Hospitalized COVID-19 Patients and Venous Thromboembolism

Abstract

he coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 has taken the world by storm.As of May 4, 2020, there are >1.2 million confirmed cases in the United States and >66 000 deaths.Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is common in seriously ill patients with infection.Early reports suggested a VTE rate of approximately 27% in critically ill patients hospitalized with This high rate of VTE, and, in particular, PE, is consistent with what has been reported in critically ill patients with pneumonias caused by other viruses, including H1N1 pneumonia and severe acute respiratory syndrome.2,3 Key markers of inflammation and coagulopathy have been associated with morbidity and increased mortality in hospitalized patients with COVID-19, suggesting that either the severe acute respiratory syndrome coronavirus 2 infection itself or the cytokine storm produced by the hyperinflammatory state induces a prothrombotic state. 4COVID-19 is associated with a coagulopathy characterized by mild thrombocytopenia, high levels of d-dimer and fibrin(ogen) degradation products, slight prolongation of the prothrombin time, and elevated levels of fibrinogen and factor VIII. [4][5][6] Although the drivers of this coagulopathy are uncertain, overexpression of tissue factor, endothelial dysfunction, and activation of the contact and complement systems are potential candidates.In patients dying of COVID-19, multiple thrombi are found in the vessels of the lungs, and those of the liver, heart, and kidneys.This hypercoagulable state may explain the high rate of VTE reported in patients with COVID-19 despite anticoagulant thromboprophylaxis, 1 and the acute kidney injury, myocardial infarction, ischemic stroke, and arterial occlusion, as well, that have been described in these patients.6,7 In this issue of Circulation, case series of hospitalized patients with COVID-19 reported from China by Zhang et al 8 and Ren et al 9 and from France by Poissy et al 10 highlight the high prevalence of VTE in this population.Consistent with earlier reports of high VTE rates in critically ill patients with COVID-19, the prevalence of PE in 107 consecutive patients in the intensive care unit was 20.6% in the study by Poissy et al. 10 Of the 22 patients with documented PE, 20 were receiving anticoagulant thromboprophylaxis at the time of PE diagnosis.When 48 patients in an intensive care unit with documented COVID-19 were screened with compression ultrasonography of the lower extremities, Ren et al 9 reported a prevalence of asymptomatic DVT of 85.4%, with 75% localized to the calf veins.In the patients with DVT, all but 1 were receiving low-molecular-weight heparin thromboprophylaxis.Likewise, with compression ultrasound screening of 143 hospitalized patients with COVID-19 on medical wards, Zhang et al 8 found DVT in 46.1% overall, of which the location is

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