A retrospective observational study of in-hospital anticoagulation at prophylactic and therapeutic doses, vs. no anticoagulation, was associated with decreased morality and intubation in patients positive for COVID-19. The findings were published Aug. 26 in the Journal of the American College of Cardiology.

The study led by Girish N. Nadkarni, MD, MPH, CPH and Anuradha Lala, MD, FACC, and colleagues at Mount Sinai in New York, extends previous research from the institution that showed improved outcomes with anticoagulation in patients hospitalized with COVID-19. Thromboembolic disease is commonly seen in the setting of COVID-19.

“As a clinician who has treated COVID-19 patients on the front lines, I recognize the importance of having answers as to what the best treatment for these patients entails, and these results will inform the design of clinical trials to ultimately give concrete information,” says corresponding author Lala.

The researchers examined the electronic health records of 4,389 adult patients confirmed COVID-19 positive and admitted between March 1 and April 30 to five New York City hospitals in the Mount Sinai system. The median age of the patients was 65 years and 44% were female; 26% self-identified as African American and 27% as Hispanic/Latino.

For the primary outcome of in-hospital mortality, compared with no anticoagulation (n=1,530, 34.9%), therapeutic (n=900, 20.5%) and prophylactic anticoagulation (n=1,959, 44.6%) were associated with lower risk (adjusted hazard ratio [aHR], 0.53; 95% confidence interval [CI], 0.45-0.62) and aHR, 0.50; 95% CI, 0.45-0.57, respectively). The risk was also lower for the secondary endpoint of intubation (aHR 0.69; 95% CI: 0.51-0.94, and aHR 0.72; 95% CI, 0.58-0.89, respectively).

A subanalysis of patients in whom anticoagulation was initiated within 48 hours of admission showed no statistically significant difference between therapeutic (n=766) and prophylactic doses (n=1,860) (aHR 0.86, 95% CI, 0.73-1.02; p=0.08).

The secondary endpoint of major bleeding occurred in 89 (2%) patients, adjudicated by clinician review, with 27/900 (3.0%) on therapeutic, 33/1,959 (1.7%) on prophylactic, and 29/1,530 (1.9%) on no anticoagulation. Major bleeding was defined using ICD-10 codes or receiving two or more packed red blood cell transfusions with 48 hours.

The researchers also reviewed data from the first consecutive autopsies of COVID-19 patients performed at their institution and found that 11 of 26 patients (42%) had thromboembolic disease that was not suspected clinically. Of these, 3 patients (27%) were on therapeutic anticoagulation.

"This work from the Mount Sinai COVID Informatics Center provides additional insight on the role of anticoagulation in the management of patients admitted to the hospital with COVID-19," says senior corresponding author Valentin Fuster, MD, PhD, MACC. "Although this is an observational study, it helped in the design of a large-scale international clinical trial that we are coordinating." The randomized trial is focusing on three antithrombotic regimens, therapeutic and prophylactic subcutaneous low-molecular weight heparin and therapeutic oral apixaban, to determine the type, duration and doses for improved treatment and outcomes for patients with COVID-19.

Clinical Topics: Anticoagulation Management, COVID-19 Hub

Keywords: Heparin, Low-Molecular-Weight, Anticoagulants, Fibrinolytic Agents, COVID-19, Hospital Mortality, Retrospective Studies, Electronic Health Records, International Classification of Diseases, Erythrocyte Transfusion, severe acute respiratory syndrome coronavirus 2, Pyridones

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