Department of Orthopaedics, Xiangya Hospital, Central South University.
Hunan Key Laboratory of Joint Degeneration and Injury.
Int J Surg. 2024 Jun 1;110(6):3910-3922. doi: 10.1097/JS9.0000000000001307.
There was controversy surrounding the optimal thromboprophylaxis strategy for coronavirus disease 2019 (COVID-19) patients. This included debates on the dosage of anticoagulants for thromboembolism prophylaxis, the requirement for additional antiplatelet therapy, and the necessity of prophylaxis for outpatients and postdischarge. To explore this, the authors performed a meta-analysis of randomized controlled trials.
PubMed, Cochrane Library, Embase, and Web of Science were last searched on 26 July 2023 for studies comparing the effect of different dose of anticoagulation, additional antiplatelet, and postdischarge prophylaxis for COVID-19 patients. The results of eligible studies were analyzed in terms of thromboembolism events, major bleeding and all-cause mortality during follow-up.
Our study included a total of 25 randomized controlled trials, involving 17 911 patients. Our results revealed that, compared to prophylactic dose, therapeutic dose showed lower thrombotic risk (RR, 0.66; 95% CI: 0.45-0.96) but had similar major bleeding risk for critically ill patients with COVID-19. On the other hand, intermediate dose and prophylactic dose demonstrated similar thromboembolism risk and major bleeding risk. For noncritically ill patients with COVID-19, therapeutic dose of anticoagulants was associated with lower thrombotic risk (RR, 0.50; 95% CI: 0.34-0.72) but, at the same time, increased the risk of major bleeding (RR, 2.01; 95% CI: 1.22-3.33). However, intermediate dose showed lower thromboembolism risk (RR, 0.38; 95% CI: 0.21-0.69) while maintaining a similar major bleeding risk. In critically ill patients, additional antiplatelet therapy showed similar thromboembolism, major bleeding risk, and mortality when compared to no treatment. For outpatients, additional prophylactic anticoagulation showed similar thromboembolism, major bleeding risk, and mortality when compared to no treatment. For postdischarge patients, postdischarge prophylaxis reduced thromboembolism risk (RR, 0.49; 95% CI: 0.31-0.76) but increased major bleeding risk (RR, 2.63; 95% CI: 1.13-6.14).
For noncritically ill patients, therapeutic dose prophylactic anticoagulation significantly reduced venous thromboembolism but increases major bleeding risk. Intermediate dose effectively lowered venous thromboembolism without raising major bleeding risk. The optimal dose and need for additional antiplatelet therapy in critically ill patients, as well as the necessity of prophylactic anticoagulation in outpatient and postdischarge patients, required further investigation and confirmation through rigorous evidence studies.
针对 2019 年冠状病毒病（COVID-19）患者，最优的血栓预防策略存在争议。这包括对血栓栓塞预防用抗凝剂剂量、是否需要额外抗血小板治疗，以及门诊和出院后患者是否需要预防的争论。为了探讨这一点，作者对随机对照试验进行了荟萃分析。
作者于 2023 年 7 月 26 日对 PubMed、Cochrane 图书馆、Embase 和 Web of Science 进行了最后一次检索，以比较不同抗凝剂量、额外抗血小板治疗和 COVID-19 患者出院后预防的效果。根据血栓栓塞事件、随访期间大出血和全因死亡率对合格研究的结果进行了分析。
本研究共纳入 25 项随机对照试验，涉及 17911 名患者。我们的结果表明，与预防性剂量相比，治疗性剂量可降低危重症 COVID-19 患者的血栓形成风险（RR，0.66；95%CI：0.45-0.96），但大出血风险相似。另一方面，中剂量和预防性剂量显示出相似的血栓栓塞风险和大出血风险。对于非危重症 COVID-19 患者，抗凝剂的治疗性剂量可降低血栓形成风险（RR，0.50；95%CI：0.34-0.72），但同时增加大出血风险（RR，2.01；95%CI：1.22-3.33）。然而，中剂量显示出较低的血栓栓塞风险（RR，0.38；95%CI：0.21-0.69），同时保持相似的大出血风险。在危重症患者中，与不治疗相比，额外使用抗血小板治疗在血栓形成、大出血风险和死亡率方面无差异。对于门诊患者，与不治疗相比，额外的预防性抗凝治疗在血栓形成、大出血风险和死亡率方面无差异。对于出院后患者，出院后预防可降低血栓形成风险（RR，0.49；95%CI：0.31-0.76），但增加大出血风险（RR，2.63；95%CI：1.13-6.14）。
对于非危重症患者，治疗性剂量预防性抗凝可显著降低静脉血栓栓塞风险，但增加大出血风险。中剂量可有效降低静脉血栓栓塞风险，而不增加大出血风险。危重症患者的最佳剂量和是否需要额外抗血小板治疗，以及门诊和出院后患者是否需要预防性抗凝治疗，需要通过严格的证据研究进一步调查和确认。
