Clinical question
Introduction
Methods
Relevant outcome measures
Search and select
Summary of literature
Group A: Anticoagulant drug use before hospital admission
Group B: Prophylactic anticoagulant drug use started at hospital admission
Group C: Mixed or unclear start of anticoagulant therapy
Description of studies
Group A: Anticoagulant drug use before hospital admission
Group B: Prophylactic anticoagulant drug use started at hospital admission
Group C: Mixed or unclear start of anticoagulant therapy
Group | Author, year | Comparison | Start anticoagulants | Setting | Country | Study design | Outcomes | Publication type |
---|---|---|---|---|---|---|---|---|
A. Anticoagulant drug use before hospital admission | Tremblay, 2020 [8] | Anticoagulant use at moment of infection (therapeutic dose) vs patients not using anticoagulants at moment of infection | Pre-admission | Hospitalised and ambulatory COVID-19 patients | US | Retrospective, observational | Mortality, hospital admission, mechanical ventilation Propensity matched analysis | To the editor |
A. Anticoagulant drug use before hospital admission | Klok, 2020 [2] | Use of long-term therapeutic anticoagulation vs prophylactic dose | Pre-admission | Patients with proven COVID-19 pneumonia admitted to the ICU | Netherlands | Observational | Mortality (HR), a composite outcome (symptomatic acute pulmonary embolism, deep vein thrombosis, ischaemic stroke, myocardial infarction and/or systemic arterial embolism) (corrected for competing risk of death) | Research paper update |
A. Anticoagulant drug use before hospital admission | Russo, 2020 [9] | Pre-admission anticoagulant users vs non-users | Pre-admission | Emergency department | Italy | Retrospective, observational | Mortality Propensity score model | Research paper |
A. Anticoagulant drug use before hospital admission | Sivaloganathan, 2020 [10] | Pre-admission antiplatelet/anticoagulant use vs non-users | Pre-admission | Hospitalised COVID-19 patients | UK | Retrospective, case control | Mortality (log rank, no correction for confounders) ICU admission | Correspondence |
A. Anticoagulant drug use before hospital admission | Rossi, 2020 [11] | Chronic anticoagulant users vs non-users | Pre-admission | Elderly COVID-19 patients with coronary heart disease followed in the outpatient clinic | Italy | Retrospective observational | Mortality (corrected for age and gender) | Letter to the editor |
B. Prophylactic anticoagulant drug use start at hospital admission | Tang, 2020 [7] | Prophylactic heparin vs non-users | Hospital admission | Hospitalised severe COVID-19 patients | China | Retrospective, observational | 28-day mortality (adjusted for age, sex, underlying disease, platelet count, D‑dimer) | Research paper |
C. Mixed or unclear start of anticoagulant | Paranjpe, 2020 [12] | Therapeutic dose vs (prophylactic dose or non-users) | Unclear | Hospitalised COVID-19 patients | US | Retrospective, observational | Invasive mechanical ventilation (no correction for confounders), mortality (no correction for confounders) | Letter |
C. Mixed or unclear start of anticoagulant | Llitjos, 2020 [13] | Patients using a therapeutic dose of anticoagulant vs patients using a prophylactic dose of anticoagulant | 7 patients pre-admission, 11 patients at admission | COVID-19 patients admitted to the ICU | France | Retrospective, observational | Mortality, pulmonary embolism, acute kidney injury, (comparison between 2 groups, no correction for confounders), renal replacement therapy, VTE (including non-symptomatic VTE) | Brief report |
Results
Mortality
Group A: Anticoagulant drug use before hospital admission
Group B: Prophylactic anticoagulant drug use started at hospital admission
Group C: Mixed or unclear start of anticoagulant therapy
ICU admission
Group A: Anticoagulant drug use before hospital admission
Group B: Prophylactic anticoagulant drug use started at hospital admission
Group C: Mixed or unclear start of anticoagulant therapy
Length of stay
Group A–C
Thromboembolic complications
Group A: Anticoagulant drug use before hospital admission
Group B: Prophylactic anticoagulant drug use started at hospital admission
Group C: Mixed or unclear start of anticoagulant therapy
Ventilation
Group A: Anticoagulant drug use before hospital admission
Group B: Prophylactic anticoagulant drug use started at hospital admission
Group C: Mixed or unclear start of anticoagulant therapy
Acute kidney injury therapy
Group A–B
Group C: Mixed or unclear start of anticoagulant therapy
Renal replacement therapy
Group A: Anticoagulant drug use before hospital admission
Group B: Prophylactic anticoagulant drug use started at hospital admission
Group C: Mixed or unclear start of anticoagulant therapy
Level of evidence of the literature
Mortality (crucial)
Group A: Anticoagulant drug use before hospital admission
Group B: Prophylactic anticoagulant drug use started at hospital admission
Group C: Mixed or unclear start of anticoagulant therapy
ICU admission
Group A: Anticoagulant drug use before hospital admission
Length of stay
Thromboembolic complications
Group A: Anticoagulant drug use before hospital admission
Group C: Mixed or unclear start of anticoagulant therapy
Ventilation
Group A: Anticoagulant drug use before hospital admission
Group C: Mixed or unclear start of anticoagulant therapy
Acute kidney injury
Group C: Mixed or unclear start of anticoagulant therapy
Renal replacement therapy
Group A: Anticoagulant drug use before hospital admission
Group C: Mixed or unclear start of anticoagulant therapy
Conclusion
Mortality
Group A: Anticoagulant drug use before hospital admission
Group B: Anticoagulant drug use started at hospital admission
Group C: Mixed or unclear start of anticoagulant therapy
ICU admission
Length of stay
Thromboembolic complications
Group A: Anticoagulant drug use before hospital admission
Group C: Mixed or unclear start of anticoagulant therapy
Ventilation
Group A: Anticoagulant drug use before hospital admission
Group C: Mixed or unclear start of anticoagulant therapy
Acute kidney injury
Group C: Mixed or unclear start of anticoagulant therapy
Renal replacement therapy
Group A: Anticoagulant drug use before hospital admission
Group C: Mixed or unclear start of anticoagulant therapy
Discussion
CAPACITY registry
Recommendations
-
Administer prophylactic dose anticoagulation to all patients admitted with COVID-19.
-
Administer double standard prophylactic dose anticoagulation to COVID-19 patients admitted to the ICU.
-
There is no indication for therapeutic dose anticoagulation in COVID-19, in the absence of pre-existing indications.
-
When convincing evidence becomes available to change these recommendations, the multidisciplinary guideline will be updated. (https://richtlijnendatabase.nl/richtlijn/antitrombotisch_beleid/antitrombotisch_beleid_-_korte_beschrijving.html).