COVID-19 and coagulation: bleeding and thrombotic manifestations of SARS-CoV-2 infection

Abstract

Patients with coronavirus disease 2019 (COVID-19) have elevated D-dimer levels. Early reports describe high venous thromboembolism (VTE) and disseminated intravascular coagulation (DIC) rates, but data are limited. This multicenter, retrospective study described the rate and severity of hemostatic and thrombotic complications of 400 hospital-admitted COVID-19 patients (144 critically ill) primarily receiving standard-dose prophylactic anticoagulation. Coagulation and inflammatory parameters were compared between patients with and without coagulation-associated complications. Multivariable logistic models examined the utility of these markers in predicting coagulation-associated complications, critical illness, and death. The radiographically-confirmed VTE rate was 4.8% (95% CI, 2.9-7.3%) and the overall thrombotic complication rate was 9.5% (6.8-12.8%). The overall and major bleeding rates were 4.8% (2.9-7.3%) and 2.3% (1.0-4.2%). In the critically ill, radiographically-confirmed VTE and major bleeding rates were 7.6% (3.9-13.3%) and 5.6% (2.4-10.7%). Elevated D-dimer at initial presentation was predictive of coagulation-associated complications during hospitalization [D-dimer >2,500 ng/mL, adjusted OR for thrombosis, 6.79 (2.39-19.30), adjusted OR for bleeding, 3.56 (1.01-12.66)], critical illness, and death. Additional markers at initial presentation predictive of thrombosis during hospitalization included platelet count >450×109/L [adjusted OR, 3.56 (1.27-9.97)], C-reactive protein (CRP) >100 mg/L [adjusted OR, 2.71 (1.26-5.86)], and erythrocyte sedimentation rate >40 mm/h [adjusted OR, 2.64 (1.07-6.51)]. ESR, CRP, fibrinogen, ferritin, and procalcitonin were higher in patients with thrombotic complications than those without. DIC, clinically-relevant thrombocytopenia, and reduced fibrinogen were rare and were associated with significant bleeding manifestations. Given the observed bleeding rates, randomized trials are needed to determine any potential benefit of intensified anticoagulant prophylaxis in COVID-19 patients.

Anticoagulation practice patterns in COVID‐19: A global survey

“…In a study of 150 French ICU patients, only 4 (2.7%) were reported to have bleeding complications, which included intracerebral hemorrhage and extracorporeal circulation cannula hematoma 19 . In the Boston area study, the overall rate of hemorrhage was 4.8%, which was similar to the overall rate of VTE reported 7 . In a recent study from the United Kingdom of patients admitted to a critical care unit, 11% suffered from a major bleed 17 .…”

“…Laboratory monitoring of hospitalized patients with COVID‐19 provides a means to guide care but also may provide predictive and prognostic information. One of the most commonly reported abnormal laboratory findings in patients with COVID‐19 is highly elevated D‐dimer levels 3‐7 . Others include elevated fibrinogen, normal or mildly decreased platelets, and normal or near‐normal aPTT and PT 58‐60 .…”

“…The overall incidence of venous thromboembolism (VTE) in patients with COVID‐19 is unknown. Studies evaluating incidence have been limited to case reports and case series, with estimates ranging from as low as 1% in the general wards to as high as 69% in intensive care units using screening ultrasound 3‐7,10‐27 . The limited data present a challenge for health care providers in prevention, diagnosis, and management of VTE in patients with COVID‐19.…”

Serum iron, prealbumin, D-dimer and prothrombin time are indicators of the diagnosis, severity and outcome of Salmonella enterica serovar Enteritidis infection

“…S. Typhi infection has been reported to activate the coagulation system, increase serum brinogen and D-dimer and prolong PT and APTT [18]. COVID-19 infection may lead to disturbances in the procoagulation, anticoagulation and brinolytic systems [30][31][32][33][34]; a high concentration of D-dimer and prolonged PT are associated with severe COVID-19 and a poor prognosis [24]. In this study, we found that RBCs were detected in the stool of 2 patients, PT was prolonged and D-dimer was elevated in all 6 patients, while APTTs and brinogen levels were normal.…”

High Incidence of Venous Thromboembolism in Patients with Coronavirus Disease 2019: A Call for Improved Awareness and Prevention

“…Thirteen studies used lower-extremity venous ultrasound scanning or CTPA to con rm the diagnosis of VTE only in the presence of a clinical suspicion, and we prede ned this study group as the "suspected screening group." [1,[3][4][5][6][8][9][10][11][12][13][14][15] Seven studies routinely screened VTE in every patient using lower-extremity venous ultrasound scanning, and this study group was prede ned as the "routine screening group." [16][17][18][19][20][21][22] Our primary aim was to determine the incidence of VTE in COVID-19 patients in two prede ned cohort subtypes:…”