Clinician Article
Anticoagulation Among Patients Hospitalized for COVID-19 : A Systematic Review and Prospective Meta-analysis.
PMID: 39715559
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Hemostasis and ThrombosisRelevance - 7/7
Newsworthiness - 6/7 -
Hospital Doctor/HospitalistsRelevance - 6/7
Newsworthiness - 6/7 -
Internal MedicineRelevance - 6/7
Newsworthiness - 6/7 -
Intensivist/Critical CareRelevance - 5/7
Newsworthiness - 4/7
Abstract
BACKGROUND: Reported results of clinical trials assessing higher-dose anticoagulation in patients hospitalized for COVID-19 have been inconsistent.
PURPOSE: To estimate the association of higher- versus lower-dose anticoagulation with clinical outcomes.
DATA SOURCES: Randomized trials were identified from the World Health Organization's International Clinical Trials Registry Platform and ClinicalTrials.gov with no restriction by trial status or language.
STUDY SELECTION: Eligible randomized trials assigned patients hospitalized for COVID-19 to higher- versus lower-dose anticoagulation.
DATA EXTRACTION: 20 eligible trials provided data in a prospectively agreed format. Two further studies were included based on published data. The primary outcome was all-cause mortality 28 days after randomization. Secondary outcomes were progression to invasive mechanical ventilation or death, thromboembolic events, and major bleeding.
DATA SYNTHESIS: Therapeutic- compared with prophylactic-dose anticoagulation with heparins reduced 28-day mortality (OR, 0.77 [95% CI, 0.64 to 0.93]; I2 = 29%; 11 trials, 6297 patients, of whom 5456 required low or no oxygen at randomization). The ORs for 28-day mortality were 1.21 (CI, 0.93 to 1.58; I2 = 0%) for therapeutic-dose compared with intermediate-dose anticoagulation (6 trials, 1803 patients, 843 receiving noninvasive ventilation at randomization) and 0.95 (CI, 0.76 to 1.19; I2 = 0%; 10 trials, 3897 patients, 2935 receiving no or low oxygen at randomization) for intermediate- versus prophylactic-dose anticoagulation. Treatment effects appeared broadly consistent across predefined patient subgroups, although some analyses were limited in power. Higher- compared with lower-dose anticoagulation was associated with fewer thromboembolic events, but a greater risk for major bleeding.
CONCLUSION: Therapeutic-dose compared with prophylactic-dose anticoagulation reduced 28-day mortality. Mortality was similar for intermediate-dose compared with prophylactic-dose anticoagulation and higher for therapeutic-dose compared with intermediate-dose anticoagulation, although this comparison was not estimated precisely.
PRIMARY FUNDING SOURCE: No direct funding. (PROSPERO: CRD42020213461).
Clinical Comments
Hemostasis and Thrombosis
This confirms prior evidence and current guidelines in favor of treatment-dose anticoagulation for non-critically ill patients hospitalized with COVID, and a lack of benefit for critically ill patients. It's not emphasized by the authors, but the findings suggest the benefit of treatment-dose AC extends to NIV.
Hospital Doctor/Hospitalists
Noteworthy that therapeutic anticoagulation has that effect; however, the abstract buries the lead a bit. There's high significance in sicker groups, with less so as patients become less critically ill. It's not significant for the vast majority of hospitalized patients.
Intensivist/Critical Care
Well done MA but this is NOT new information.
Intensivist/Critical Care
The crucial issue is to extract a clinically useful message. It's not clear it will be easy beyond current thinking - full in less sick and prophylactic in sicker patients (likely MV).
Internal Medicine
It's difficult to know what to do with these data - are they still applicable in today's COVID-infected world? The bottom line is confusing.
