I'm going to be asking for heparin
immediately hoping that swift application will neutralize the virus
before it can get to the brain.
I'm going to be asking for heparin as a blood thinner because of this:
Common FDA-approved drug may effectively neutralize virus that causes COVID-19
You can't listen to me, I'm not medically trained.
Anticoagulation Again Shown to Improve Survival in COVID-19 Patients;-Mortality risk about 50% lower
Study Authors: Girish N. Nadkarni, Anuradha Lala, et al.
Target Audience and Goal Statement: Infectious disease specialists, hematologists, pathologists, intensivists, pulmonologists
The goal of this study was to examine the association of anticoagulation with in-hospital outcomes in patients with COVID-19.
Question Addressed:
- Did treatment with anticoagulation benefit hospitalized patients with COVID-19?
Study Synopsis and Perspective:
At the end of August, hospitalizations due to COVID-19 in New York dropped to 418 – a dramatic turnaround from more than 12,000 COVID-19-related hospitalizations across the five boroughs of New York City alone at the height of the pandemic. According to the tracking project Covid ActNow, less than 1% of New Yorkers recently tested positive for SARS-CoV-2, down from a high of more than 40%.
Action Points
- Both prophylactic and therapeutic doses of anticoagulation were associated with reduced risks of mortality and intubation in hospitalized patients with COVID-19, according to a retrospective observational study from New York City.
- Note that this study has limitations due to its retrospective nature, and prospective studies on different anticoagulation strategies are needed.
Early in the COVID-19 pandemic, Anuradha Lala, MD, of the Icahn School of Medicine at Mount Sinai in New York City, and colleagues found an in-hospital survival advantage with therapeutic-dose anticoagulation among mechanically ventilated patients and with longer duration of anticoagulation.
However, a subsequent study suggested an elevated mortality risk with preemptive therapeutic-dose anticoagulation in COVID-19 patients.
Thus, there remained questions about this approach, such as the size of the possible benefit and what dose would be appropriate.
In a retrospective observational study from New York City's pandemic peak, Lala and team found that anticoagulation was associated with lower risk of death or intubation in patients hospitalized with COVID-19.
In-hospital mortality risk was a relative 50% lower with standard prophylactic dosing and 47% lower with higher therapeutic dosing after adjustment for other factors, both statistically significant when compared with COVID-19 patients in Mount Sinai hospitals not given an anticoagulant (mortality rates of 21.6%, 28.6%, and 25.6%, respectively), they reported in the Journal of the American College of Cardiology.
Lala and team analyzed the electronic health records of 4,389 adults (median age 65 years, 44% women, 26% Black, 27% Hispanic/Latino) with laboratory-confirmed SARS-CoV-2 infection admitted from March 1 to April 30 at the five New York City hospitals in the Mount Sinai system.
They adopted a conservative approach, wherein patients receiving <48 hours of anticoagulation were considered as fitting in the control group. In total, 900 patients (20.5%) received a therapeutic dose of anticoagulation, 1,959 patients (44.6%) received a prophylactic dose, and 1,530 (34.5%) did not receive anticoagulation.
The primary outcome was in-hospital mortality. Intubation and major bleeding served as secondary outcomes.
Compared with no anticoagulation, therapeutic and prophylactic doses were associated with lower in-hospital mortality (adjusted hazard ratio [aHR] 0.53, 95% CI 0.45-0.62, and aHR 0.50, 95% CI 0.45-0.57, respectively).
Intubation was less likely for anticoagulant-treated COVID-19 patients as well (adjusted HR 0.69 with prophylactic dosing, 95% CI 0.51-0.94, and aHR 0.72 with therapeutic dosing, 95% CI 0.58-0.89).
International Classification of Diseases-10 codes or receipt of ≥2 packed red blood cell transfusions within 48 hours were used to define major bleeding. Major bleeding events adjudicated by clinician chart review turned up a "low" rate of 1.7% (33 of 1,959) on prophylactic anticoagulation and 3% (27 of 900) on therapeutic anticoagulation compared with 1.9% (29 of 1,530) on no anticoagulant during hospitalization.
Overall, 24.4% of patients died during the study period, 65.9% were discharged alive, and 9.7% were still hospitalized by the dataset freeze date, the researchers noted.
Lala and colleagues also evaluated the first 26 autopsies on COVID-19 patients in the health system, which turned up thromboembolism in 11 (42%), while it had been suspected pre-mortem in only one.
The researchers acknowledged that, given the observational study design, there might have been confounders leading to differences in the outcomes for the treatment groups. Other study limitations included residual bias, limited generalizability of the autopsy data, and lack of analysis of novel antiviral treatments.
Source Reference: Journal of the American College of Cardiology 2020; DOI: 10.1016/j.jacc.2020.08.041
Study Highlights and Explanation of Findings:
Anticoagulation at prophylactic or therapeutic doses for patients hospitalized with COVID-19 was associated with lower risk of mortality or intubation, according to a retrospective observational study from New York City.
"This report is much more in-depth than our previous brief report and includes many more patients, longer follow-up, and rigorous methodology. Clearly, anticoagulation is associated with improved outcomes and bleeding rates appear to be low," said Lala in a press release. "As a clinician who has treated COVID-19 patients on the front lines, I recognize the importance of having answers as to what the best treatment for these patients entails, and these results will inform the design of clinical trials to ultimately give concrete information."
Nevertheless, more than a third of the COVID-19 patients in this study did not receive anticoagulation. These patients might have been treated earlier in the pandemic when practices were changing, said Lala, who pointed to the increasing observational data supporting prophylactic anticoagulation over time. But the predominant factor appeared to be less severe illness, she said.
Even so, there's plenty of data from prior randomized trials supporting pharmacologic thrombotic prophylaxis that makes it the standard of care in-hospital, regardless of COVID-19, said Behnood Bikdeli, MD, of Brigham and Women's Hospital and Harvard in Boston, who has been involved with COVID-related anticoagulation consensus recommendations and clinical trials.
"Since this study has been completed, thank God New York is not under grips of COVID and we hope that it stays that way. But if I were to consider how to treat a patient if they came to my doorstep now, I would be inclined to use anticoagulation. Nonetheless, I think the dose and the agent need to be confirmed with clinical trials," Lala agreed.
The current study has better explanation of methodology and more confirmatory analyses that make the results more believable than the previous study from the organization, but trials like INSPIRATION and the NIH's ACTIV will be the ones to really provide answers, Bikdeli said.
"The question they are trying to answer is perhaps one of the top three or four important questions we face as clinicians dealing with COVID-19," he told MedPage Today.
"The study has severe limitations due to its retrospective nature," cautioned Stephan Moll, MD, of the University of North Carolina at Chapel Hill Hemophilia and Thrombosis Center.
"However, NIH prospective studies on inpatient and outpatient [prophylaxis] comparing different anticoagulation management strategies are planned and hopefully starting soon so that we can get beyond all these retrospective studies and data of the last few months, which all have ascertainment bias," he told MedPage Today.
Primary Source
Journal of the American College of Cardiology
Secondary Source
MedPage Today
Source Reference: Phend C "Blood Thinners Again Linked to COVID-19 Survival in Hospital" 2020.
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