Written by Bo Stubblefield
Patients hospitalized with COVID-19 are at increased risk for venous thromboembolism (VTE). The risk is largest in those patients hospitalized in the intensive care unit (ICU).
Why does this matter?
A profound coagulopathy associated with COVID-19 was described shortly after the onset of the pandemic. Patients exhibit a hypercoagulable state characterized by thromboinflammation or a COVID-19-associated coagulopathy (CAC).1,2 As expected, this state is associated an increased risk of VTE with incidence rates ranging from 10-60%.3-5
CAC is where it’s at, you betta believe it jack!
This was a single-site, retrospective cohort study of 198 adult patients admitted to the hospital ward or ICU with either confirmed COVID-19 (87%) or highly suspected COVID-19 by symptoms + imaging (13%). The primary outcome was a confirmed diagnosis of VTE (DVT or PE) and this included catheter-related thromboses.
The overall, observed rate of VTE in hospitalized patients was high (20%), and there was a large disparity in rate of VTE between patients admitted to the ward and those admitted to the ICU. Of important note, the study conducted routine lower extremity ultrasounds on a portion of the admitted patients, and they report overall VTE rates in addition to rates from only those patients exhibiting signs/symptoms of VTE…and this is the key. The cumulative incidence of symptomatic VTE in ward patients at 7, 14, and 21 days was 5.8%, 9.2%, and 9.2%, respectively; incidence in the ICU was 15%, 28%, and 34%, respectively. Here is a figure showing the cumulative incidence of symptomatic VTE in ICU v. ward patients over time:
Unsurprisingly, VTE was significantly associated with a 2.4x higher risk of death (95% CI 1.02-5.5). Whether this high incidence of VTE justifies higher or therapeutic doses of anticoagulation at an acceptable bleeding risk to improve outcomes of severe COVID-19 is yet to be seen, but there are >20 ongoing, international clinical trials.6
Incidence of venous thromboembolism in hospitalized patients with COVID-19. J Thromb Haemost. 2020;18(8):1995-2002. doi:10.1111/jth.14888
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Reviewed by Clay Smith
Connors JM, Levy JH. Thromboinflammation and the hypercoagulability of COVID-19. Journal of thrombosis and haemostasis : JTH 2020;18:1559-61.
Iba T, Levy JH, Connors JM, Warkentin TE, Thachil J, Levi M. The unique characteristics of COVID-19 coagulopathy. Crit Care 2020;24:360.
Klok FA, Kruip M, van der Meer NJM, et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thrombosis research 2020;191:145-7.
Wichmann D, Sperhake JP, Lutgehetmann M, et al. Autopsy Findings and Venous Thromboembolism in Patients With COVID-19: A Prospective Cohort Study. Ann Intern Med 2020;173:268-77.
Moll M, Zon RL, Sylvester KW, et al. VTE in ICU Patients With COVID-19. Chest 2020.
Tritschler T, Mathieu ME, Skeith L, et al. Anticoagulant interventions in hospitalized patients with COVID-19: A scoping review of randomized controlled trials and call for international collaboration. Journal of thrombosis and haemostasis : JTH 2020.