Arterial Thromboembolic Complications Research Articles

The Additional Value of Activated Clotting Time-Guided Heparinization During Interventions for Peripheral Arterial Disease.

Unfractionated heparin is widely used to lower the risk of arterial thromboembolic complications (ATECs) during interventions for peripheral arterial disease (PAD), but it is still unknown which heparin dose is the safest in terms of preventing ATECs and bleeding complications. This study aims to evaluate the incidence of complications during interventions for PAD and the relation between this incidence and different heparinization protocols. A retrospective analysis of a prospective multicenter cohort study was performed. Between June 2015 and September 2022, 355 patients who underwent peripheral interventions for PAD were included. All patients who were included before July 2018 received 5000 international units (IU) of heparin (group 1). Starting from July 2018, all included patients received an initial dose of 100 IU/kg, with potential additional heparin doses based on activated clotting time (ACT) values (group 2). Data on ACT values and complications within 30 days post-procedurally were collected. In total, 24 ATECs and 48 bleeding complications occurred. In group 1, 8.7% (n=11) of patients suffered from ATEC, compared with 5.7% (n=13) in group 2. Thirteen percent of patients (n=17) in group 1 had a bleeding complication, compared with 14% (n=31) in group 2. Arterial thromboembolic complications were more often found in patients with peak ACT values of <200 seconds, compared with ACT values between 200 and 250 seconds, 15% (n=6) versus 5.9% (n=9), respectively, p=0.048. Patients with peak ACT values >250 seconds had a higher incidence of bleeding complications compared with an ACT between 200 and 250 seconds, 24% (n=21) versus 9.8% (n=15), respectively, p=0.003. Forty-four percent of patients (n=23) in group 1 reached a peak ACT of >200 seconds, compared with 95% (n=218) of patients in group 2 (p=0.001). ATEC was found in 6.8% (n=24) and bleeding complications in 14% (n=48) of patients who underwent a procedure for PAD. There was a significantly higher incidence of ATECs in patients with a peak ACT value <200 seconds, and a higher incidence of bleeding complications in patients with a peak ACT value >250 seconds. The findings obtained from this study may serve as a basis for conducting future research on heparinization during procedures for PAD, with a larger sample size. Heparin is administered during arterial interventions for peripheral arterial disease (PAD) to decrease the risk of arterial (thrombo)embolic complications (ATEC) during or shortly following surgery. The effect of heparin is unpredictable in the individual patient, and the optimal dosage of this anticoagulant has not yet been established. Using the activated clotting time (ACT), the anticoagulatory effect of heparin can be monitored periprocedurally. Previous research on the incidence of both ATEC and bleeding complications, or on the optimal dosage of heparin administration, is scarce. This study aims to investigate the incidence of ATEC and bleeding complications between 2 different dosage protocols of heparin-a standard bolus of 5000 IU or ACT-guided heparinization-and thereby provide clarity on the optimal dose of heparin during peripheral arterial interventions for PAD.

Arterial and Venous Thromboembolic Complications in 832 Patients with BCR-ABL-Negative Myeloproliferative Neoplasms.

Arterial (ATE) and venous (VTE) thromboembolic complications are common causes of morbidity and mortality in BCR-ABL-negative myeloproliferative neoplasms (MPNs). However, there are few studies that include all MPN subtypes and focus on both MPN-associated ATE and VTE. In our single-center retrospective study of 832 MPN patients, a total of 180 first thromboembolic events occurred during a median follow-up of 6.6 years (range: 0-37.6 years), of which 105 were VTE and 75 were ATE. The probability of a vascular event at the end of the follow-up period was 36.2%, and the incidence rate for all first ATE/VTE was 2.43% patient/year. The most frequent VTE localizations were deep vein thrombosis with or without pulmonary embolism (incidence rate: 0.59% patient/year), while strokes were the most frequent ATE with an incidence rate of 0.32% patient/year. When comparing the group of patients with ATE/VTE (n = 180) and the group without such an event (n = 652) using multivariate Cox regression analyses, patients with polycythemia vera (hazard ratio [HR]: 1.660; [95% confidence interval [CI] 1.206, 2.286]) had a significantly higher risk of a thromboembolic event than the other MPN subtypes. In contrast, patients with a CALR mutation had a significantly lower risk of thromboembolism compared with JAK2-mutated MPN patients (HR: 0.346; [95% CI: 0.172, 0.699]). In summary, a high incidence of MPN-associated VTE and ATE was observed in our retrospective study. While PV patients or generally JAK2-mutated MPN patients had a significantly increased risk of such vascular events, this risk was reduced in CALR-mutated MPN patients.

PREMATURE VENTRICULAR CONTRACTIONS AS AN ADDITIONAL RISK FACTOR FOR THE ARTERIAL THROMBOEMBOLISM

Premature ventricular contractions (PVCs) are not included in the risk factors for arterial thromboembolism. Aim: To determine the relationship between PVCs and the development of arterial thromboembolic complications. Methods: The study included 440 patients with PVCs 700 or more per 24 hours, control group - 88 people with PVCs less than 700. All patients underwent laboratory and instrumental studies: lipid spectrum, hemostasis indicators; 24-hours ECG monitoring; echocardiography (EchoCG); Doppler ultrasound and digital sphygmography (SG) of the main arteries; ultrasound of the aorta branches, renal arteries. According to the indications - stress EchoCG with physical exercises, coronary angiography, pancerebral angiography, renal arteries angiography, computed tomography, magnetic resonance imaging of the brain. All patients of the main group were divided into 2 subgroups, depending on the moment of occurrence of PVCs ventricular systole in the cardiac cycle, regardless of the ectopic center: subgroup A (120) - patients with PVCs before the peak of transmitral blood flow; subgroup B (320) - after the peak of the transmitral blood flow. Patients were observed during 1 year and the development of arterial thromboembolic events was analyzed. Results: According to the main clinical, laboratory and instrumental data, patients of subgroups A, B and the control group were equivalent. Also, during 1 year, a statistically significantly higher development of arterial thromboembolic events was observed in subgroup A. When comparing linear blood flow velocity and volumetric blood flow, there was a significant increase in parameters during the spreading of the first post-extrasystolic contraction wave. A similar trend was observed in the parameters of the kinetics of the arterial vascular wall (velocity, acceleration, power, work). Conclusion: PVCs are an additional risk factor for arterial thromboembolic events. The main danger is not the PVC itself, but the wave of the first post-extrasystolic contraction, which can become the starting point for the instability of atherosclerotic plaques, leading to tears, parietal thrombosis, and embolism in the arterial vessels.

The risk of arterial thromboembolic complications in bladder cancer patients after radical cystectomy – population-based nationwide matched cohort study

The risk of arterial thromboembolic complications in bladder cancer patients after radical cystectomy – population-based nationwide matched cohort study

Arterial thromboembolism (ATE) and mortality among COVID-19 patients in the intensive care unit (ICU): prevalence and risk factors

Abstract Funding Acknowledgements Type of funding sources: None. Objective To investigate the prevalence of arterial thromboembolic (TE) complications including stroke, peripheral arterial disease (PAD) and myocardial infarction (MI) and mortality among COVID-19 patients admitted to an ICU at a single centre hospital in the area of Klang Valley, Malaysia. The proportions of patients with ATE complication who died, and factors associated with the occurrence of ATE were explored. Methods Patients admitted to a single centre ICU with PCR confirmed of SARS-CoV-2 virus and received adequate thromboprophylaxis within February 2020-2021 were included in this retrospective Malaysian cohort study. ATE event is a combination of ≥1 stroke, PAD and MI. Results Mean (SD) age 56.6 (13.7), 63.5% were male, 61.6% Malays, median (IQR) 7 (3-14) days of ICU admission, 64.2%, 53.2 % and 20.9% had underlying hypertension, diabetes and obesity respectively. Of 534 patients, 21 (3.9%) developed stroke, 39 (7.3%) MI, 1(0.2%) PAD and 22.8% died despite adequate thromboprophylaxis. In total, only 58 (10.9%) developed ATE event during their ICU admission. Significantly higher proportions of COVID-19 patients admitted to ICU who developed complications of stroke (12.3% vs. 1.5; p&amp;lt;0.001) and MI (16.4% vs. 4.6%; p&amp;lt;0.001) died. Age, duration of ICU admission, proportion of underlying hypertension, stroke, IHD, diabetes, kidney disease, troponin, D-Dimer were significantly greater among those with ATE events. Predictors of ATE event on multivariate logistic regression analysis were duration of ICU admission [OR 1.0 (95% CI 1.00-1.04)] and troponin [OR 1.3 (95% CI 1.1-1.4)] level. Conclusion The overall prevalence of ATE complication among the severely ill COVID-19 patients was low (10.9%) with the overall mortality of 22.8% despite adequate thromboprophylaxis. Key predictors of ATE events included increased troponin level and duration of ICU admission. Perhaps a more aggressive preventive strategies can be undertaken to prevent further increase in the prevalence of arterial thromboembolism and death.

Relationship between COVID-19 Infection and Buerger's Disease-Related Amputations

Introduction: Thromboangiitis obliterans (TAO) or Buerger's disease is a non-atherosclerotic, inflammatory arteritis involving small and medium-sized arteries and veins of the extremities, often causing gangrene and scarring. Coronavirus disease (COVID-19) may predispose to both arterial and venous thromboembolic complications. This study examined the relationship between COVID-19 infection and Buerger's disease-related amputations. Materials and Methods: Between January 2018 and July 2023, 54 patients who applied to our clinic for Buerger's disease and were followed up and treated were analyzed retrospectively. Follow-up information, demographic data of patients (age, gender, body mass index (BMI), education status), when they were diagnosed, amount of smoking (pack/year), all treatments applied for Buerger's disease (Pre-Covid – Covid period – Covid Afterwards), presence or absence of limb amputation, continued smoking, medications, cardiovascular risk factors, Charlson Comorbidity Index (CCI), Venous Thromboembolic Event (Pulmonary Embolism), Covid-19 History and vaccination information were noted. Results: The mean age of 54 patients included in the study was 38.1 (27-49), all male. The mean smoking rate was 32 (16 - 60) packs/year, and the mean exposure to the SARS-CoV-2 virus was 1.22 (0-4) times. There was a significant correlation between major amputations due to Buerger's disease and age, severity of COVID-19 disease, and systemic hypertension (p&lt;0.005). Major amputation rates increased during the period of COVID-19 disease (p&lt;0.05). Conclusion: We found a statistically significant increase in major amputations as the exposure to the virus or the severity of the COVID-19 disease increased. We also observed a significant increase in major amputation rates in the presence of systemic hypertension. The presence of COVID-19 disease and hypertension should be considered when planning treatment to prevent amputation in Buerger's patients.

Acute limb ischemia in COVID-19 patients despite therapeutic anticoagulation: Experience from Africa

BackgroundHypercoagulability is a common complication seen in COVID-19 infection. However, arterial thrombosis such as acute limb ischemia (ALI) is far less common. Data on the incidence and nature of arterial thromboembolic complications in patients with COVID-19 is limited, originating from a few case reports and case series. Data in the African continent are very scarce. MethodThis is a case series of 10 patients with COVID-19 who developed ALI while on treatment at Eka Kotebe General Hospital, Addis Ababa, Ethiopia. All patients with ALI and COVID-19 admitted between February 1, 2021, and December 31, 2021, were retrospectively identified and reviewed. COVID-19 was confirmed by RT-PCR and ALI was confirmed by Doppler ultrasound and/or computed tomography angiography in the presence of clinical suspicion. ResultsA total of 3098 patients were hospitalized with confirmed COVID-19 during the study period. In a series of 10 patients, 8 (80%) males with a median age of 53.5 years were included. All except one (10%) had one or more risk factors for ALI and one had a ‘possible’ case of vaccine-induced thrombotic thrombocytopenia (VITT) associated with ALI. All were admitted with severe COVID-19 and most (80%) developed ALI during hospitalization (median of seven days from admission). The median duration between COVID-19 and ALI symptom onset was 14.5 days (IQR, 11–15). The majority (60%) were taking therapeutic anticoagulation at the time of ALI onset which is the standard of care for patients with severe disease. Five (50%) were successfully revascularized (median time of 3.5 days) and the rest underwent amputation. All survived and were discharged improved. ConclusionALI can occur in the context of COVID-19 even while a patient is on therapeutic dose anticoagulation and in the absence of traditional risk factors. It is wise to be vigilant of this complication for timely intervention and better treatment outcomes.

Independent risk factors for an increased incidence of thromboembolism after lung transplantation

BackgroundThromboembolism (TE) after lung transplantation (LTX) is associated with increased morbidity and mortality. The aim of this study is to analyze the incidence and outcome of venous and arterial thromboembolic complications and to identify independent risk factors.Patients and methodsWe retrospectively analyzed the medical records of 221 patients who underwent LTX at our institution between 2002 and 2021. Statistical analysis was performed using SPSS and GraphPad software.Results74 LTX recipients (33%) developed TE. The 30-days incidence and 12-months incidence were 12% and 23%, respectively. Nearly half of the patients (48%) developed pulmonary embolism, 10% ischemic stroke. Arterial hypertension (p = 0.006), a body mass index (BMI) > 30 (p = 0.006) and diabetes mellitus (p = 0.041) were independent predictors for TE. Moreover, a BMI of > 25 at the time of transplantation was associated with an increased risk for TE (43% vs. 32%, p = 0.035). At the time of LTX, 65% of the patients were older than 55 years. An age > 55 years also correlated with the incidence of TE (p = 0.037) and these patients had reduced overall post-transplant survival when the event occurred within the first postoperative year (59% vs. 72%, p = 0.028).ConclusionsThe incidence of TE after LTX is high, especially in lung transplant recipients with a BMI > 25 and an age > 55 years as well as cardiovascular risk factors closely associated with the metabolic syndrome. As these patients comprise a growing recipient fraction, intensified research should focus on the risks and benefits of regular screening or a prolonged TE prophylaxis in these patients.Trial registration number DKRS: 00021501.

Extrasystoles: relationship with arterial thromboembolic complications

Aim to determine the relationship between extrasystoles (ES) and the development of arterial thromboembolic complications.&#x0D; Material and methods. The study included 440 patients with ES 700 or more per 24 hours, control group 88 people with ES less than 700. All patients underwent laboratory and instrumental examinations: lipid spectrum, hemostasis indicators; 24-hours ECG monitoring; echocardiography (EchoCG); Doppler ultrasound and digital sphygmography (SG) of the main arteries; ultrasound of the aorta branches, renal arteries. According to the indications, the patients were administered: stress EchoCG with physical exercises, coronary angiography, pancerebral angiography, renal arteries angiography, computed tomography, magnetic resonance imaging of the brain. All patients of the main group were divided into 2 subgroups, depending on the moment of occurrence of ES ventricular systole in the cardiocycle, regardless of the ectopic center: subgroup A (120) patients with ES before the peak of transmitral blood flow; subgroup B (320) after the peak of the transmitral blood flow. Patients were observed during 1 year and the development of arterial thromboembolic events was analyzed.&#x0D; Results. According to the main clinical, laboratory and instrumental data, patients of subgroups A, B and the control group were equivalent. Also, during 1 year follow-up, a significantly higher development of arterial thromboembolic events was observed in subgroup A. When comparing the linear blood flow velocity and volumetric blood flow, there was a significant increase in parameters during the spreading of the first post-extrasystolic contraction wave. A similar trend was observed in the parameters of the kinetics of the arterial vascular wall (velocity, acceleration, power, work).&#x0D; Conclusion. Extrasystoles are an additional risk factor for arterial thromboembolic events. The main danger is not the ES itself, but the wave of the first post-extrasystolic contraction, which can become the starting point for the instability of atherosclerotic plaques, leading to tears, parietal thrombosis, and embolism along the arterial vessel.

Editor's Choice – Sex Differences in Response to Administration of Heparin During Non-Cardiac Arterial Procedures

Females are more prone to complications during non-cardiac arterial procedures (NCAPs) than males. The current study investigated the difference in the effect of peri-procedural prophylactic heparin in males and females, using the activated clotting time (ACT). This was a retrospective analysis of a prospective multicentre cohort study. All patients undergoing elective NCAP using heparin and ACT measurements between January 2016 and March 2020 were included. Two heparin dosage protocols were used: weight based dosing of 100 IU/kg (international units per kilogram) or a bolus of 5 000 IU. The primary outcome was the anticoagulatory effect of heparin after five minutes, measured by ACT. Secondary outcomes were the effect of heparin after 30 minutes, bleeding complications, and arterial thromboembolic complications (ATECs). A total of 778 patients were included; 26% were female. After 100 IU/kg (n= 300), females more often reached longer ACT (< 200 seconds: 22% vs. 25%, p= .62; 200 - 250 seconds: 41% vs. 53%, p= .058; 251 - 280 seconds, 26% vs. 15%, p= .030). The mean ACT after 100 IU/kg heparin was 233 seconds (95% confidence interval [CI] 224 - 243) for females and 226 seconds (95% CI 221 - 231) for males (p= .057). After a bolus of 5 000 IU of heparin (n= 411), females reached significantly higher levels of anticoagulation than males (mean ACT 204 seconds vs. 190 seconds: p ≤ .001; ACT < 200 seconds: 44% vs. 66%; p < .001; ACT 200 - 250 seconds: 47% vs. 30%, p= .001; ACT 251 - 280 seconds: 7.8% vs. 2.3%, p= .009). Thirty minutes after heparin administration, 58% of all patients had an ACT < 200 seconds. ATECs did not differ between females and males (6.9% vs. 5.1%, p= .33) but bleeding complications were higher in females (27% vs. 16%, p= .001). Heparin leads to significantly longer ACT in females during NCAP. Further research is needed to investigate whether individually based heparin protocols lead to fewer bleeding complications and lower incidence of ATECs.

Thromboembolic events in COVID-19 ambulatory patients: An observational study about incidence, and thromboprophylaxis outcomes.

IntroductionThere are no clear data about the incidence and the prophylactic strategies of arterial and venous thromboembolic events (TE) in COVID-19 ambulatory patients. Thus, we conducted this study to analyze thromboembolic complications in this setting and to assess thromboprophylaxis management and outcomes in the real life.Patients and methodsThis is an observational study including Covid-19 ambulatory patients. We assessed incidence of venous and arterial TE events as well as thromboprophylaxis outcomes and hemorrhagic complications. We defined high risk thrombo-embolic factor according to the Belgian guidelines which are the only guidelines that described thromboprophylaxis in COVID-19 ambulatory patients.ResultsWe included 2089 patients with a mean age of 43±16 years. The incidence of 30 days venous and arterial TE complications in our cohort was 1%. Venous thromboembolic complications occurred in 0.8% and arterial thromboembolic complications occurred in 0.3%.We noted at least one high-risk TE factor in 18.5% of patients but thromboprophylaxis was prescribed in 22.5% of the cases, LMWH in 18.1%, and Rivaroxaban in 3.7%. Hemorrhagic events occurred in eight patients (0.3%): five patients showed minor hemorrhagic events and three patients showed major ones (0.14%).ConclusionsOur study showed that the incidence of thromboembolic complications is very low in COVID-19 ambulatory patients. Paradoxically, there is an over prescription of thrombo-prophylaxis in this population.

Rotational thromboelastometry in critically ill COVID‐19 patients does not predict thrombosis

BackgroundCritically ill COVID‐19 patients are in a hypercoagulable state with increased risk of thrombotic complications. Rotational thromboelastometry (ROTEM) is a viscoelastic test with the potential to reflect COVID‐19‐associated hypercoagulability and may therefore be useful to predict thrombotic complications. ObjectiveTo investigate the potential of ROTEM profiles to predict thrombotic complications in critically ill COVID‐19 patients. Patients/MethodsRetrospective multicenter cohort study in 113 adult patients with confirmed COVID‐19 infection admitted to the intensive care unit (ICU) of two large teaching hospitals in the United States and in the Netherlands. ROTEM profiles of the EXTEM, INTEM, and FIBTEM tracings were measured within 72 h of ICU admission. Thrombotic complications encompass both arterial and venous thromboembolic complications, diagnosed with electrocardiogram, ultrasound, or computed tomography. ROTEM profiles were compared between patients with and without thrombosis. Univariable logistic regression followed by receiver operating characteristic (ROC) curves analysis was performed to identify ROTEM parameters associated with thrombosis. Results and ConclusionsOf 113 patients, 27 (23.9%) developed a thrombotic event. In the univariable analysis, EXTEM clot amplitude at 10 min (CA10) and EXTEM maximum clot formation (MCF) were associated with thrombosis with a p < 0.2 (p = 0.07 and p = 0.05, respectively). In ROC curve analysis, EXTEM CA10 had an area under the curve (AUC) of 0.58 (95% CI 0.47–0.70) and EXTEM MCF had an AUC of 0.60 (95% CI 0.49–0.71). Thereby, ROTEM profiles at ICU admission did not have the potential to differentiate between patients with a high and low risk for thrombotic complications.

Weight Based Heparin Dosage with Activated Clotting Time Monitoring Leads to Adequate and Safe Anticoagulation in Non-Cardiac Arterial Procedures

Unfractionated heparin has an unpredictable effect in an individual patient. The activated clotting time (ACT) can be used to measure the effect of heparin in the individual patient and guide additional heparin dosages. Previous cohort studies showed that a standardized bolus of 5,000 IU during noncardiac arterial procedures (NCAP) does not lead to an adequate ACT in the vast majority of patients. The aim of this study was to investigate whether an initial heparin dose of 100 IU/kg leads to an adequate but safe ACT, from 200 to 300s. In this multicenter prospective study, 186 patients undergoing NCAP were enrolled and received an initial heparin dose of 100 IU/kg. Target ACT was set at ≥250s initially; during the course of the study the target ACT was lowered to ≥200s. After the initialheparin dose, additional heparin dosages were administered depending on the ACT values following a heparin dose protocol. ACT measurements and complications were monitored. The mean baseline ACT was 134±17s. The mean ACT 5minutes after the initial heparin dose was 227±37s. After the initial dose of heparin, 78 and 46% of patients reached an ACT of 200 and 250s, respectively. Seven patients (4%) reached an ACT of 300s or more. Ninety-four patients (51%) received at least one additional dose of heparin. After one additional dose of heparin, 91% of patients reached an ACT of 200s and 13 patients (7%) reached an ACT of 300s or more. Arterial thromboembolic complications occurred in 4.3% and bleeding complications occurred in 9.7%. A bolus of 100 IU/kg of heparin during NCAP results in adequate coagulation in most patients. ACT measurements enable accurate additional dosing, ensuring the individual patient tailored and safe coagulation. anticoagulants; heparin; blood coagulation tests; vascular surgical procedures; peripheral vascular disease.

Arterial and Venous Thromboembolism in Critically Ill, COVID-19 Positive Patients Admitted to Intensive Care Unit

Arterial and Venous Thromboembolism in Critically Ill, COVID-19 Positive Patients Admitted to Intensive Care Unit

Thromboembolic complications during and after hospitalization for COVID-19: Incidence, risk factors and thromboprophylaxis

IntroductionThe incidence of thromboembolism during COVID-19 and the use of thromboprophylaxis vary greatly between studies. Only a few studies have investigated the rate of thromboembolism post-discharge. This study determined the 90-day incidence of venous and arterial thromboembolic complications, risk factors for venous thromboembolic events and characterized the use of thromboprophylaxis during and after hospitalization. Materials and methodsWe retrospectively reviewed medical records for adult patients hospitalized for >24 h for COVID-19 before May 15, 2020, in ten Norwegian hospitals. We extracted data on demographics, thromboembolic complications, thromboembolic risk factors, and the use of thromboprophylaxis. Cox proportional hazards regression was used to determine risk factors for VTE. Results550 patients were included. The 90-day incidence of arterial and venous thromboembolism in hospitalized patients was 6.9% (95% CI: 5.1–9.3) overall and 13.8% in the ICU. Male sex (hazard ratio (HR) 7.44, 95% CI 1.73–32.02, p = 0.007) and previous VTE (HR 6.11, 95% CI: 1.74–21.39, p = 0.005) were associated with risk of VTE in multivariable analysis. Thromboprophylaxis was started in 334 patients (61%) with a median duration of 7 days (25th–75th percentile 3–13); in the VTE population 10/23 (43%) started thromboprophylaxis prior to diagnosis. After discharge 20/223 patients received extended thromboprophylaxis and 2/223 (0.7%, 95% CI: 0.3–1.9) had a thromboembolism. ConclusionsThe 90-day incidence of thromboembolism in COVID-19 patients was 7%, but <1% after discharge. Risk factors were male sex and previous VTE. Most patients received thromboprophylaxis during hospitalization, but only <10% after discharge.

COVID-19 Induced Coagulopathy (CIC): Thrombotic Manifestations of Viral Infection.

Coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and may result in an overactive coagulative system, thereby resulting in serious cardiovascular consequences in critically affected patients. The respiratory tract is a primary target for COVID-19 infection, which is manifested as acute lung injury in the most severe form of the viral infection, leading to respiratory failure. A proportion of infected patients may progress to serious systemic disease including dysfunction of multiple organs, acute respiratory distress syndrome (ARDS), and coagulation abnormalities, all of which are associated with increased mortality, additionally depending on age and compromised immunity. Coagulation abnormalities associated with COVID-19 mimic other systemic coagulopathies otherwise involved in other severe infections, such as disseminated intravascular coagulation (DIC) and may be termed COVID-19 induced coagulopathy (CIC). There is substantial evidence that patients with severe COVID-19 exhibiting CIC can develop venous and arterial thromboembolic complications. In the initial stages of CIC, significant elevation of D-dimer and fibrin/fibrinogen degradation products is observed. Alteration in prothrombin time, activated partial thromboplastin time, and platelet counts are less common in the early phase of the disease. In patients admitted to intensive care units (ICUs), coagulation test screening involving the measurement of D-dimer and fibrinogen levels, has been recommended. Prior established protocols for thromboembolic prophylaxis are also followed for CIC, including the use of heparin and other standard supportive care measures. In the present review, we summarize the characteristics of CIC and its implications for thrombosis, clinical findings of coagulation parameters in SARS-CoV-2 infected patients with incidences of thromboembolic events and plausible therapeutic measures.

КЛИНИЧЕСКИЙ СЛУЧАЙ ВНУТРИСЕРДЕЧНОГО ТРОМБОЗА НА ФОНЕ ПЕРЕНЕСЕННОЙ ИНФЕКЦИИ SARS-COV-2

The damage to humanity and global healthcare done by the COVID-19 pandemic is hard to overestimate. According to the World Health Organization (WHO), there were more than 500 million confirmed cases of SARS-CoV-2 infection, more than 6 million of which were fatal. The high incidence of arterial thrombosis and venous thromboembolic complications despite the ongoing antithrombotic therapy, often leading to death in patients with new coronavirus infection SARS-CoV-2, indicates the need for profound study of the pathogenetic aspects of procoagulant status and a more rational personalized approach in prophylactic measures in this category of patients. Special interest is the development of thrombotic complications in COVID-19 convalescents. This article presents a clinical case of a 43-year-old man with no cardiovascular history who suffered viral myocarditis with thrombus formation in the heart cavities, thrombosis of deep veins of the lower extremities and consequent pulmonary thromboembolism, all of which developed within a month after coronavirus infection. In the article authors discuss the leading pathophysiological mechanisms that potentially could propagate the development of thrombosis and thromboembolic complications in patients with COVID-19.

Cardiovascular outcomes in hospitalized patients with COVID-19 and history of cancer: a CORONA-VTE analysis

BackgroundIn hospitalized patients with COVID-19, active cancer has been identified as a potential risk factor for adverse cardiovascular outcomes, including thrombosis. However, the impact of COVID-19 on outcomes in patients with a remote history of cancer is poorly understood. We evaluated hospitalized patients with a history of remote cancer and COVID-19 to examine whether a history of cancer contributes to 30-day major adverse cardiovascular outcomes among patients with COVID-19.MethodsUsing a retrospective cohort of 1114 patients from CORONA-VTE (Registry of Arterial and Venous Thromboembolic Complications in Patients With COVID-19), we looked at 399 hospitalized patients diagnosed with polymerase chain reaction (PCR)-confirmed COVID-19 within a large heath care network that consists of two large academic medical centers and several community hospitals. Twenty-six patients with active cancer or receiving cancer treatment within 1-year of COVID-19 diagnosis and five patients with unknown cancer history were excluded. We assessed 46 patients with a history of cancer and 322 patients without any history of cancer. The primary endpoint was the frequency of adjudicated major adverse cardiovascular outcomes, defined as myocardial infarction, stroke, pulmonary embolism, deep vein thrombosis, and mortality.ResultsAmong the 46 hospitalized patients with COVID-19 and a history of cancer, 23.9% were non-white and 43.48% women. Compared to patients without any history of cancer, patients with a history of cancer were older (median 59.0 vs. 75.5 years, p<0.001) and had higher BMI (median 26.4 vs. 29.6 kg/m2, p<0.05). Patients with a history of cancer had higher rates of underlying CVD than those without (42.4% vs. 23.2%). Rates of major adverse cardiovascular events were similar in patients with and without a history of cancer (28.3% vs. 23.6%, respectively). Those with a history of cancer had a higher mortality rate (28.9% vs. 11.2%, p<0.05). Acute Respiratory Distress Syndrome (ARDS) and preexisting CVD were independently associated with mortality in this patient cohort (OR 19.7, 95% CI 7.5–51.7 and OR 2.9, 95% CI 1.2–6.9). History of remote cancer was not independently associated with mortality (OR 2.39, 95% CI 0.93–6.15, p=0.07).ConclusionOur findings indicate that a history of remote cancer is not independently associated with increased mortality in hospitalized COVID-19 patients. These data suggest that the cause of death among hospitalized patients with COVID-19 and history of cancer is most likely multifactorial, with a strong contribution from cardiovascular disease.Funding AcknowledgementType of funding sources: Private company. Main funding source(s): Janssen Pharmaceuticals

Major arterial and venous thromboembolic complications in patients with COVID-19

Abstract Background Cardiovascular complications; myocardial infarction (MI), ischemic stroke, and pulmonary embolism (PE), represent an important source of adverse outcomes in COVID-19 disease. Objectives To evaluate the incidence of thromboembolic events, specifically PE, MI and stroke; risk factors, management patterns and outcomes in patients who tested positive for COVID-19 through RT-PCR in a regional hospital. Methods We included 1125 adults patients admitted for COVID-19 infection between April 1 and October 30, 2020. The total cohort was analyzed by site of care: Intensive care (n=124) and nonintensive care (n=1001). Results Cardiovascular risk factors prevalence in patients with COVID-19 were: hypertension (25.5%), hyperlipidemia (23.2%) and diabetes (12%). Prophylactic anticoagulation and therapeutic anticoagulation was prescribed in intensive care group (91.1% and 33.1%, respectively) versus (84.8% and 12.5%, respectively) in nonintensive care setting. Frequencies of major arterial or venous thromboembolism, pulmonary embolism and myocardial infarction were highest in the intensive care group (29%, 20% and 8%, respectively) than nonintensive care cohort (1.4%, 0.7% and 0,5%, respectively). Hospital mortality was 29% in intensive care group and 1.3% in nonintensive care group. Conclusions Patients admitted for COVID-19 had a high risk of major arterial or venous thromboembolism events, especially in the intensive care setting, despite the use of thromboprophylaxis with heparin. Funding Acknowledgement Type of funding sources: None.

ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION SECONDARY TO COVID-19

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Coronavirus disease (COVID-19) is known to cause severe respiratory pathology such as acute respiratory distress syndrome. Although the pathophysiology of this lethal virus is still not fully understood, it has been suspected to attach to the ACE2 receptors leading to its deadly pathogenesis. Found to be the cause of venous thrombotic and embolic events, arterial thrombotic events such as ST-segment elevation myocardial infarction (STEMI) have been an unusual phenomenon. CASE PRESENTATION: A 37-year-old female with a past medical history of COVID-19 infection 12 days prior to admission presented to the emergency department (ED) complaining of shortness of breath for 2 to 3 days prior to admission. In the ED she was hypoxic with an oxygen saturation of 80% on room air for which she was placed on 90% FiO2 via OptiFlow and nonrebreather mask. Her D-Dimer on admission was noted to be 506 ng/mL (normal value 80.00 ng/mL (normal value <0.04 ng/mL). The decision was made to proceed with cardiac catheterization for which complete stenosis of the left anterior descending (LAD) artery was noted. She received one drug eluding stent to the proximal LAD and due to severe cardiogenic shock an Impella was placed for hemodynamic support. Despite aggressive intervention and multiple vasopressors and Impella support she continued to decompensate and ultimately succumbed to her condition. DISCUSSION: STEMI is a rare complication of COVID-19 infection with an incidence of about 1%. The pathophysiology of STEMI in this setting is still not yet understood;however, COVID-19 infection is known to cause a hypercoagulable state through cytokine and complement activation as well as endothelial damage. CONCLUSIONS: Although uncommon, COVID-19 should be considered as a cause for arterial thrombotic events such as STEMI. It is imperative that clinicians are aware of the complications of this deadly virus and aggressively manage the hypercoagulable state observed in these patients to prevent morbidity and mortality. REFERENCE #1: Lodigiani C, Iapichino G, Carenzo L, et al. Humanitas COVID-19 Task Force. Venous and arterial thromboembolic complications in COVID-19 patients admitted to an academic hospital in Milan, Italy. Thromb Res. 2020;191:9-14. doi: 10.1016/j.thromres.2020.04.024. REFERENCE #2: Abou-Ismail MY, Diamond A, Kapoor S, at al. The hypercoagulable state in COVID-19: Incidence, pathophysiology, and management. Thromb Res. 2020;194:101-115. REFERENCE #3: Bangalore S, Sharma A, Slotwiner A, et al. ST-Segment Elevation in Patients with Covid-19 - A Case Series. N Engl J Med. 2020;382(25):2478-2480. doi:10.1056/NEJMc2009020 DISCLOSURES: No relevant relationships by Nasam Alfraji, source=Web Response No relevant relationships by Abbas Alshami, source=Web Response No relevant relationships by Eric Costanzo, source=Web Response No relevant relationships by Steven Douedi, source=Web Response No relevant relationships by matthew meleka, source=Web Response No relevant relationships by Matthew Saybolt, source=Web Response