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Anticoagulation Intensity for Hospitalized Non-ICU Patients with COVID-19
Although SARS-CoV-2 infection raises risk for venous thromboembolism (VTE), researchers evaluating patients with COVID-19 who were admitted to intensive care units (ICUs) have failed to demonstrate outcome benefits of anticoagulation above the intensity of usual VTE prophylaxis (NEJM JW Gen Med May 1 2021 and JAMA 2021; 325:1620). International investigators randomized 465 moderately ill hospitalized adults with confirmed SARS-CoV-2 infection to receive therapeutic anticoagulation or VTE prophylaxis (predominantly with low-molecular-weight heparin [LMWH]). Moderate illness was defined as elevated D-dimer levels with no ICU admission or mechanical ventilation. Patients at high risk for bleeding were excluded.
One-month outcomes for therapeutic anticoagulation versus usual VTE prophylaxis were as follows:
- Primary outcome (composite of death, mechanical ventilation, or ICU admission): 16.2% vs. 21.9% (P=0.12)
- Death from any cause: 1.8% vs. 7.6% (P=0.006; number needed to treat, 17)
- Death or mechanical ventilation: 10.1% vs. 16.0% (P=0.06)
- VTE: 0.9% vs. 2.5% (P=0.19)
- Major bleeding: no between-group difference
Comment
This study's sample size ultimately was underpowered for the primary outcome, which might explain why statistical significance was not attained. Some healthcare systems — including my own — still employ protocols for more-intense VTE prophylaxis for floor patients with COVID-19 and elevated D-dimer levels. The mortality reduction seen in this study might support benefit with higher prophylactic anticoagulation dosing with LMWH in moderately ill hospitalized patients with COVID-19 and elevated D-dimer levels.
Citation(s)
Author:
Sholzberg M et al.
Title:
Effectiveness of therapeutic heparin versus prophylactic heparin on death, mechanical ventilation, or intensive care unit admission in moderately ill patients with covid-19 admitted to hospital: RAPID randomised clinical trial.
Source:
BMJ
2021
Oct
14; [e-pub].
(Abstract/FREE Full Text)
Empfohlen von
Daniel D. Dressler, MD, MSc, MHM, FACP