Thromboembolic Events Common In COVID-19 Patients In ICU Despite Prophylaxis

Despite routine thromboprophylaxis, major arterial and venous thromboembolic disease as well as other major adverse cardiovascular events are common in patients with COVID-19, according to an observational cohort study.

The morbidity and mortality associated with COVID-19 are usually attributed to acute respiratory distress syndrome and end-organ failure, Dr. Gregory Piazza of Brigham and Women's Hospital, in Boston, and colleagues note in the Journal of the American College of Cardiology. But cardiovascular complications also cause disability and death in these patients, they say.

To gauge the latter's impact, the team examined data on more than 1,100 patients in their health network. Of these, 170 were in the intensive-care unit (ICU), 229 were hospitalized but not in intensive care, and the remaining 715 were outpatients.

Prophylactic anticoagulation was prescribed for 89.4% of the ICU patients and 84.7% of the other hospitalized patients.

Cardiovascular risk factors were common in all groups with 35.8% having hypertension, 28.6% hyperlipidemia and 18.0% diabetes.

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At 30 days after diagnosis, 35.3% of the ICU patients and 2.6% of the other hospitalized patients had experienced major arterial or venous thromboembolism, and 45.9% and 6.1%, respectively, had major cardiovascular adverse events.

Symptomatic venous thromboembolism was seen in 27.0% of ICU patients and 2.2% of the other hospitalized patients. No such events were seen in any of the outpatients.

Overall, all-cause 30-day mortality was 5.7%. Sepsis was the most frequent cause of death (89.5%) followed by cardiovascular disease (7%).

Dr. Gaetano Santulli, a cardiologist at Albert Einstein College of Medicine in New York City, told Reuters Health by email that the most remarkable results of the study "are the dramatically high mortality rate in COVID-19 patients in intensive care . . . and the observation of numerous thromboembolic events in patients in intensive care despite a nearly 90% prescription of thromboprophylaxis."

"Unfortunately, it is not clear when the thromboprophylaxis has been actually initiated in these patients," added Dr. Santulli, who was not involved in the research. "Nevertheless, this study further confirms that endothelial dysfunction, which leads to thromboembolic events, plays a crucial role in COVID-19."

In an accompanying editorial, Dr. Robert D. McBane of Mayo Clinic, in Rochester, Minnesota, says that until the results of ongoing clinical trials that seek to optimize thromboprophylaxis in COVID-19 are known "the lessons of thoughtful anticoagulant prophylaxis and treatment guidelines harvested from years of clinical research appear to apply."

He told Reuters Health by email that, "While rare individuals suffer catastrophic thrombotic complications . . . the incidence for the majority of patients does not appear to be greatly different compared to pre-pandemic numbers."

"While additional high-quality randomized controlled studies are needed," he concluded, "current guidelines provide sufficiently balanced and thoughtful management recommendations avoiding over-treatment and bleeding complications."

Dr. Piazza did not respond to requests for comments.

—David Douglas

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