed with COVID-19 confirmed via viral PCR resting. The median age was 66.5 years, males were 52.2% and blacks were 47.2%. 16.3% had coronary artery disease (CAD), 38.6% had Diabetes Mellitus (DM), 63.1% had hypertension and 21.6% had pulmonary disease. 181 patients (26.5%) were intubated and transferred to ICU. The median LDH was 438 U/L, the median CRP was 107 mg/L and the median ferritin was 687 ng/mL. 4.6% of patients developed a thromboembolic event. The overall inpatient mortality rate was 32.1%. There were 178 patients in the CPS-High cohort while there were 41 patients who qualified for the CPS-Low cohort. The median age of CPS-High was 65 years and the median age of CPS-Low was 58 years. The percentage of CAD, DM, hypertension, pulmonary disease in CPS-High and CPS-Low were 11.8%, 39.3%, 57.9%, 10.7% and 19.5%, 17.1%, 43.9%, 12.2% respectively. In the CPS-High cohort the overall inpatient mortality was 42% while the inpatient mortality rate for CPS-Low was 7.3%. In univariate analysis, patients who had CPS low had significantly reduced inpatient mortality (Odds ratio 0.108, 95% CI 0.03-0.36, p-value = 0.0003). Discussion Our study suggests that a combination of hematological characteristics and inflammatory markers can be used to assess the severity of illness with COVID-19. This study shows that there is a likelihood of 6-times higher mortality with COVID-19 if all the clinical characteristics are abnormal including lymphocyte count, LDH, CRP, and ferritin. This simple clinical prognostic score can be used at the time of hospital admission to efficiently triage patients, which may likely improve the outcomes of these patients. This prognostic tool needs to be validated in a larger dataset or prospective clinical study. Disclosures No relevant conflicts of interest to declare.