Prognostic Value of Venous Thromboembolism Risk Assessment Models in Patients with Severe COVID-19

Abstract

Introduction Severe novel corona virus disease 2019 (COVID-19) causes dysregulation of the coagulation system with arterial and venous thromboembolism (VTE). We hypothesize that validated VTE risk scores would have prognostic ability in this population. Methods Retrospective observational cohort with severe COVID-19 performed in NorthShore University Health System. Patients were >18 years of age and met criteria for inpatient or intensive care unit (ICU) care. The International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) and Caprini scores were calculated and patients were stratified. Results This study includes 184 patients, mostly men (63.6%), Caucasian (54.3%), 63 years old (interquartile range [IQR]: 24–101), and 57.1% of them required ICU care. Twenty-seven (14.7%) thrombotic events occurred: 12 (6.5%) cases of disseminated intravascular coagulation (DIC), 9 (4.9%) of pulmonary embolism, 5 (2.7%) of deep vein thrombosis, and 1 (0.5%) stroke. Among them, 86 patients (46.7%) died, 95 (51.6%) were discharged, and 3 (1.6%) were still hospitalized. “Moderate risk for VTE” and “High risk for VTE” by IMPROVE score had significant mortality association: (hazard ratio [HR]: 5.68; 95% confidence interval [CI]: 2.93–11.03; p < 0.001) and (HR = 6.22; 95% CI: 3.04–12.71; p < 0.001), respectively, with 87% sensitivity and 63% specificity (area under the curve [AUC] = 0.752, p < 0.001). “High Risk for VTE” by Caprini score had significant mortality association (HR = 17.6; 95% CI: 5.56–55.96; p < 0.001) with 96% sensitivity and 55% specificity (AUC = 0.843, p < 0.001). Both scores were associated with thrombotic events when classified as “High risk for VTE” by IMPROVE (HR = 6.50; 95% CI: 2.72–15.53; p < 0.001) and Caprini scores (HR = 11.507; 95% CI: 2.697–49.104; p = 0.001). Conclusion The IMPROVE and Caprini risk scores were independent predictors of mortality and thrombotic events in severe COVID-19. With larger validation, this can be useful prognostic information.

Cumulative Evidence for the Association of Thrombosis and the Prognosis of COVID-19: Systematic Review and Meta-Analysis

“…Table 1 shows the characteristics of the 25 included studies. Among the included studies, 6 studies ( 24 , 26 , 37 – 40 ) were cross-sectional studies, and 19 studies ( 7 , 25 , 27 , 28 , 41 – 55 ) were cohort studies. The association between thrombosis and COVID-19-related mortality was the primary outcome of interest in 19 studies, and the association between thrombosis and COVID-19-related critical status was the primary outcome in 10 studies.…”

“…Five studies ( 25 , 38 , 42 , 51 , 55 ) were conducted in the United States, 5 studies ( 24 , 26 , 39 , 46 , 54 ) were conducted in Asia, 14 studies ( 7 , 27 , 28 , 37 , 40 , 41 , 43 , 44 , 47 – 50 , 52 , 53 ) were conducted in Europe, and one study ( 45 ) was conducted in Brazil. All the included studies included both adult men and women.…”

“…Among the included studies, 13 studies ( 25 – 27 , 39 , 42 , 45 , 46 , 48 – 50 , 52 , 53 , 55 ) adjusted for age, 7 studies ( 27 , 39 , 48 , 49 , 52 , 53 , 55 ) adjusted for sex, one study ( 42 ) adjusted for BMI, 8 studies ( 26 , 39 , 47 , 49 , 50 , 52 , 53 , 55 ) adjusted for diabetes mellitus, and 7 studies ( 39 , 43 , 46 , 47 , 49 , 52 , 55 ) adjusted for 8 or more confounding factors.…”

“…Among the 25 selected studies, 19 studies revealed the association between thrombosis and COVID-19-related mortality, and 10 studies investigated the association between thrombosis and COVID-19-related critical status. Among the included studies, 5 studies ( 26 , 43 , 47 , 48 , 51 ) found a non-significant association between thrombosis and COVID-19-related mortality, while the other 14 studies ( 24 , 25 , 27 , 28 , 39 , 40 , 42 , 45 , 46 , 49 , 50 , 52 , 53 , 55 ) revealed that thrombosis would increase the risk of mortality from COVID-19. All 19 studies reported risks as ORs, ranging from 0.79 to 40.27.…”

Good practice statements for antithrombotic therapy in the management of COVID‐19: Guidance from the SSC of the ISTH

“…Studies suggest that patients with classic cardiovascular risk factors or renal comorbidities, ICU stay, or an IMPROVE VTE risk score of 4 or more or a score of 2 or 3 plus an elevated Dd (>2X ULN), are associated with an increased risk of thrombotic events and mortality in the post‐discharge period 88,89 . The IMPROVE VTE risk model with or without elevated Dd and the IMPROVE‐DD VTE risk model that incorporates elevated Dd (>2X ULN) have both been externally validated in multiple studies of hospitalized COVID‐19 populations to identify a high‐risk hospitalized COVID‐19 population for thrombosis and death that would likely benefit from extended thromboprophylaxis 90–92 …”