Current best evidence for clinical care (more info)
Hypercoagulability in coronavirus disease 2019 (COVID-19) may aggravate disease severity during hospitalization but the reported survival benefits from anticoagulation (AC) vary among studies. We performed a literature research to estimate pooled odds ratios (ORs) of in-hospital mortality and major bleeding comparing among intermediate-to-therapeutic dose AC, prophylactic dose AC, and no AC. Until October 22, 2020, PubMed, EMBASE, and Cochrane Library Database were searched for studies reporting AC utilization and mortality in COVID-19. Studies with suspected risk of bias were excluded before the synthesis of pooled ORs with 95% confidence intervals (CIs) using random-effects models. Of 37 identified studies (N = 19,510), 17 (N = 17,833) were aggregated in the meta-analysis. The overall mortality rate was 23.1% (95% CI 18.7-28.2). The pooled odds of mortality comparing anticoagulated to non-anticoagulated patients were similar, but lower in prophylactic dose AC group (OR 0.83; 95% CI 0.73-0.95). Notably, intermediate-to-therapeutic dose AC increased mortality (OR 1.60; 95% CI 1.11-2.31) and major bleeding compared to prophylactic dose AC (OR 3.33; 95% CI 2.34-4.72). Our findings support the optimal efficacy and safety profiles of prophylactic dose AC in hospitalized COVID-19 patients.
|Discipline / Specialty Area||Score|
|Hemostasis and Thrombosis||
The literature about the management of patients with COVID-19 has been appearing at the speed of light, but is still a bit behind the times due to publication lag and the challenge of making a good study design actually work. This paper is a sincere effort to understand the potential survival benefit/harm of different anticoagulation strategies. The conclusion is that aggressive immediate anticoagulation is likely slightly harmful but that prophylaxis may be beneficial. This is not a startling outcome since anticoagulation is always at least somewhat challenging when patients have a specific documented need. However, in patients with unknown other risks, it is likely helpful AND harmful depending on the specifics of the case. This kind of outcome is very difficult to discern and hard to explain in publication. There may be significant heterogeneity based on the international nature of the work, the varied study design and mixed primary and secondary outcomes.
This systematic review unfortunately does not distinguish between critically ill and non-critically ill hospitalized patients, which appears to be vital in addressing the utility and dangers of prophylactic vs therapeutic anti-coagulation in COVID-19 patients.
The efficacy of anticoagulation for COVID-19 was systematically reviewed. I understand that routine anticoagulation was not recommended.
This meta-analysis finds that prophylactic anticoagulation for in-patients with Covid-19 infection have lower risk of mortality and less bleeding than patients therapeutically anticoagulated. This paper adds to the body of literature favoring avoidance of excess anticoagulation in these patients.
Prophylactic anticoagulation for hospitalized patients with COVID-19 infection in our practice is standard. The findings of no improvement in survival benefit and excess bleeding using intermediate to therapeutic anticoagulation doses indicates that increasing anticoagulation for more severely affected patients, or in patients who are worsening, is probably not a good idea. This work gives more assurance that prophylactic anticoagulation in COVID-19 infection should continue to be standard in the treatment plan. Further studies are needed to determine if subsets of patients with COVID-19 infection might benefit from higher levels of anticoagulation.