Understanding the COVID‐19 coagulopathy spectrum

Thachil, Jecko; Agarwal, Sushant

doi:10.1111/anae.15141

Cited by 45 publications

(57 citation statements)

References 35 publications

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“…Interestingly Oxley et al noted an increased occurrence of younger SARS CoV2 virus-infected patients with no significant traditional risk factors for AIS, presenting with large vessel occlusion (6). Putative mechanisms suggested as inducing AIS in association with SARS CoV2 have included systemic inflammation, inflammatory cytokine storm, hyper-coagulability, and imbalances in the classical and alternative Renin Angiotensin System (RAS) in relation to SARS-CoV-2 spike glycoprotein-ACE2 binding related molecular mechanisms (3,(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)). The RAS system comprises both a plasmabased RAS regulating cardiovascular system and tissue-based RAS regulating long term changes via a complex hormonal system, endocrine, paracrine, and autocrine in action.…”

Section: Introductionmentioning

confidence: 99%

Acute Ischemic Stroke in COVID-19: A Case-Based Systematic Review

2020

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Corona virus disease (COVID-19), caused by the severe acute respiratory syndrome coronavirus2 (SARS-CoV-2) is recognized as a global pandemic by WHO 2020 with 5,934 936 infections, 367,166 deaths and affecting over 200 countries as of 30th May 2020. Acute Ischemic Stroke (AIS) in brain is also emerging as an important neurovascular/neurological complication of COVID-19, associated with extreme immune responses leading to dysregulated coagulation system and generalized thrombo-embolic status and increased risk of AIS especially among usually less vulnerable younger adults in this cohort. Thus, in early June 2020, we aimed to review the clinical data on all published cases of COVID-19 and concomitant AIS, with a view to understanding the pertinent clinical, laboratory and imaging features. The neutrophil-lymphocyte ratio (NLR) at time of hospital admission for COVID infection correlates positively with the duration of time before onset of clinical features of AIS. Higher NLR, C-Reactive protein, serum ferritin, D-dimer and fibrinogen levels are associated with poor prognosis of AIS in COVID-19 with 75% of patients dying or being severely disabled at present. Currently it is too early to comment on the long-term outcomes for survivors.

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Section: Introductionmentioning

confidence: 99%

Acute Ischemic Stroke in COVID-19: A Case-Based Systematic Review

2020

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“…A decline in the production of fresh naïve T cells, a less expansive T cell receptor (TCR) repertoire, T cell metabolic dysfunction, and weaker activation of T cells also contribute to immune vulnerability of the aged to COVID-19. An exploration of the link between the immune system and coagulopathy in the aged, which makes them a vulnerable population, identified that one in two fatal cases of COVID-19 experience a CS, among whom 82% are over the age of 60 [43]. Inflammaging is a major driver for this increased CS occurring in aged individuals, exacerbated by obesity, poor diet and oral health, microbial dysbiosis, and sedentary lifestyle [43].…”

Section: Coagulopathy and Covid-19incidence And Vulnerable Populationsmentioning

confidence: 99%

“…An exploration of the link between the immune system and coagulopathy in the aged, which makes them a vulnerable population, identified that one in two fatal cases of COVID-19 experience a CS, among whom 82% are over the age of 60 [43]. Inflammaging is a major driver for this increased CS occurring in aged individuals, exacerbated by obesity, poor diet and oral health, microbial dysbiosis, and sedentary lifestyle [43]. Age-related correlation of higher basal circulating levels of pro-inflammatory cytokines, including IL-6, TNF-α, IL-1α, and CRP, is a reported phenomenon.…”

Section: Coagulopathy and Covid-19incidence And Vulnerable Populationsmentioning

confidence: 99%

“…This process is further aggravated by decreased activity of sirtuin 2 (SIRT2) in the aged, as SIRT2 directly controls NLRP3 [41]. This cytokine storm disrupts the feedback control mechanisms of thrombin generation by antithrombin III, a tissue factor pathway inhibitor, and the protein C system, which predisposes individuals to the development of microthrombosis and DIC [43].…”

Section: Coagulopathy and Covid-19incidence And Vulnerable Populationsmentioning

confidence: 99%

“…It also explains why children rarely experience severe illness due to COVID-19, as thrombotic complications in the paediatric age group are rare in the absence of an underlying cancer or a central venous access device. While pregnant women should be expected to have high vulnerability to coagulopathy, they have, in fact, been found to have only milder illness because of immune suppression during the gestational period to avoid foetal rejection, and thus, immunothrombosis does not come into play [43].…”

Section: Coagulopathy and Covid-19incidence And Vulnerable Populationsmentioning

confidence: 99%

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Coagulopathy associated with COVID-19 – Perspectives & Preventive strategies using a biological response modifier Glucan

et al. 2020

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Direct endothelial injury by viruses and dysregulation of clotting mechanisms due to cytokine storm are the major precipitating factors of mortality in COVID-19; both are attributed to a fundamental dysregulation of the immune system. While immune dysregulation can be attributed to several factors, the risk of associated thrombogenic disruption varies across individuals. This variation depends on several factors, such as comorbidities, including diabetes, hypertension, and cardiovascular diseases. When considering ethnic variations, the vulnerability of Caucasians, African Americans and Hispanics needs to be addressed before arriving at strategies to handle thromboembolic complications, which have been identified in recent reports as the leading causes of mortality in COVID-19. Although evaluation of D-dimer and prothrombin during admission is considered to predict prognosis and mortality, there are no preventive or prophylactic strategies before hospital admission. Herein, we present our perspectives on the effect of regular supplementation with the biological response modifier beta glucan based on its relevance to immune modulation. This effect is of paramount importance in decreasing the development of severe COVID-19 and reducing mortality against the background of coagulopathy, especially in vulnerable populations.

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Emergency biventricular assist device implantation in a patient with suspected COVID‐19 disease

Nwaejike

Strang

García

et al. 2020

Anaesthesia Reports

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Summary Severe coronavirus disease 2019 (COVID‐19) is a multisystem inflammatory disorder and knowledge and experience with severe acute respiratory failure in infected patients has grown considerably since reports of the first few cases. Little is known about the effect of the severe acute respiratory syndrome‐coronavirus‐2 (SARS‐CoV‐2) virus on the heart, and it has been suggested that fulminant cardiac failure, with or without respiratory failure, may occur several weeks following infection. A young man presented after a recent viral illness. He was in severe cardiogenic shock and was implanted with an emergency biventricular assist device, which also incorporated an extracorporeal membrane oxygenator. He stabilised soon after and, despite an intracerebral haemorrhage which resolved and bleeding into the trachea following percutaneous tracheostomy, he survived to explant and was successfully stepped down to a rehabilitation unit on postoperative day 50. He tested positive for SARS‐CoV‐2 antibodies when the test became available on postoperative day 33. We envisage there will be many more such presentations of acute COVID‐19‐associated cardiogenic shock and we recommend clinicians consider this diagnosis when presented with an acutely unwell patient with an unclear diagnosis following a viral illness. These patients should be discussed as early as possible with a transplant/mechanical circulatory support team.

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Understanding the COVID‐19 coagulopathy spectrum

Cited by 45 publications

References 35 publications

Acute Ischemic Stroke in COVID-19: A Case-Based Systematic Review

Acute Ischemic Stroke in COVID-19: A Case-Based Systematic Review

Coagulopathy associated with COVID-19 – Perspectives & Preventive strategies using a biological response modifier Glucan

Emergency biventricular assist device implantation in a patient with suspected COVID‐19 disease

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