COVID-19 and VTE

Ananya Mahesh, Akshay Kulkarni,

Sonal Churiwal, and Krishan Patel
The GTF Group
 Abstract
Since its inception a few months ago in Wuhan, China, COVID-19 has affected
the entire World, making it a pandemic. Unfortunately, the lack of adequate
resources compounded with the long 14 day incubation period of COVID-19 is
enabling the rapid spread of the virus. Diagnosis of COVID-19 includes
nasopharyngeal swabs and serological testing. Patients at high-risk of
contracting COVID-19 include the elderly and patients with asthma, chronic
lung disease, immunocompromised patients, etc. One prevalent complication
of COVID 19 includes thrombosis, which although has been highest among
patients that are not receiving adequate prophylaxis, is still prevailing among
those who are receiving prophylaxis. Thrombosis is managed through
anticoagulants; however, care should be exercised in order to prevent excess
bleeding.
 Introduction
• COVID-19is the viral illness caused by the severe acute respiratory
syndrome coronavirus 2 (SARS-CoV2)
• Increased inflammation due to COVID-19 is harmful by causing increased
clotting.
• PE and DVT frequently occur in spite of standard-dose anticoagulation
because of the lack of response.
• Extensive microvascular thrombosis associated with hemorrhage in the
lung occurs.
 Introduction, contd.
• COVID-19-associated coagulopathy (CAC) has high inflammatory markers
in the blood, such as D-dimer and fibrinogen.
• Our colleagues in GTF are investigating other aspects of COVID-19 such
as COVID-19 and PE and COVID-19 and DVT
• Kulkarni et al (2020) had reviewed the preliminary findings
• Bikdeli B; Madhavan MV; Fareed, et al (In Press) have recently published a
preliminary review on COVID-19.
 History of COVID-19
• December 2019: The first case of Covid-19 was reported in Wuhan, Hubei
Province, China
• Progressed very rapidly through 6 continents and over 100 countries
• Many countries adopted measures of social distancing policies to slow the
spread of the virus
• February 29, 2020: First report of COVID-19 in the United States in
Seattle
• To date, there have been 3,360,000 cases, 239,000 deaths, and 1,060,000
recoveries Worldwide (Figure 1)
Figure 1: Spread of COVID-19
 Spread, Symptoms, Challenges
• Spreads through many ways including respiratory droplets, fomites, and
through asymptomatic carriersCOVID-19 expresses flu-like symptoms.
• Major symptoms include low-grade fever, coughing, and lessened sense of
taste/smell.
• Challenges include a long incubation period, difficulty in diagnosis, lack of
resources and lack of vaccine.
• High risk patients include the elderly and those with underlying medical
conditions such as asthma, diabetes, hypertension, as well as those who
are immunocompromised.
 Diagnosis
• Difficult, due to the limited availability of tests, that precludes universal
screening of people under investigation (PUI)
• Two main types of diagnostic techniques: nasopharyngeal swabs and
serological tests:
– Nasopharyngeal swabs sample the upper respiratory tract (Figure 2)
– Serological tests detect antibodies to COVID-19 in the blood (Figure 3)

Figure 2 Figure 3
 General Complications
• Potential cardiac, pulmonary, GI, neurologic and even dermatologic
manifestations
• Pulmonary complications: pneumonia, ARDS/SIRS and PE
– Figure 4 demonstrates bilateral pneumonia
– Figure 5 illustrates ground glass infiltrates
Figure 4: Bilateral Pneumonia
Figure 4: Bilateral Ground Glass Infiltrates
 Thrombotic Complications
• May be caused by severe systemic inflammation, hypoxia, immobilization
and diffuse intravascular coagulopathy.
• Wang, et al (2020) studied with 1,099 patients with a confirmed COVID-19
infection
– Forty percent were at high risk
– An estimated 11% of high risk patients developed venous
thromboembolism without appropriate thromboprophylaxis.
– High risk patients were often requiring mechanical ventilation
– With appropriate prophylaxis, the venous thromboembolism could be
prevented.
– Only 7% of high risk patients had anticoagulation data, emphasizing
the need to identify high risk patients
 Thrombotic Complications, contd.
• Kloka et al. (In Press) studied 184 patients with proven COVID-19
pneumonia (Table 1)
– Thirteen percent died, 12% were discharged and 76% were still in the
ICU and needed to be followed for 7 days
– Despite all patients receiving thromboprophylaxis, the incidence of
VTE observed was 27% and arterial thrombosis was 3.7%
– Pulmonary embolism was the most commonly observed
– Total incidence of thrombotic complications was 31% in the ICU
patients
– The authors recommended to practice a strict VTE prophylaxis at high
therapeutic doses.
– VTE screening abilities were limited -- further screening could yield
higher incidence rates
 Table 1: Description of
Thrombotic Complications
Type of event Number of cases Relevant details
Pulmonary embolism 25 • 18 cases with at least PE in segmental
arteries, 7 cases of PE limited to
subsegmental arteries

Other venous 3 • 1 proximal deep-vein thrombosis of the

thromboembolic leg
events • 2 catheter related upper extremity
thrombosis
Arterial thrombotic 3 • All ischemic strokes
events
Note: Acute pulmonary embolism was diagnosed with CT-pulmonary angiography,
deep vein thrombosis/upper extremity thrombosis was diagnosed with
ultrasonography, and strokes were diagnosed with CT scanning
 Managing COVID-19
• Some thrombotic events could have been prevented with adequate
thromboprophylaxis (Wang et al, 2020)
• Conflicting cases where despite receiving at least standard prophylactic
care, the incidence rate of venous thromboembolism events was high
(Klok, et al, In press)
– Better alternatives to standardized anticoagulant therapy
– Physicians ought to be attentive to patients displaying signs of
thrombosis so appropriate diagnostic tests can determine the future
treatment necessity and intensity of prophylaxis needed
• COVID-19 management algorithm prepared at UNC Medical Center
(Figure 6) would be a good tool to use (Moll et al, 2020)
Figure 8: COVID-19
Patients
 Preventing COVID-19
• The prevention of COVID-19 is similar to preventing any other airborne
diseases, with some extra precautions added due to the contagiosity of the
virus
• Preventative measures include:
– Washing your hands often, especially after coming in contact with
other people
– Distance yourself from others by at least 6 feet
– Cover your mouth with a cloth or mask when leaving the house or
around others
– Avoid contact with those who are affected
– Stay at home to prevent the spread of the virus
 General Recommendations
• All hospitalized COVID-19 patients need DVT/PE prophylaxis with
anticoagulation
– Thrombosis appears to be a bigger problem in COVID-19 patients
than bleeding.
– The choice of the ideal anticoagulant and dosage have not yet been
established.
 General Recommendations, contd.
• Caution should be exercised to avoid excess bleeding from the
anticoagulation therapy
– Particularly in the elderly, patients with thrombocytopenia (most
concerning if platelet count < 50k /μL), coagulopathy with progressive
disseminated intravascular coagulation (DIC) leading to decreased
coagulation factor levels, renal dysfunction, liver impairment,
multiorgan failure, h/o bleeding or active bleeding sites.
• Patients need to be evaluated individually with respect to the possible
etiology of their respiratory and other organ failure, bleeding risk, and
suitability for anticoagulation
 Recommendations from
the Anticoagulation Forum
• Pharmacologic VTE prophylaxis for all hospitalized non-pregnant patients
with confirmed or highly suspected COVID-19, regardless of VTE risk
assessment score, unless a contraindication exists (e.g. active bleeding,
profound thrombocytopenia).
• Pharmacologic VTE prophylaxis for all hospitalized pregnant patients with
confirmed or highly suspected COVID-19.
• In patients with a contraindication to pharmacologic VTE prophylaxis, a
consistent application of intermittent pneumatic compression devices with
regular reassessment for conversion to pharmacologic prophylaxis.
• In critically ill patients, it is reasonable to employ both pharmacologic and
mechanical VTE prophylaxis (i.e., intermittent pneumatic compression
devices) as long as no contraindication to either modality exists.
 Summary and Conclusions
• COVID-19 is rather difficult to control because of its many methods of
spreading
• Heightened risk of infection raises chances of thrombotic events
• Important to consider preventive and therapeutic use of antithrombotic
agents, especially for high-risk patients
• Other complications include respiratory problems such as pneumonia
• Precautions include wearing masks, frequent hand washing, social
distancing, etc.
 Acknowledgements
• Dr. Atul Laddu and Mrs. Jayashree Laddu for their help and support
throughout the presentation.
• Dr. Rashmi Kulkarni for her mentorship throughout the project
• Ms. Archana Athalye for her organization of the project.
• GTF for providing us a platform for this presentation.
• Our parents for their encouragement throughout the process.
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