Management of Thrombotic Complications in COVID-19: An Update

Abstract

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is now a global pandemic. This virus primarily affects the respiratory tract and causes lung injury characterized by acute respiratory distress syndrome. Although the pathophysiology of COVID-19 is not yet clear, the most widely accepted mechanism is systemic inflammation. A clinically significant effect of the inflammation is coagulopathy. As a result of this effect, patients are found to have a high risk of venous thromboembolism. Studies have reported a high incidence of thrombotic complications in critically ill patients with COVID-19. In this review, we discuss the most updated evidence on the pathophysiology, diagnosis, and treatment of the coagulopathy of COVID-19. Prophylactic anticoagulation is recommended for all in-patients with COVID-19. Those with a higher risk of developing thromboembolic events or who have already developed venous thromboembolism should be treated with therapeutic anticoagulation. We also discuss post-discharge prophylaxis for highrisk patients and some newly proposed treatments for the hypercoagulability that could improve the outcomes of the affected patients.

Hematological Abnormalities in COVID-19: A Narrative Review

“…The treatment with a full dose of anticoagulation may be beneficial for patients with sepsis-induced coagulopathy (SIC). 121 In a retrospective study by Tang et al, 122 the use of heparin was shown to reduce mortality in patients who met the SIC criteria or had a markedly increased D -dimer levels. In patients with a thromboembolic event or an increased suspicion for thromboembolic disease, therapeutic anticoagulation is recommended.…”

Clinical Characteristics, Diagnosis, and Treatment of Major Coronavirus Outbreaks

“…COVID-19 is a prothrombotic state leading to both microvascular and macrovascular thromboembolic events in pulmonary and extrapulmonary organs (136). Venous thromboembolism, particularly pulmonary embolism, is the most common coagulopathic manifestation in COVID patients (137). Several proposed mechanisms for thrombosis in COVID-19 patients include angiotensin-converting enzyme-2 receptor-mediated endothelial damage leading to cytokine storm, intussusceptive angiogenesis, and macrophage activation syndrome leading to activation of the coagulation cascade (136)(137)(138)(139).…”

“…Venous thromboembolism, particularly pulmonary embolism, is the most common coagulopathic manifestation in COVID patients (137). Several proposed mechanisms for thrombosis in COVID-19 patients include angiotensin-converting enzyme-2 receptor-mediated endothelial damage leading to cytokine storm, intussusceptive angiogenesis, and macrophage activation syndrome leading to activation of the coagulation cascade (136)(137)(138)(139). The incidence of thrombotic events in COVID patients is 7.7-49% in various retrospective and prospective studies (140)(141)(142)(143)(144).…”

Endothelial Cells in Emerging Viral Infections

“…Disseminated intravascular coagulation and thrombotic microvascular occlusion are complications of severe systemic inflammation and a sequela to most infections discussed in this article ( Table 1 ). Notably, COVID-19 has been strongly associated with thrombosis ( 85 ), more so than other coronaviruses and H1N1 ( 39 ). This is not entirely surprising, as severely ill SARS-CoV-2-infected patients have intra-endothelial viral inclusion bodies, endothelial apoptosis, and inflammation (endotheliitis) ( 2 – 4 ).…”