Division of General Internal Medicine, Department of Internal Medicine University of Utah Salt Lake City UT.
Division of Health System Innovation and Research, Department of Population Health Science University of Utah Salt Lake City UT.
J Am Heart Assoc. 2022 Oct 4;11(19):e025914. doi: 10.1161/JAHA.122.025914. Epub 2022 Sep 8.
Background A recent randomized trial, the MICHELLE trial, demonstrated improved posthospital outcomes with a 35-day course of prophylactic rivaroxaban for patients hospitalized with COVID-19 at high risk of venous thromboembolism. We explored how often these findings may apply to an unselected clinical population of patients hospitalized with COVID-19. Methods and Results Using a 35-hospital retrospective cohort of patients hospitalized between March 7, 2020, and January 23, 2021, with COVID-19 (MI-COVID19 database), we quantified the percentage of hospitalized patients with COVID-19 who would be eligible for rivaroxaban at discharge per MICHELLE trial criteria and report clinical event rates. The main clinical outcome was derived from the MICHELLE trial and included a composite of symptomatic venous thromboembolism, pulmonary embolus-related death, nonhemorrhagic stroke, and cardiovascular death at 35 days. Multiple sensitivity analyses tested different eligibility and exclusion criteria definitions to determine the effect on eligibility for postdischarge anticoagulation prophylaxis. Of 2016 patients hospitalized with COVID-19 who survived to discharge and did not have another indication for anticoagulation, 25.9% (n=523) would be eligible for postdischarge thromboprophylaxis per the MICHELLE trial criteria (range, 2.9%-39.4% on sensitivity analysis). Of the 416 who had discharge anticoagulant data collected, only 13.2% (55/416) were actually prescribed a new anticoagulant at discharge. Of patients eligible for rivaroxaban per the MICHELLE trial, the composite clinical outcome occurred in 1.2% (6/519); similar outcome rates were 5.7% and 0.63% in the MICHELLE trial's control (no anticoagulation) and intervention (rivaroxaban) groups, respectively. Symptomatic venous thromboembolism events and all-cause mortality were 6.2% (32/519) and 5.66% in the MI-COVID19 and MICHELLE trial control cohorts, respectively. Conclusions Across 35 hospitals in Michigan, ≈1 in 4 patients hospitalized with COVID-19 would qualify for posthospital thromboprophylaxis. With only 13% of patients actually receiving postdischarge prophylaxis, there is a potential opportunity for improvement in care.
最近的一项随机试验 MICHELLE 试验表明，对于因 COVID-19 住院且有发生静脉血栓栓塞高风险的患者，使用利伐沙班预防性治疗 35 天可改善住院后结局。我们探讨了这些发现对因 COVID-19 住院的未经选择的临床患者人群适用的频率。
我们使用 2020 年 3 月 7 日至 2021 年 1 月 23 日期间因 COVID-19 住院的 35 家医院回顾性队列（MI-COVID19 数据库）中的患者，量化了根据 MICHELLE 试验标准，出院时符合利伐沙班使用条件的 COVID-19 住院患者的比例，并报告了临床事件发生率。主要临床结局源自 MICHELLE 试验，包括 35 天内有症状静脉血栓栓塞、肺栓塞相关死亡、非出血性卒中以及心血管死亡的复合结局。多项敏感性分析测试了不同的入选和排除标准定义，以确定对出院后抗凝预防治疗的入选影响。在 2016 例因 COVID-19 住院且存活至出院且无其他抗凝指征的患者中，根据 MICHELLE 试验标准，25.9%（n=523）符合出院后血栓预防条件（敏感性分析范围为 2.9%-39.4%）。在收集了出院抗凝数据的 416 例患者中，仅有 13.2%（55/416）实际在出院时开具了新的抗凝药物。在根据 MICHELLE 试验标准有资格使用利伐沙班的患者中，复合临床结局的发生率为 1.2%（6/519）；在 MICHELLE 试验的对照组（未抗凝）和干预组（利伐沙班）中，该结局的发生率分别为 5.7%和 0.63%。在 MI-COVID19 和 MICHELLE 试验对照组中，有症状静脉血栓栓塞事件和全因死亡率分别为 6.2%（32/519）和 5.66%。
在密歇根州的 35 家医院中，约有 1/4 因 COVID-19 住院的患者有资格接受住院后血栓预防治疗。仅有 13%的患者实际接受了出院后预防治疗，因此存在改善治疗的潜在机会。
