COVID-19 associated thrombotic complications and solutions Menno Huisman MD PhD FESC Department of Thrombosis and Hemostasis Leiden University Medical Center the Netherlands m.v.huisman@lumc.nl
Nederland in de top drie
COVID-19 coagulopathy Iba T et al , 2020
COVID-19 associated VTE: initial reports Geen woord over trombose (ook niet over het hart, wel over diabetes)
COVID-19 coagulopathy must give events + Zhou F et al , Lancet 2020
Our Dutch experience; 10 April 2020 online
Dutch experience ✓ 184 ICU patients with proven COVID-19 pneumonia ✓ All received LMWH thromboprophylaxis in different doses ✓ Diagnostic tests in case of suspected thrombotic complications ✓ At risk period from moment of admission to death, discharge from ICU or censoring at April 7 th and April 14 th 2020 respectively
First analysis ✓ Cumulative incidence 31% (95% BI 20-41) ➢ VTE: 27% (95%BI 17-37%) ➢ Ischemic stroke: 3.7% (95%BI 0-8.2%)
COVID-IC study ✓ Cumulative incidence in competing risk model: 49% (95%CI 41-57) ➢ Acute PE overall majority – 87% ➢ Ischemic stroke – 6 % ➢ Thrombotic complications strongly predictive of mortality: adjusted HR 5.4; 95%CI 2.4-12 Klok FA, et al . Thrombosis Research 2020; 191: 148 – 150 Helms J et al. Intensive Care Medicine 2020; 46:1089 – 1098 Middeldorp S et al. J Thromb Haemost 2020; doi: 10.1111/JTH.14888
Pulmonary emboli: from leg veins or in situ Stroke: PFO; locally formed ‘immuno - thrombosis’
Thrombosis and COVID solution: prevention! Give LMWH prophylaxis to all hospitalized patients with COVID-19 ICU patients: intermediate prophylactic dose • Enoxaparin 40mg OD to 80 mg OD • If weight ≥ 100 kgf double the dose again • Increased bleeding risk (e.g. thrombocytopenia < 30 x10 9 /L) stay with standard thromboprophylaxis (e.g. enoxaparin 40 mg OD) • E-GFR < 30 ml/min: standard thromboprophylaxis or doubling with anti-Xa activity monitoring
VTE in COVID: treatment Provoked VTE - 3 months is enough → → ICU -ward Ward at home ✓ ✓ LMWH/UFH LMWH ✓ DOAC
Doen het hart en diabetes niet mee? Garibaldi et al. Patient Trajectories Among Persons Hospitalized for COVID-19. Ann Int Med 2020 online
Doen hart en diabetes niet mee? Puntmann et al JAMA Cardiology 2020
Conclusions and remaining questions ✓ Thrombotic complications frequent at ICU – less so at wards – home? ✓ (Doubled) intermediate thromboprophylaxis indicated may be not enough to prevent thrombosis to occur ✓ Diagnostic tests in case of suspected thrombotic complications - or screen? ✓ Strokes are surprising and enigmatic – PFO likely responsible for some
Dutch COVID & Thrombosis Coalition Dutch COVID & Thrombosis Coalition, RPTH 2020
LUMC in Leiden… LUMC in Leiden 20
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