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Coronavirus Disease 2019 (COVID-19) is caused by a novel coronavirus (SARS-CoV2) and is a highly contagious disease that first appeared in Wuhan, Hubei province of China in December 2019. Many nations are battling to control the spread of the infection. In the infected population, although most of the patients have mild symptoms of fever, fatigue and cough, in some severe cases, patients can progress rapidly and develop the acute respiratory distress syndrome, metabolic acidosis, septic shock, and coagulopathy, venous thromboembolism (VTE) and disseminated intravascular coagulation (DIC). This article focuses on the emerging guidelines and various recommendations of different institutions on how to manage thrombotic risk, coagulopathy and DIC in patients with COVID-19. The data presented below is intended to provide guidance for anticoagulation prophylaxis and treatment in COVID-19 patients and should not supersede clinical judgement.
Thromboembolism; coagulopathy; coronavirus
The coronavirus enter cells by binding to angiotensin-converting enzyme 2 (ACE2), which is found mainly on alveolar epithelium and endothelium apart from many other tissues. Severe COVID-19 disease is associated with features of VTE, disseminated intravascular coagulation (DIC) with coagulopathy. The large inflammatory response may be responsible for induction of this pro-thrombotic state. The exact mechanism of venous thromboembolism is unknown and is likely multifactorial attributed to systemic inflammatory response, stasis, and direct endothelium damage from viral injury and ACE 2 binding . Pulmonary thrombosis appears to be common in severe Covid-19 pneumonia. The factors attributing to high rate of pulmonary thrombosis in severe COVID-19 are observed to be intense endothelial inflammation leading to local micro vascular thrombosis > disturbances in Virchow's triad within the lung due to altered pulmonary blood flow > classical DVT to PE transition which may have a minor role. There is emerging strong evidence from the autopsy studies from different countries that the extensive micro vascular thrombosis to be the leading cause of death in COVID-19. It has been shown in many studies that the highly elevated levels of D-Dimer with no other sites of thrombosis to explain the raised D-Dimer levels are more prone to death. A study of 449 confirmed COVID-19 patients observed that anticoagulation decrease the 28 day mortality by 20% in highly raised D-Dimer levels. Another study of 184 ICU patients with proven COVID-19 pneumonia observed a remarkably high 31% incidence of thrombotic complications. The study recommends thrombosis prophylaxis and to consider higherdose prophylaxis in high-risk population even in the absence of randomized evidence .
All hospitalized adults with COVID-19 shouldreceivepharmacologic thromboprophylaxis with LMWH over unfractionated heparin. A caution to keep in mind before starting the prophylaxis is the risk of bleeding outweighing the risk of thrombosis . In the setting of heparin-induced thrombocytopenia, fondaparinux is suggested. Dose adjustment for obesity could also be used per institutional guidance. In patients where anticoagulants are contraindicated or unavailable, use mechanical thromboprophylaxis (e.g. pneumatic compression devices). Combined pharmacologic and mechanical prophylaxis isn't generally recommended.
The clinician may exercise caution and follow their institutional protocols before following any of the guidelines mentioned in this article and tailor the treatment depending upon the clinical scenario and availability of resources. The data provided is for information purposes only and is neither an attempt to substitute for the practice of medicine nor as a substitute for the provision of any medical professional services. Also the data is not meant to be complete, exhaustive, or a substitute for medical professional advice, diagnosis, or treatment. The information herein should be adapted to every specific patient supported the treating medical professional’s independent professional judgment and consideration of the patient’s needs, the resources available at the location from where the medical professional services are being provided (e.g., healthcare institution, ambulatory clinic, physician’s office, etc.), and the other unique circumstances. This information should not be used to replace, substitute for, or overrule a qualified medical professional’s judgement. This article may contain third party materials and/or links to third party materials and third party websites for your information and convenience. The author is not responsible for the availability, accuracy, or content of any of those third party materials or websites nor does endorse them. Prior to accessing this information or these third party websites you'll be asked to comply with additional terms and conditions Provided by such third parties who govern access to and use of those websites or materials. The reader should be aware of the fact that the above recommendations are collected from various sites and sources, retrospective studies and may be old and not valid and are emerging and are subjected to change by every day basis based on recent emerging studies. Some of the various modifications are also listed from earlier to latest versions.
Citation: Kattekola P (2020) Role of Anticoagulation in COVID-19 Treatment. J Hematol Thrombo Dis. 8:305. DOI: 10.24105/2329-8790.2020.8.305.
Received: 14-Jul-2020 Accepted: 29-Jul-2020 Published: 03-Aug-2020 , DOI: 10.35248/2329-87126.96.36.1995
Copyright: © 2020 Kattekola P, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.