New Studies Explore Anticoagulation and COVID-19

New studies from the Mount Sinai Health System and NYU Langone Medical Center explore efficacy and risks of anticoagulation in hospitalized patients with COVID-19. Questions about the relationship between thrombosis and the coronavirus have puzzled clinicians since symptoms of abnormal coagulation were first reported in patients with COVID-19 in mid-February.

The Mount Sinai study, published in the Journal of the American College of Cardiology, examined associations between in-hospital anticoagulation and survival in a cohort of 2,773 hospitalized patients with COVID-19.

For anticoagulated patients, the in-hospital mortality rate was 22.5% with a median survival of 21 days, compared with 22.8% and 14 days for those who did not receive anticoagulation. However, those who received anticoagulation also were more likely to require mechanical ventilation compared with those who received prophylactic-dose anticoagulation or did not receive anticoagulation (29.8% vs. 8.1%), and mechanically ventilated patients did not experience a survival benefit with anticoagulation: The in-hospital mortality rates and median survival lengths among anticoagulated patients and non-anticoagulated patients were 29.1% versus 62.7%, and 21 days versus 9 days, respectively. The findings suggest that systemic treatment-dose anticoagulation may be associated with improved outcomes among patients hospitalized with COVID-19, but the potential benefits need to be weighed against the risk of bleeding.

NYU Langone researchers conducted a retrospective study of patients with hemorrhagic stroke hospitalized between March 1 and May 15, 2020 within a major New York health system. Findings were published in Neurocritical Care. The team compared clinical characteristics of patients admitted to the hospital with stroke and COVID-19 with those of a control group of patients with stroke but without COVID-19, as well as a historical group of patients admitted for stroke in the spring of 2019.

Of 4,071 patients hospitalized with COVID-19, 19 (0.5%) had hemorrhagic stroke. Within this cohort, coagulopathy was the most common stroke etiology (73.7%). Patients hospitalized for COVID-19 more often received empiric anticoagulation, compared with patients without COVID-19 in the contemporary and historical control groups (89.5% vs. 4.2% and 10%, respectively). Compared with patients without COVID-19 in both the contemporary and historical controls, those with the infection had higher rates of in-hospital mortality (84.6% vs. 4.6%). The team concluded that the overall rate of hemorrhagic stroke was low among hospitalized COVID-19 patients. Most hemorrhages occurred in the setting of therapeutic anticoagulation, which was associated with increased mortality.

The findings from these observational studies, “[have] given us the nuts and bolts to do a randomized clinical trial, which is now ongoing internationally,” said Valentin Fuster, MD, PhD, Physician-in-Chief of Mount Sinai Hospital. “That, I think, is the most important message to be derived from this report.”

Sources: Paranjpe I, Fuster V, Lala A, et al. Association of Treatment Dose Anticoagulation With In-Hospital Survival Among Hospitalized Patients With COVID-19. J Am Coll Cardiol. 2020;76:122-124. Kvernland A, Kumar A, Yaghi S, et al. Anticoagulation use and Hemorrhagic Stroke in SARS-CoV-2 Patients Treated at a New York Healthcare System. Neurocrit Care. 2020 Aug 24. [Epub ahead of print]