D-Dimer-Driven Anticoagulation Reduces Mortality in Intubated COVID-19 Patients: A Cohort Study With a Propensity-Matched Analysis

Abstract

Objective: Examine the possible beneficial effects of early, D-dimer driven anticoagulation in preventing thrombotic complications and improving the overall outcomes of COVID-19 intubated patients.Methods: To address COVID-19 hypercoagulability, we developed a clinical protocol to escalate anticoagulation based on serum D-dimer levels. We retrospectively reviewed all our first 240 intubated patients with COVID-19. Of the 240, 195 were stratified into patients treated based on this protocol (ON-protocol, n = 91) and the control group, patients who received standard thromboprophylaxis (OFF-protocol, n = 104). All patients were admitted to the Stony Brook University Hospital intensive care units (ICUs) between February 7th, 2020 and May 17, 2020 and were otherwise treated in the same manner for all aspects of COVID-19 disease.Results: We found that the overall mortality was significantly lower ON-protocol compared to OFF-protocol (27.47 vs. 58.66%, P < 0.001). Average maximum D-dimer levels were significantly lower in the ON-protocol group (7,553 vs. 12,343 ng/mL), as was serum creatinine (2.2 vs. 2.8 mg/dL). Patients with poorly controlled D-dimer levels had higher rates of kidney dysfunction and mortality. Transfusion requirements and serious bleeding events were similar between groups. To address any possible between-group differences, we performed a propensity-matched analysis of 124 of the subjects (62 matched pairs, ON-protocol and OFF-protocol), which showed similar findings (31 vs. 57% overall mortality in the ON-protocol and OFF-protocol group, respectively).Conclusions: D-dimer-driven anticoagulation appears to be safe in patients with COVID-19 infection and is associated with improved survival.What This Paper Adds: It has been shown that hypercoagulability in patients with severe COVID-19 infection leads to thromboembolic complications and organ dysfunction. Anticoagulation has been variably administered to these patients, but it is unknown whether routine or escalated thromboprophylaxis provides a survival benefit. Our data shows that escalated D-dimer driven anticoagulation is associated with improved organ function and overall survival in intubated COVID-19 ICU patients at our institution. Importantly, we found that timely escalation of this anticoagulation is critical in preventing organ dysfunction and mortality in patients with severe COVID-19 infection.

Prevention of venous thromboembolism and haemostasis monitoring in patients with COVID-19: Updated proposals (April 2021)

“…Retrospective studies have suggested that increasing the dose of prophylactic anticoagulation from a standard dose to an intermediate or therapeutic dose in severe patients may be beneficial [14] , [15] , [16] .…”

C Reactive Protein based early intervention for home quarantined COVID-19 patients to avoid complications and hospitalization

“…The pathology of COVID 19 has an inflammatory and a thrombotic component 2,3,4 . COVID-19 is characterized by distinct changes in hematological, biochemical and radiological findings.…”

“…2,3,4,5,6) with their consent. The group consisted of 25 patients in the age group of 19 years to 72 years with an average of 52 years.…”

Kidney implications of SARS-CoV2 infection in children

“…Given the preponderance of evidence of SARS-CoV2 causing microthrombi and coagulation cascade abnormalities, there is growing evidence that adults infected with SARS-CoV2 can have thrombotic microangiopathy (TMA)-related changes in the kidney [ 33 , 34 ]. A propensity score-matched cohort analysis found anti-coagulation directed therapy to lower d-dimer levels had both lower mortality and AKI rates compared to standard of care [ 35 ]. This may reflect the role of systemic microthrombi as an important driver in COVID-19 complications and mortality [ 35 ].…”