COVID-19-associated coagulopathy

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For COVID-19 frequently asked inpatient questions, click here

For COVID-19 frequently asked outpatient questions, click here

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ifrah Fatima, M.B.B.S[2]

Synonyms and Keywords: Hematological findings and COVID-19, hypercoagulability in COVID-19, clotting disorder in COVID-19

Overview

Hypercoagulability is a major complication seen in as many as 31% of patients with COVID-19. It leads to many life-threatening outcomes, pulmonary embolism being the most common thrombotic complication. Hypercoagulability is characterized by elevated Fibrinogen and D-dimer levels. Coagulopathy in COVID-19 must be differentiated from other diseases that cause disseminated intravascular coagulation (DIC). Prophylactic anticoagulation with low molecular weight heparin is given to all inpatients in the absence of active bleeding. Full dose anticoagulation is administered in patients with documented and confirmed venous thromboembolism (VTE) .

Historical Perspective

Classification

  • To view the classification of COVID-19, click here.

Pathophysiology

Causes

Differentiating COVID-19 associated coagulopathy from other Diseases

For further information about the differential diagnosis, click here.

Epidemiology and Demographics

Incidence

To view the epidemiology and demographics for COVID-19, click here.

Age

Gender

Race

Risk Factors

Common hypothesized risk factors for coagulopathy in COVID-19 pneumonia based on studies include:[14][17][18]

Other general risk factors for venous thromboembolism (VTE) are:

To view the risk factors of COVID-19, click here.

Screening

  • Routine screening with imaging is not done as there is no evidence to indicate an improvement in clinical outcomes.
  • Depending on the clinical state of the patient and suspicion for the development of VTE or arterial thrombi, repeat testing and further imaging investigations are done.

To view screening for COVID-19, click here.

Natural History, Complications, and Prognosis

Natural History

Complications

Prognosis

Prognosis depends on numerous factors:[21]

Independent predictors of thrombotic complications include:


To view natural history, complications, and prognosis of COVID-19, click here.

Diagnosis

Diagnostic Study of Choice

History and Symptoms

The symptoms depend on the vessels and the organ systems involved.

Pulmonary Embolism: Many symptoms of PE overlap with the respiratory symptoms seen in COVID-19.

A positive history of the following is suggestive of and contributory:

Deep Vein Thrombosis

Arterial thrombosis involving various systems show the following symptoms:

To view the history and symptoms of COVID-19, click here.

Physical Examination

Pulmonary Embolism

Physical examination of patients with Pulmonary Embolism is usually remarkable for:

Deep Vein Thrombosis

Physical examination of patients with Deep Vein Thrombosis includes:

Arterial thrombosis:

To view the complete physical examination in COVID-19, click here.

Laboratory Findings

To view the laboratory findings on COVID-19, click here.

Electrocardiogram

An ECG may be helpful in the diagnosis of pulmonary embolism or myocardial infarction caused due to hypercoagulability in COVID-19.

  • Findings on an ECG suggestive of/diagnostic of pulmonary embolism include tachycardia and S1Q3T3 pattern.
  • Findings on an ECG suggestive of/diagnostic of myocardial infarction include STE elevation in various leads.
  • To view the electrocardiogram findings on COVID-19, click here.

X-ray

  • There are no specific x-ray findings associated with PE.
  • However, an x-ray may be helpful in ruling out other causes with similar symptoms like pneumonia, cardiogenic causes of dyspnea, and pneumothorax.
  • To view the x-ray finidings on COVID-19, click here.

Echocardiography or Ultrasound

CT scan

CTPA and Ventilation Perfusion(V/Q) Scan
Right-sided segmental and subsegmental pulmonary arterial filling defects (yellow arrows) in keeping with acute distal pulmonary emboli. Case courtesy of Dr Gianluca Martinelli, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/76817">rID: 76817</a>

To view the CT scan findings on COVID-19, click here.

MRI

Other Imaging Findings

There are no other imaging findings associated with coagulopathy of COVID-19.

Other Diagnostic Studies

Treatment

Medical Therapy

Prophylactic dose of anticoagulation

Indications:

Intermediate or therapeutic dose anticoagulation

Indications:

Therapeutic/ full-dose anticoagulation

  • Preferred regimen: Enoxaparin 1 mg/kg every 12 hours

Indications:

Post-discharge thromboprophylaxis

  • Drug and dose- Regulatory-approved regimen[32]
    • Preferred regimen (1): Betrixaban 160 mg on day 1, followed by 80 mg once daily for 35-42 days
    • Preferred regimen (2): Rivaroxaban 10 mg daily for 31-39 days

Indications:

  • Patients with documented venous thromboembolism (VTE) require thromboprophylaxis for up to 90 days after discharge.
  • Some patients who do not have VTE but require extended thromboprophylaxis include:
    • Acute medical illness, older age, immobilization, recent surgery, or trauma.
  • Most of these criteria are met by patients with COVID-19, and they require thromboprophylaxis for up to 90 days after discharge.[33]

Bleeding in COVID-19

  • To view medical treatment for COVID-19, click here.

Surgery

Surgical intervention is not recommended for the management of COVID-19 associated coagulopathy.

Primary Prevention

  • Since there is no vaccine for COVID-19 there are plenty of primary prevention suggested from CDC such as:[34]
    • Hand washing every 10 minutes.
    • Using alcoholic hand sanitizer.
    • Self quarantine for two weeks if symptomatic.
  • To view the primary prevention measures of COVID-19, click here.

Secondary Prevention

  • WHO recommends home care for patients with suspected COVID-19 who present with mild symptoms:[35]
    • Family members of an infected patient are better to wear masks.
    • Using separate bathroom and bedroom by the infected person.
    • Using antipyretics and analgesics for fever, myalgias, and headaches
  • To view the secondary prevention measures of COVID-19, click here.
Patho covid anticoagulation.jpg

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