Division of Hematology Oncology, Massachusetts General Hospital, Boston, MA.
Harvard Medical School, Boston, MA; and.
Blood. 2020 Jul 23;136(4):489-500. doi: 10.1182/blood.2020006520.
Patients with coronavirus disease 2019 (COVID-19) have elevated D-dimer levels. Early reports describe high venous thromboembolism (VTE) and disseminated intravascular coagulation (DIC) rates, but data are limited. This multicenter retrospective study describes the rate and severity of hemostatic and thrombotic complications of 400 hospital-admitted COVID-19 patients (144 critically ill) primarily receiving standard-dose prophylactic anticoagulation. Coagulation and inflammatory parameters were compared between patients with and without coagulation-associated complications. Multivariable logistic models examined the utility of these markers in predicting coagulation-associated complications, critical illness, and death. The radiographically confirmed VTE rate was 4.8% (95% confidence interval [CI], 2.9-7.3), and the overall thrombotic complication rate was 9.5% (95% CI, 6.8-12.8). The overall and major bleeding rates were 4.8% (95% CI, 2.9-7.3) and 2.3% (95% CI, 1.0-4.2), respectively. In the critically ill, radiographically confirmed VTE and major bleeding rates were 7.6% (95% CI, 3.9-13.3) and 5.6% (95% CI, 2.4-10.7), respectively. Elevated D-dimer at initial presentation was predictive of coagulation-associated complications during hospitalization (D-dimer >2500 ng/mL, adjusted odds ratio [OR] for thrombosis, 6.79 [95% CI, 2.39-19.30]; adjusted OR for bleeding, 3.56 [95% CI, 1.01-12.66]), critical illness, and death. Additional markers at initial presentation predictive of thrombosis during hospitalization included platelet count >450 × 109/L (adjusted OR, 3.56 [95% CI, 1.27-9.97]), C-reactive protein (CRP) >100 mg/L (adjusted OR, 2.71 [95% CI, 1.26-5.86]), and erythrocyte sedimentation rate (ESR) >40 mm/h (adjusted OR, 2.64 [95% CI, 1.07-6.51]). ESR, CRP, fibrinogen, ferritin, and procalcitonin were higher in patients with thrombotic complications than in those without. DIC, clinically relevant thrombocytopenia, and reduced fibrinogen were rare and were associated with significant bleeding manifestations. Given the observed bleeding rates, randomized trials are needed to determine any potential benefit of intensified anticoagulant prophylaxis in COVID-19 patients.
新冠肺炎（COVID-19）患者的 D-二聚体水平升高。早期报告描述了高静脉血栓栓塞（VTE）和弥散性血管内凝血（DIC）的发生率，但数据有限。这项多中心回顾性研究描述了 400 名住院 COVID-19 患者（144 名重症患者）的止血和血栓并发症的发生率和严重程度，这些患者主要接受标准剂量的预防性抗凝治疗。比较了有和无凝血相关并发症患者的凝血和炎症参数。多变量逻辑模型检查了这些标志物在预测凝血相关并发症、重症和死亡方面的效用。影像学证实的 VTE 发生率为 4.8%（95%可信区间 [CI]，2.9-7.3），总血栓并发症发生率为 9.5%（95% CI，6.8-12.8）。总出血和主要出血发生率分别为 4.8%（95% CI，2.9-7.3）和 2.3%（95% CI，1.0-4.2）。在重症患者中，影像学证实的 VTE 和主要出血发生率分别为 7.6%（95% CI，3.9-13.3）和 5.6%（95% CI，2.4-10.7）。初始 D-二聚体升高提示住院期间存在凝血相关并发症（D-二聚体>2500ng/ml，血栓形成的调整优势比 [OR] 为 6.79[95%CI，2.39-19.30]；出血的调整 OR 为 3.56[95%CI，1.01-12.66]）、重症和死亡。初始表现的其他标志物预测住院期间血栓形成，包括血小板计数>450×10^9/L（调整 OR，3.56[95%CI，1.27-9.97]）、C 反应蛋白（CRP）>100mg/L（调整 OR，2.71[95%CI，1.26-5.86]）和红细胞沉降率（ESR）>40mm/h（调整 OR，2.64[95%CI，1.07-6.51]）。与无血栓并发症患者相比，ESR、CRP、纤维蛋白原、铁蛋白和降钙素原在有血栓并发症患者中更高。DIC、临床相关血小板减少症和纤维蛋白原减少罕见，与明显的出血表现相关。鉴于观察到的出血率，需要进行随机试验来确定 COVID-19 患者强化抗凝预防的潜在益处。
