Prophylactic anticoagulation associated with lower in-hospital and 60-day mortality for patients hospitalized with COVID-19

1. For patients hospitalized with COVID-19, both prophylactic- and treatment-dose anticoagulation were associated with lower in-hospital mortality compared with no anticoagulation.

2. However, given that only prophylactic anticoagulation was associated with mortality benefit at 60 days, anticoagulation prophylaxis should be considered in all patients hospitalized with COVID-19.

Evidence Rating Level: 2 (Good)

Study Rundown: Venous thromboembolism (VTE) has been established as a leading complication of COVID-19 that has influenced clinical decision-making regarding VTE prophylaxis and treatment-dose anticoagulation in hospitalized patients. In recent months, there has been a collaborative emphasis on VTE prophylaxis for hospitalized COVID-19 patients with several experts advocating for increased doses of prophylactic anticoagulation in these high-risk patients. Furthermore, the potential benefits of these practices have been highlighted by recent clinical trials showing mortality benefit for both treatment- or prophylactic-dose anticoagulation as well as a significant decrease in the combined outcome of in-hospital mortality and organ support free days with treatment-dose anticoagulation in patients outside of intensive care. Given these findings, this retrospective cohort study sought to characterize the frequency and variation of VTE prophylaxis and treatment-dose anticoagulation use across hospitals over time in patients with COVID-19, as well as their effect on outcomes such as in-hospital and 60-day mortality. The main outcomes and measures of the analysis were the effects of nonadherence and variations in anticoagulation strategies on in-hospital and 60-day mortality assessed through multinomial logit models with inverse probability of treatment weighting. In total, from 1,351 hospitalized COVID-19 patients, 1,127 patients received anticoagulation. Additionally, both the use of prophylactic- and treatment-dose anticoagulation was associated with lower in-hospital mortality compared with no anticoagulation. However, only prophylactic-dose anticoagulation was associated with lower 60-day mortality. As with other retrospective studies looking at VTE, a limitation of this study was that investigators were limited by incomplete diagnostic workup for VTE across various acute clinical settings, exacerbated by hospital resources during the COVID-19 pandemic.

Click to read the study in JAMA Network Open

Click to read an accompanying editorial in JAMA Network Open

Relevant Reading: Anticoagulation, mortality, bleeding and pathology among patients hospitalized with COVID-19: a single health system study

In-Depth [retrospective cohort]: This large, multicenter cohort study of adults hospitalized with COVID-19 used a pseudorandom sample from 30 hospitals in the state of Michigan, United States. Data was compiled from patients hospitalized between March to June 2020 and analysis was completed through March 2021. In total, 1,351 hospitalized patients with COVID-19 were included in the analysis (median [IQR] age, 64 [52-75] years; 47.7% women, 48.9% Black patients). Of these, 1,127 patients received anticoagulation, 18 (1.3%) had a confirmed diagnosis of VTE, and 219 (16.2%) received treatment-dose anticoagulation. Across the 30 centers, use of treatment-dose anticoagulation without imaging ranged from 0% to 29% and gradually increased over time (adjusted odds ratio [aOR], 1.46; 95%CI, 1.31-1.61 per week). Of the 1,127 patients who did receive anticoagulation, 392 (34.8%) missed 2 or more days of prophylaxis. In addition, variation of nonadherence to prophylaxis ranged from 11% to 61% across centers and decreased markedly over time (aOR, 0.89; 95%CI, 0.82-0.97 per week). VTE nonadherence was associated with higher 60-day mortality (adjusted hazard ratio [aHR], 1.31; 95%CI, 1.03-1.67) excluding in-hospital mortality (aHR, 0.97; 95%CI, 0.91-1.03) and in particular, receiving any dose of anticoagulation was associated with lower overall in-hospital mortality (only prophylactic dose: aHR, 0.36; 95%CI, 0.26-0.52; any treatment dose: aHR, 0.38; 95%CI, 0.25-0.58). However, only prophylactic-dose anticoagulation was associated with lower 60-day mortality (prophylactic dose: aHR, 0.71; 95%CI, 0.51-0.90; treatment dose: aHR, 0.92; 95%CI, 0.63-1.35).

Image: PD

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