tetano
Editor, Senior Moderator
EClinicalMedicine
. 2021 Nov;41:101139.
doi: 10.1016/j.eclinm.2021.101139. Epub 2021 Sep 24.
Outpatient and inpatient anticoagulation therapy and the risk for hospital admission and death among COVID-19 patients
Sameh M Hozayen[SUP] 1 [/SUP], Diana Zychowski[SUP] 2 [/SUP], Sydney Benson[SUP] 3 [/SUP], Pamela L Lutsey[SUP] 4 [/SUP], Jasmin Haslbauer[SUP] 5 [/SUP], Alexandar Tzankov[SUP] 5 [/SUP], Zachary Kaltenborn[SUP] 1 [/SUP], Michael Usher[SUP] 1 [/SUP], Surbhi Shah[SUP] 6 [/SUP], Christopher J Tignanelli[SUP] 7 8 9 [/SUP], Ryan T Demmer[SUP] 4 10 [/SUP]
Affiliations
Abstract
Background: Coronavirus disease 2019 (COVID-19) is associated with a hypercoagulable state. Limited data exist informing the relationship between anticoagulation therapy and risk for COVID-19 related hospitalization and mortality.
Methods: We evaluated all patients over the age of 18 diagnosed with COVID-19 in a prospective cohort study from March 4th to August 27th, 2020 among 12 hospitals and 60 clinics of M Health Fairview system (USA). We investigated the relationship between (1) 90-day anticoagulation therapy among outpatients before COVID-19 diagnosis and the risk for hospitalization and mortality and (2) Inpatient anticoagulation therapy and mortality risk.
Findings: Of 6195 patients, 598 were immediately hospitalized and 5597 were treated as outpatients. The overall case-fatality rate was 2•8% (n = 175 deaths). Among the patients who were hospitalized, the inpatient mortality was 13%. Among the 5597 COVID-19 patients initially treated as outpatients, 160 (2.9%) were on anticoagulation and 331 were eventually hospitalized (5.9%). In a multivariable analysis, outpatient anticoagulation use was associated with a 43% reduction in risk for hospital admission, HR (95% CI = 0.57, 0.38-0.86), p = 0.007, but was not associated with mortality, HR (95% CI=0.88, 0.50 - 1.52), p = 0.64. Inpatients who were not on anticoagulation (before or after hospitalization) had an increased risk for mortality, HR (95% CI = 2.26, 1.17-4.37), p = 0.015.
Interpretation: Outpatients with COVID-19 who were on outpatient anticoagulation at the time of diagnosis experienced a 43% reduced risk of hospitalization. Failure to initiate anticoagulation upon hospitalization or maintaining outpatient anticoagulation in hospitalized COVID-19 patients was associated with increased mortality risk.
Funding: No funding was obtained for this study.
Keywords: %, percentage;
, number; ACEi, angiotensin-converting enzyme inhibitors; ARBs, angiotensin receptor blockers; Anticoagulation; CI, confidence intervals; CKD, chronic kidney disease; CO2, carbon dioxide; COPD, chronic obstructive pulmonary disease; COVID-19; COVID-19, coronavirus disease 2019; D-dimer; DIC, disseminated intravascular coagulation; DOAC, direct oral anticoagulant; EHR, electronic health records; EMR, electronic medical records; HCT, hematocrit; HIT, heparin-induced thrombocytopenia; HR, hazard ratio; Hospitalization; IPAC, inpatient anticoagulation therapy; IRB, institutional review board; Inpatient; MI, prior myocardial infarction; Mortality; OPAC, outpatient persistent anticoagulation therapy; Outpatient; RDW, red blood cell distribution width; SARS-CoV-2, severe Acute Respiratory Syndrome Coronavirus-2; SBP, systolic blood pressure; SBP-min, minimum systolic blood pressure; SD, standard deviations; SE, standard errors; SpO2-min, minimum oxygen saturation; T1DM, type 1 diabetes mellitus; T2DM, type 2 diabetes mellitus; VTE, venous thromboembolism; WBC, white blood cell; mg/dl, milligram per deciliter; rt-PCR, reverse transcriptase-polymerase chain reaction.
. 2021 Nov;41:101139.
doi: 10.1016/j.eclinm.2021.101139. Epub 2021 Sep 24.
Outpatient and inpatient anticoagulation therapy and the risk for hospital admission and death among COVID-19 patients
Sameh M Hozayen[SUP] 1 [/SUP], Diana Zychowski[SUP] 2 [/SUP], Sydney Benson[SUP] 3 [/SUP], Pamela L Lutsey[SUP] 4 [/SUP], Jasmin Haslbauer[SUP] 5 [/SUP], Alexandar Tzankov[SUP] 5 [/SUP], Zachary Kaltenborn[SUP] 1 [/SUP], Michael Usher[SUP] 1 [/SUP], Surbhi Shah[SUP] 6 [/SUP], Christopher J Tignanelli[SUP] 7 8 9 [/SUP], Ryan T Demmer[SUP] 4 10 [/SUP]
Affiliations
- PMID: 34585129
- PMCID: PMC8461367
- DOI: 10.1016/j.eclinm.2021.101139
Abstract
Background: Coronavirus disease 2019 (COVID-19) is associated with a hypercoagulable state. Limited data exist informing the relationship between anticoagulation therapy and risk for COVID-19 related hospitalization and mortality.
Methods: We evaluated all patients over the age of 18 diagnosed with COVID-19 in a prospective cohort study from March 4th to August 27th, 2020 among 12 hospitals and 60 clinics of M Health Fairview system (USA). We investigated the relationship between (1) 90-day anticoagulation therapy among outpatients before COVID-19 diagnosis and the risk for hospitalization and mortality and (2) Inpatient anticoagulation therapy and mortality risk.
Findings: Of 6195 patients, 598 were immediately hospitalized and 5597 were treated as outpatients. The overall case-fatality rate was 2•8% (n = 175 deaths). Among the patients who were hospitalized, the inpatient mortality was 13%. Among the 5597 COVID-19 patients initially treated as outpatients, 160 (2.9%) were on anticoagulation and 331 were eventually hospitalized (5.9%). In a multivariable analysis, outpatient anticoagulation use was associated with a 43% reduction in risk for hospital admission, HR (95% CI = 0.57, 0.38-0.86), p = 0.007, but was not associated with mortality, HR (95% CI=0.88, 0.50 - 1.52), p = 0.64. Inpatients who were not on anticoagulation (before or after hospitalization) had an increased risk for mortality, HR (95% CI = 2.26, 1.17-4.37), p = 0.015.
Interpretation: Outpatients with COVID-19 who were on outpatient anticoagulation at the time of diagnosis experienced a 43% reduced risk of hospitalization. Failure to initiate anticoagulation upon hospitalization or maintaining outpatient anticoagulation in hospitalized COVID-19 patients was associated with increased mortality risk.
Funding: No funding was obtained for this study.
Keywords: %, percentage;
, number; ACEi, angiotensin-converting enzyme inhibitors; ARBs, angiotensin receptor blockers; Anticoagulation; CI, confidence intervals; CKD, chronic kidney disease; CO2, carbon dioxide; COPD, chronic obstructive pulmonary disease; COVID-19; COVID-19, coronavirus disease 2019; D-dimer; DIC, disseminated intravascular coagulation; DOAC, direct oral anticoagulant; EHR, electronic health records; EMR, electronic medical records; HCT, hematocrit; HIT, heparin-induced thrombocytopenia; HR, hazard ratio; Hospitalization; IPAC, inpatient anticoagulation therapy; IRB, institutional review board; Inpatient; MI, prior myocardial infarction; Mortality; OPAC, outpatient persistent anticoagulation therapy; Outpatient; RDW, red blood cell distribution width; SARS-CoV-2, severe Acute Respiratory Syndrome Coronavirus-2; SBP, systolic blood pressure; SBP-min, minimum systolic blood pressure; SD, standard deviations; SE, standard errors; SpO2-min, minimum oxygen saturation; T1DM, type 1 diabetes mellitus; T2DM, type 2 diabetes mellitus; VTE, venous thromboembolism; WBC, white blood cell; mg/dl, milligram per deciliter; rt-PCR, reverse transcriptase-polymerase chain reaction.