Jornal Vascular Brasileiro
https://jvascbras.org/article/doi/10.1590/1677-5449.200203
Jornal Vascular Brasileiro
Original Article

Incidence, diagnosis, treatment methods, and outcomes of clinically suspected venous thromboembolic disease in patients with COVID-19 in a quaternary hospital in Brazil

Incidência, diagnóstico, métodos terapêuticos e desfechos de eventos tromboembólicos venosos em pacientes com COVID-19 em um hospital quaternário do Brasil

Marcela Juliano Silva Cunha; Carlos Augusto Ventura Pinto; João Carlos de Campos Guerra; Adriano Tachibana; Maria Fernanda Cassino Portugal; Leonardo José Rolim Ferraz; Nelson Wolosker

Downloads: 0
Views: 15

Abstract

Abstract: Background: Prothrombotic states have been associated with viral infections and the novel Sars-COV-2 infection has been associated with elevated D-dimer levels, although no causal relation has been clearly established.

Objectives: This study presents an epidemiological analysis of manifest VTE episodes in a group of patients hospitalized because of COVID-19.

Methods: Medical records of patients who presented symptomatic deep vein thrombosis and/or pulmonary embolism in concomitance with confirmed COVID-19 were retrospectively studied. Demographic characteristics, prevalence of VTE, site of occurrence, D-dimer variation over time, management, and outcomes were analyzed.

Results: During the study period, 484 confirmed cases of COVID-19 were admitted, 64 of which displayed VTE symptoms and 13 of which had confirmed symptomatic VTE(2.68% of total sample and 20.31% of symptomatic cases). Most cases (76.92%) occurred in intensive care. On the day attributed to VTE onset, D-dimer levels were over 3,000 ng/mL in 8 (80%) patients, a significant increase from baseline admission levels (p < 0.05). A significant decrease was also observed in D-dimer values at hospital discharge (p < 0.05). All patients received pharmacological thromboprophylaxis and/or anticoagulation as indicated. Two deaths occurred during the study, both patients with severe comorbidities. At the end of our study protocol, nine patients had been discharged and two remained hospitalized, but had no signs of VTE worsening.

Conclusions: VTE prevalence in hospitalized COVID-19 patients was 2.7%, and higher in intensive care units. Early institution of prophylaxis and immediate full anticoagulation when VTE is diagnosed should be the goals of those who treat this kind of patient.

Keywords

thrombosis, thromboembolism, pulmonary embolism, coronavirus disease-19, death, drug therapy

Resumo

Resumo: Contexto: Os estados pró-trombóticos têm sido associados a infecções virais. A nova infecção pela síndrome respiratória aguda grave do coronavírus 2 (SARS-CoV-2) sabidamente eleva os níveis de D-dímero, embora a relação causal não tenha sido bem estabelecida.

Objetivos: Este estudo apresenta uma análise epidemiológica de episódios sintomáticos de tromboembolismo em um grupo de pacientes hospitalizados pela doença do novo coronavírus (COVID-19).

Métodos: Foi realizada uma revisão retrospectiva de prontuários de pacientes internados por COVID-19 que apresentaram trombose venosa profunda e/ou embolia pulmonar sintomáticas. Foram avaliados os dados demográficos, a prevalência de tromboembolismo, a variação do D-dímero ao longo do tempo, o manejo e os desfechos.

Resultados: Dos 484 casos confirmados de COVID-19 admitidos entre março e julho de 2020, 64 apresentaram sintomas de tromboembolismo, que foram investigados, e 13 tiveram tromboembolismo confirmado (2,68% do total e 20,31% dos sintomáticos). A maioria dos casos ocorreu em regime de terapia intensiva (76,92%). Houve um aumento significativo no número de pacientes com D-dímero acima de 3.000 ng/mL no dia atribuído ao diagnóstico de tromboembolismo com relação aos níveis do momento da admissão (80%, p < 0,05).Uma queda significativa de pacientes nesse limiar também foi observada no momento da alta (p < 0,05). Todos os pacientes receberam tromboprofilaxia ou anticoagulação conforme indicado. Houve dois óbitos na amostra, ambos pacientes com comorbidades severas. Ao fim do protocolo, nove pacientes receberam alta e dois permaneceram hospitalizados, mas sem sinais de piora.

Conclusões: A prevalência de tromboembolismo em pacientes hospitalizados por COVID-19 foi de 2,7%, sendo mais frequente em regime de terapia intensiva. A instituição precoce de profilaxia e anticoagulação imediata ao diagnóstico é primordial nesse grupo de pacientes.
 

Palavras-chave

trombose, tromboembolismo venoso, embolia pulmonar, COVID-19, óbito, tratamento farmacológico

References

1 Hunt BJ. Preventing hospital associated venous thromboembolism. BMJ. 2019;365:l4239. http://dx.doi.org/10.1136/bmj.l4239. PMid:31227478.

2 Darze ES, Casqueiro JB, Ciuffo LA, Santos JM, Magalhães IR, Latado AL. Pulmonary embolism mortality in Brazil from 1989 to 2010: gender and regional disparities. Arq Bras Cardiol. 2016;106(1):4-12. http://dx.doi.org/10.5935/abc.20160001. PMid:26559854.

3 Zerati AE, Wolosker N, Yazbek G, Langer M, Nishinari K. Vena cava filters in cancer patients: experience with 50 patients. Clinics. 2005;60(5):361-6. http://dx.doi.org/10.1590/S1807-59322005000500003. PMid:16254671.

4 Ramacciotti E, Agati LB, Aguiar VCR, et al. Zika and Chikungunya virus and risk for venous thromboembolism. Clin Appl Thromb Hemost. 2019;25:1-5. http://dx.doi.org/10.1177/1076029618821184. PMid:30808213.

5 World Health Organization. WHO disease outbreak news: novel Coronavirus – Republic of Korea (ex-China). 2020 [citado 2020 maio 28]. https://www.who.int/csr/don/21- january-2020-novel

6 Tang N, Li D, Wang X, Sun Z. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. J Thromb Haemost. 2020;18(4):844-7. http://dx.doi.org/10.1111/jth.14768. PMid:32073213.

7 Lodigiani C, Iapichino G, Carenzo L, et al. Venous and arterial thromboembolic complications in COVID-19 patients admitted to an academic hospital in Milan, Italy. Thromb Res. 2020;191:9-14. http://dx.doi.org/10.1016/j.thromres.2020.04.024. PMid:32353746.

8 Klok FA, Kruip MJHA, van der Meer NJM, et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res. 2020;191:145-7. http://dx.doi.org/10.1016/j.thromres.2020.04.013. PMid:32291094.

9 Li B, Yang J, Zhao F, et al. Prevalence and impact of cardiovascular metabolic diseases on COVID-19 in China. Clin Res Cardiol. 2020;109(5):531-8. http://dx.doi.org/10.1007/s00392-020-01626-9. PMid:32161990.

10 Middeldorp S, Coppens M, van Haaps TF, et al. Incidence of venous thromboembolism in hospitalized patients with COVID-19. J Thromb Haemost. 2020;18(8):1995-2002. http://dx.doi.org/10.1111/jth.14888. PMid:32369666.

11 Xu J, Wang L, Zhao L, et al. Risk assessment of venous thromboembolism and bleeding in COVID-19 patients. Res Sq. 2020. In press.

12 Wells PS, Anderson DR, Bormanis J, et al. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet. 1997;350(9094):1795-8. http://dx.doi.org/10.1016/S0140-6736(97)08140-3. PMid:9428249.

13 Wang D, Hu B, Hu C, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA. 2020;323(11):1061-9. http://dx.doi.org/10.1001/jama.2020.1585. PMid:32031570.

14 Chen S, Zhang D, Zheng T, Yu Y, Jiang J. DVT incidence and risk factors in critically ill patients with COVID-19. J Thromb Thrombolysis. 2021;51(1):33-9. http://dx.doi.org/10.1007/s11239-020-02181-w. PMid:32607652.

15 Artifoni M, Danic G, Gautier G, et al. Systematic assessment of venous thromboembolism in COVID - 19 patients receiving thromboprophylaxis : incidence and role of D - dimer as predictive factors. J Thromb Thrombolysis. 2020;50(1):211-6. http://dx.doi.org/10.1007/s11239-020-02146-z. PMid:32451823.

16 Zhang L, Feng X, Zhang D, et al. Deep vein thrombosis in hospitalized patients with COVID-19 in Wuhan, China: prevalence, risk factors, and outcome. Circulation. 2020;142(2):114-28. http://dx.doi.org/10.1161/CIRCULATIONAHA.120.046702. PMid:32421381.

17 Demelo-Rodríguez P, Cervilla-Muñoz E, Ordieres-Ortega L, et al. Incidence of asymptomatic deep vein thrombosis in patients with COVID-19 pneumonia and elevated D-dimer levels. Thromb Res. 2020;192:23-6. http://dx.doi.org/10.1016/j.thromres.2020.05.018. PMid:32405101.

18 Di Minno A, Ambrosino P, Calcaterra I, Di Minno MND. COVID-19 and venous thromboembolism: a meta-analysis of literature studies. Semin Thromb Hemost. 2020;46(7):763-71. http://dx.doi.org/10.1055/s-0040-1715456. PMid:32882719.

19 Chi G, Lee JJ, Jamil A, et al. Venous thromboembolism among hospitalized patients with covid-19 undergoing thromboprophylaxis: a systematic review and meta-analysis. J Clin Med. 2020;9(8):2489. http://dx.doi.org/10.3390/jcm9082489. PMid:32756383.

20 Moores LK, Tritschler T, Brosnahan S, et al. Prevention, diagnosis, and treatment of VTE in patients with COVID-19. Chest. 2020;158(3):1143-63. http://dx.doi.org/10.1016/j.chest.2020.05.559. PMid:32502594.

21 Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European respiratory society (ERS). Eur Heart J. 2020;41(4):543-603. http://dx.doi.org/10.1093/eurheartj/ehz405. PMid:31504429.

22 Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for VTE disease: CHEST guideline. Chest. 2016;149(2):315-52. http://dx.doi.org/10.1016/j.chest.2015.11.026. PMid:26867832.

23 Yamashita Y, Morimoto T, Amano H, et al. Deep vein thrombosis in upper extremities: clinical characteristics, management strategies and long-term outcomes from the COMMAND VTE registry. Thromb Res. 2019;177:1-9. http://dx.doi.org/10.1016/j.thromres.2019.02.029. PMid:30825719.

24 Lippi G, Favaloro E. D-dimer is associated with severity of Coronavirus disease 2019: a pooled analysis. Thromb Haemost. 2020;120(5):876-8. http://dx.doi.org/10.1055/s-0040-1709650. PMid:32246450.

25 Zhang L, Yan X, Fan Q, et al. D-dimer levels on admission to predict in-hospital mortality in patients with COVID-19. J Thromb Haemost. 2020;18(6):1324-9. http://dx.doi.org/10.1111/jth.14859. PMid:32306492.

26 Favaloro EJ, Thachil J. Reporting of D-dimer data in COVID-19: some confusion and potential for misinformation. Clin Chem Lab Med. 2020;58(8):1191-9. http://dx.doi.org/10.1515/cclm-2020-0573. PMid:32432563.

27 Samama MM, Cohen AT, Darmon JY, et al. A comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients. N Engl J Med. 1999;341(11):793-800. http://dx.doi.org/10.1056/NEJM199909093411103. PMid:10477777.

28 Kahn SR, Lim W, Dunn AS, et al. Prevention of VTE in nonsurgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2, Suppl.):e195S-226S. http://dx.doi.org/10.1378/chest.11-2296. PMid:22315261.

29 Gregorio M, Laborda A, de Blas I, Medrano J, Mainar A, Oribe M. Tratamiento endovascular mediante fibrinolisis y fragmentación del embolismo pulmonar masivo con instabilidad hemodinámica: experiencia de un solo centro en 111 pacientes. ¿Por qué no seguimos las recomendaciones de la ACCP? Arch Bronconeumol. 2011;47(1):17-24. http://dx.doi.org/10.1016/j.arbres.2010.08.004. PMid:21208705.

30 Galastri F, Valle LGM, Affonso B, et al. COVID-19 complicated by pulmonary embolism treated with catheter directed thrombectomy. Vasa. 2020;49(4):333-7. http://dx.doi.org/10.1024/0301-1526/a000880.

31 Rossi FH. Tromboembolismo venoso em pacientes COVID-19. J Vasc Bras. 2020;7301(19):1-5.

32 Sobreira ML, Marques MA. A panaceia dos anticoagulantes na infecção pela COVID-19. J Vasc Bras. 2020;7301(19):e20200063. http://dx.doi.org/10.1590/1677-5449.200063.
 


Submitted date:
12/07/2020

Accepted date:
02/15/2021

60c0d1d1a953951a226219b4 jvb Articles
Links & Downloads

J Vasc Bras

Share this page
Page Sections