tetano
Editor, Senior Moderator
Ann Intern Med
. 2021 Jan 26.
doi: 10.7326/M20-6739. Online ahead of print.
Thrombosis, Bleeding, and the Observational Effect of Early Therapeutic Anticoagulation on Survival in Critically Ill Patients With COVID-19
Hanny Al-Samkari[SUP] 1 [/SUP], Shruti Gupta[SUP] 2 [/SUP], Rebecca Karp Leaf[SUP] 1 [/SUP], Wei Wang[SUP] 3 [/SUP], Rachel P Rosovsky[SUP] 1 [/SUP], Samantha K Brenner[SUP] 4 [/SUP], Salim S Hayek[SUP] 5 [/SUP], Hanna Berlin[SUP] 5 [/SUP], Rajat Kapoor[SUP] 6 [/SUP], Shahzad Shaefi[SUP] 7 [/SUP], Michal L Melamed[SUP] 8 [/SUP], Anne Sutherland[SUP] 9 [/SUP], Jared Radbel[SUP] 10 [/SUP], Adam Green[SUP] 11 [/SUP], Brian T Garibaldi[SUP] 12 [/SUP], Anand Srivastava[SUP] 13 [/SUP], Amanda Leonberg-Yoo[SUP] 14 [/SUP], Alexandre M Shehata[SUP] 15 [/SUP], Jennifer E Flythe[SUP] 16 [/SUP], Arash Rashidi[SUP] 17 [/SUP], Nitender Goyal[SUP] 18 [/SUP], Lili Chan[SUP] 19 [/SUP], Kusum S Mathews[SUP] 19 [/SUP], S Susan Hedayati[SUP] 20 [/SUP], Rajany Dy[SUP] 21 [/SUP], Stephanie M Toth-Manikowski[SUP] 22 [/SUP], Jingjing Zhang[SUP] 23 [/SUP], Mary Mallappallil[SUP] 24 [/SUP], Roberta E Redfern[SUP] 25 [/SUP], Amar D Bansal[SUP] 26 [/SUP], Samuel A P Short[SUP] 27 [/SUP], Mark G Vangel[SUP] 28 [/SUP], Andrew J Admon[SUP] 29 [/SUP], Matthew W Semler[SUP] 30 [/SUP], Kenneth A Bauer[SUP] 31 [/SUP], Miguel A Hern?n[SUP] 32 [/SUP], David E Leaf[SUP] 2 [/SUP]
Affiliations
Abstract
Background: Hypercoagulability may be a key mechanism of death in patients with coronavirus disease 2019 (COVID-19).
Objective: To evaluate the incidence of venous thromboembolism (VTE) and major bleeding in critically ill patients with COVID-19 and examine the observational effect of early therapeutic anticoagulation on survival.
Design: In a multicenter cohort study of 3239 critically ill adults with COVID-19, the incidence of VTE and major bleeding within 14 days after intensive care unit (ICU) admission was evaluated. A target trial emulation in which patients were categorized according to receipt or no receipt of therapeutic anticoagulation in the first 2 days of ICU admission was done to examine the observational effect of early therapeutic anticoagulation on survival. A Cox model with inverse probability weighting to adjust for confounding was used.
Setting: 67 hospitals in the United States.
Participants: Adults with COVID-19 admitted to a participating ICU.
Measurements: Time to death, censored at hospital discharge, or date of last follow-up.
Results: Among the 3239 patients included, the median age was 61 years (interquartile range, 53 to 71 years), and 2088 (64.5%) were men. A total of 204 patients (6.3%) developed VTE, and 90 patients (2.8%) developed a major bleeding event. Independent predictors of VTE were male sex and higher D-dimer level on ICU admission. Among the 2809 patients included in the target trial emulation, 384 (11.9%) received early therapeutic anticoagulation. In the primary analysis, during a median follow-up of 27 days, patients who received early therapeutic anticoagulation had a similar risk for death as those who did not (hazard ratio, 1.12 [95% CI, 0.92 to 1.35]).
Limitation: Observational design.
Conclusion: Among critically ill adults with COVID-19, early therapeutic anticoagulation did not affect survival in the target trial emulation.
. 2021 Jan 26.
doi: 10.7326/M20-6739. Online ahead of print.
Thrombosis, Bleeding, and the Observational Effect of Early Therapeutic Anticoagulation on Survival in Critically Ill Patients With COVID-19
Hanny Al-Samkari[SUP] 1 [/SUP], Shruti Gupta[SUP] 2 [/SUP], Rebecca Karp Leaf[SUP] 1 [/SUP], Wei Wang[SUP] 3 [/SUP], Rachel P Rosovsky[SUP] 1 [/SUP], Samantha K Brenner[SUP] 4 [/SUP], Salim S Hayek[SUP] 5 [/SUP], Hanna Berlin[SUP] 5 [/SUP], Rajat Kapoor[SUP] 6 [/SUP], Shahzad Shaefi[SUP] 7 [/SUP], Michal L Melamed[SUP] 8 [/SUP], Anne Sutherland[SUP] 9 [/SUP], Jared Radbel[SUP] 10 [/SUP], Adam Green[SUP] 11 [/SUP], Brian T Garibaldi[SUP] 12 [/SUP], Anand Srivastava[SUP] 13 [/SUP], Amanda Leonberg-Yoo[SUP] 14 [/SUP], Alexandre M Shehata[SUP] 15 [/SUP], Jennifer E Flythe[SUP] 16 [/SUP], Arash Rashidi[SUP] 17 [/SUP], Nitender Goyal[SUP] 18 [/SUP], Lili Chan[SUP] 19 [/SUP], Kusum S Mathews[SUP] 19 [/SUP], S Susan Hedayati[SUP] 20 [/SUP], Rajany Dy[SUP] 21 [/SUP], Stephanie M Toth-Manikowski[SUP] 22 [/SUP], Jingjing Zhang[SUP] 23 [/SUP], Mary Mallappallil[SUP] 24 [/SUP], Roberta E Redfern[SUP] 25 [/SUP], Amar D Bansal[SUP] 26 [/SUP], Samuel A P Short[SUP] 27 [/SUP], Mark G Vangel[SUP] 28 [/SUP], Andrew J Admon[SUP] 29 [/SUP], Matthew W Semler[SUP] 30 [/SUP], Kenneth A Bauer[SUP] 31 [/SUP], Miguel A Hern?n[SUP] 32 [/SUP], David E Leaf[SUP] 2 [/SUP]
Affiliations
- PMID: 33493012
- DOI: 10.7326/M20-6739
Abstract
Background: Hypercoagulability may be a key mechanism of death in patients with coronavirus disease 2019 (COVID-19).
Objective: To evaluate the incidence of venous thromboembolism (VTE) and major bleeding in critically ill patients with COVID-19 and examine the observational effect of early therapeutic anticoagulation on survival.
Design: In a multicenter cohort study of 3239 critically ill adults with COVID-19, the incidence of VTE and major bleeding within 14 days after intensive care unit (ICU) admission was evaluated. A target trial emulation in which patients were categorized according to receipt or no receipt of therapeutic anticoagulation in the first 2 days of ICU admission was done to examine the observational effect of early therapeutic anticoagulation on survival. A Cox model with inverse probability weighting to adjust for confounding was used.
Setting: 67 hospitals in the United States.
Participants: Adults with COVID-19 admitted to a participating ICU.
Measurements: Time to death, censored at hospital discharge, or date of last follow-up.
Results: Among the 3239 patients included, the median age was 61 years (interquartile range, 53 to 71 years), and 2088 (64.5%) were men. A total of 204 patients (6.3%) developed VTE, and 90 patients (2.8%) developed a major bleeding event. Independent predictors of VTE were male sex and higher D-dimer level on ICU admission. Among the 2809 patients included in the target trial emulation, 384 (11.9%) received early therapeutic anticoagulation. In the primary analysis, during a median follow-up of 27 days, patients who received early therapeutic anticoagulation had a similar risk for death as those who did not (hazard ratio, 1.12 [95% CI, 0.92 to 1.35]).
Limitation: Observational design.
Conclusion: Among critically ill adults with COVID-19, early therapeutic anticoagulation did not affect survival in the target trial emulation.