Labile PT-INR in a Covid-19 Patient Under Long-term Vitamin K Antagonist Therapy: a Case Report

Abstract

The COronaVIrus Disease-19 (COVID-19) has been associated with thromboembolic complications, but evidence on its impact on hemorrhagic risk are still scarce. We describe a case of COVID-19 with hemorrhagic complication in the post-acute phase of the disease. The patient was a 93-year-old woman admitted to a post-acute care unit for COVID-19 patients in northern Italy. The patient’s medical history included moderate cognitive impairment, atrial fibrillation under oral anticoagulation (warfarin 2.5 mg and 3.75 mg on alternate days, showing stable PT-INR values since October 2018), and arterial hypertension. The patient was affected by COVID-19, treated with supportive therapy. In the post-acute phase of the disease, the patient presented with melena and showed a marked elevation of PT-INR of 25.1. She was treated with venous infusion of three-factor prothrombin complex concentrate and vitamin K until PT-INR reduction. After 5 days, blood analyses revealed normal hemoglobin, PT-INR 2.15, and a slight alteration of liver function. This case supports a strong impact of the infection on the coagulative pattern not only pro-thrombotically but also by increasing hemorrhagic risk. Special attention should therefore be paid to COVID-19 patients under anticoagulation with vitamin K antagonist and a shift to heparin treatment until illness resolution may be a safe option in these individuals.

Warfarin or Non-Vitamin K Antagonist Oral Anticoagulants: Navigating the Choice of Oral Anticoagulant Drugs in the COVID-19 Pandemic Era

“…[ 19 ] Moreover, a single case report showed that even in the postacute phase of COVID-19, patients on warfarin therapy may have liable INR. [ 20 ] These findings add to the complexity of interpreting INR results in patients on warfarin complicated by COVID-19.…”

Evolving Paradigm of Prothrombin Time Diagnostics with Its Growing Clinical Relevance towards Cardio-Compromised and COVID-19 Affected Population

“…Tang et al also reported longer PT values in non-surviving patients with COVID-19 pneumonia in addition to higher D-dimer levels with fibrinogen degradation products (FDP) [ 8 ]. Additionally, a study presented by Trevisan et al enunciated the significance of prolonged PT in predicting the level of hemorrhagic risk in critical COVID-affected cases [ 19 ]. A 93-year-old woman (already under OAT), in the post-acute phase of the disease, presented a marked elevation of PT-INR of 25.1, supporting a strong impact of the infection on the coagulative pattern and a state of critical coagulopathy [ 19 ].…”

“…Additionally, a study presented by Trevisan et al enunciated the significance of prolonged PT in predicting the level of hemorrhagic risk in critical COVID-affected cases [ 19 ]. A 93-year-old woman (already under OAT), in the post-acute phase of the disease, presented a marked elevation of PT-INR of 25.1, supporting a strong impact of the infection on the coagulative pattern and a state of critical coagulopathy [ 19 ]. This patient was provided an immediate venous infusion of three-factor prothrombin complex concentrate and vitamin K until PT-INR reduction started to happen.…”

“…Additionally, the large sector of the population affected by the recent pandemic coronavirus disease (COVID-19) is found to be experiencing immense thromboembolic and coagulopathic complications [ 7 , 35 ]. The pathophysiology of the COVID-associated coagulopathy is found to manifests a state of macro to microcirculatory embolism mediating towards coagulopathy (with prolonged PT), MODS, and associated fatalities [ 12 , 18 , 19 , 37 ]. Thus, there is a need for strict prophylactic measures along with rapid but sensitive coagulation assays such as PoC PT for efficient monitoring of coagulation processes.…”

“…Along with the respective scenario of CAC, the coagulation biomarkers such as PT and D-dimers were found to be a significant indicator of the level of criticality in the COVID-affected patients [ 18 ]. Prolonged PT has been found to be directly associated with critical CAC in addition to SIC and MODS [ 16 , 19 ]. Along with PT, prothrombin-associated markers such as prothrombin time activity % (PT-act%) and prothrombin fragment (PF) 1.2 marker were found to be strong indicators of the coagulopathic complications in patients [ 20 ].…”