COVID-19–Associated Coagulopathy and Inflammatory Response: What Do We Know Already and What Are the Knowledge Gaps?

Abstract

Patients with COVID-19 frequently experience a coagulopathy associated with a high incidence of thrombotic events leading to poor outcomes. Here, biomarkers of coagulation (such as D-dimer, fibrinogen, platelet count), inflammation (such as interleukin-6) and immunity (such as lymphocyte count) as well as clinical scoring systems (such as SOFA, ISTH DIC and SIC score) can be helpful in predicting clinical course, need for hospital resources (such as ICU beds, intubation and ventilator therapy, and ECMO) and patient’s outcome in patients with COVID-19. However, therapeutic options are actually limited to unspecific supportive therapy. Whether viscoelastic testing can provide additional value in predicting clinical course, need for hospital resources and patient’s outcome or in guiding anticoagulation in COVID-19 associated coagulopathy is still incompletely understood and currently under investigation (eg, in the ROHOCO study). This paper summarizes what we know already about COVID-19 associated coagulopathy and – perhaps even more importantly – characterizes important knowledge gaps.

Predictive Value of CAR for In-Hospital Mortality in Patients with COVID-19 Pneumonia: A Retrospective Cohort Study

“…In most cases, the COVID-19 is usually mild. However, the patients with moderate and severe COVID-19 illness can rapidly progress to acute respiratory failure and develop multiple organ failure leading to disseminated intravascular coagulopathy, septic shock, and event death ( 3 ). Hence, early identification of a prognostic biomarker is crucial to distinguish the patients in whom the risk of developing more severe forms of illness and to better manage the limited medical resources.…”

Pulmonary Thromboembolism in COVID-19

“…Since early in the coronavirus disease 2019 (COVID-19) pandemic, medical centers have reported elevated D -dimer levels and high rates of pulmonary thromboembolism in patients with COVID-19 ( 1 , 2 ). While the causes of mortality due to COVID-19 are multifactorial, respiratory failure from pneumonia and subsequent acute respiratory distress syndrome is a principal contributor ( 3 ).…”

COVID-19–associated Coagulopathy

“…Accordingly, the cell-based model of hemostasis and whole blood viscoelastic and platelet function tests are more appropriate to mirror the pathophysiology of COVID-19–associated coagulopathy. 3 , 4 …”

“…, the ROTEM Sigma in Hospitalized COVID-19 Patients [ROHOCO] Study, recruiting 500 patients in 16 hospitals and 11 countries; DRKS00023934). 3 Of note is that viscoelastic testing is reported to be superior to standard plasmatic coagulation tests such as activated partial thromboplastin time and prothrombin time in predicting thrombosis in COVID-19. 2 , 8 – 10 …”

“… 1 , 2 , 8 – 10 , 19 Notably, the systemic inflammatory response syndrome of acute infections, sepsis, disseminated intravascular coagulation, and COVID-19 are characterized by different viscoelastic and platelet function patterns. 3 , 18 We believe that differentiation and outcome management strategies can be improved by multimodal testing that includes the combination of viscoelastic, platelet function, and conventional biomarkers such as D-dimers. 9 , 10 , 20 In combination with big data, machine learning, and pattern recognition, this may offer in the near future opportunities to detect these important issues early and may allow for personalized therapy in these critically ill patients in terms of precision medicine.…”