Abstract
Background: COVID-19 caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) and other respiratory viral (non-CoV-2-RV) infections are associated with thrombotic complications. The differences in prothrombotic potential between SARS-CoV-2 and non-CoV-2-RV have not been well characterised. We compared the thrombotic rates between these two groups of patients directly and further delved into their coagulation profiles. Methods: In this single-center, retrospective cohort study, all consecutive COVID-19 and non-CoV-2-RV patients admitted between January 15th and April 10th 2020 were included. Coagulation parameters studied were prothrombin time and activated partial thromboplastin time and its associated clot waveform analysis (CWA) parameter, min1, min2 and max2.Findings: In the COVID-19 (n=181) group there were two (1.0 event/1000-hospital-days) thrombotic events while one (1.8 event/1000-hospital-day) was reported in the non-CoV-2-RV (n=165) group. All of these events were myocardial infarction occurring in the intensive care unit. Coagulation parameters did not differ throughout the course of mild COVID-19. However, CWA parameters were significantly higher in severe COVID-19 compared with mild disease, suggesting hypercoagulability (min1: 6.48%/s vs 5.05%/s, P 2 vs 0.74%/s2, P =0.033).Interpretation: The thrombotic rates were low and did not differ between COVID-19 and non-CoV-2-RV patients. The hypercoagulability in COVID-19 is a highly dynamic process with the highest risk occurring when patients were most severely ill. Such changes in haemostasis could be detected by CWA. In our population, a more individualized thromboprophylaxis approach, considering clinical and laboratory factors, is preferred over universal pharmacological thromboprophylaxis for all hospitalized COVID-19 patients and such personalized approach warrants further research. Funding: This research was funded by the SingHealth Duke-NUS Academic Medicine COVID-19 Research Grant.Declaration of Interests: The authors declare no competing interests.Ethics Approval Statement: This database is part of a prospective study to characterize emerging infectious diseases and was approved by our institutional review board (CIRB no. 2018/3045).
Highlights
Towards the end of April 2020, investigators were reporting the association of Coronavirus Disease-19 (COVID-19) with increased incidence of thrombotic events
Venous thrombotic events were defined as any venous thromboembolism including deep vein thrombosis, pulmonary embolism and thrombosis of other sites, which were objectively confirmed on radiological imaging after initial clinical suspicion by attending physicians
Among the 186 COVID-19 patients, four patients were co-infected with other respiratory viruses and were excluded from analysis
Summary
Towards the end of April 2020, investigators were reporting the association of Coronavirus Disease-19 (COVID-19) with increased incidence of thrombotic events. The thrombotic manifestations in COVID-19 patients have led to both the American Society of Hematology (ASH)[8] and International Society on Thrombosis and Hemostasis (ISTH)[9] recommending that all hospitalized patients including the non-critically ill, receive venous thromboembolism (VTE) thromboprophylaxis with low molecular weight heparin (LMWH) or fondaparinux. It is uncertain if such recommendations should be universally adopted as there is significant heterogeneity in reported thrombotic rates as most studies were carried out on critically ill COVID-19 patients[10]. Less accessible global hemostatic assays such as thromboelastogram and clot waveform analysis (CWA) have demonstrated hypercoagulability, albeit in small groups of critically ill COVID-19 patients.[14,15]
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