American Society of Hematology 2021 guidelines on the use of anticoagulation for thromboprophylaxis in patients with COVID-19

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Abstract

Background:

Coronavirus disease 2019 (COVID-19)–related critical illness and acute illness are associated with a risk of venous thromboembolism (VTE).

Objective:

These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in decisions about the use of anticoagulation for thromboprophylaxis for patients with COVID-19–related critical illness and acute illness who do not have confirmed or suspected VTE.

Methods:

ASH formed a multidisciplinary guideline panel and applied strict management strategies to minimize potential bias from conflicts of interest. The panel included 3 patient representatives. The McMaster University GRADE Centre supported the guideline-development process, including performing systematic evidence reviews (up to 19 August 2020). The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, including GRADE Evidence-to-Decision frameworks, to assess evidence and make recommendations, which were subject to public comment.

Results:

The panel agreed on 2 recommendations. The panel issued conditional recommendations in favor of prophylactic-intensity anticoagulation over intermediate-intensity or therapeutic-intensity anticoagulation for patients with COVID-19–related critical illness or acute illness who do not have confirmed or suspected VTE.

Conclusions:

These recommendations were based on very low certainty in the evidence, underscoring the need for high-quality, randomized controlled trials comparing different intensities of anticoagulation. They will be updated using a living recommendation approach as new evidence becomes available.

Abstract

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Most cited references 90

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Clinical Characteristics of Coronavirus Disease 2019 in China

Wei-jie Guan, Zheng-yi Ni, Yu Hu … (2020)

Abstract Background Since December 2019, when coronavirus disease 2019 (Covid-19) emerged in Wuhan city and rapidly spread throughout China, data have been needed on the clinical characteristics of the affected patients. Methods We extracted data regarding 1099 patients with laboratory-confirmed Covid-19 from 552 hospitals in 30 provinces, autonomous regions, and municipalities in mainland China through January 29, 2020. The primary composite end point was admission to an intensive care unit (ICU), the use of mechanical ventilation, or death. Results The median age of the patients was 47 years; 41.9% of the patients were female. The primary composite end point occurred in 67 patients (6.1%), including 5.0% who were admitted to the ICU, 2.3% who underwent invasive mechanical ventilation, and 1.4% who died. Only 1.9% of the patients had a history of direct contact with wildlife. Among nonresidents of Wuhan, 72.3% had contact with residents of Wuhan, including 31.3% who had visited the city. The most common symptoms were fever (43.8% on admission and 88.7% during hospitalization) and cough (67.8%). Diarrhea was uncommon (3.8%). The median incubation period was 4 days (interquartile range, 2 to 7). On admission, ground-glass opacity was the most common radiologic finding on chest computed tomography (CT) (56.4%). No radiographic or CT abnormality was found in 157 of 877 patients (17.9%) with nonsevere disease and in 5 of 173 patients (2.9%) with severe disease. Lymphocytopenia was present in 83.2% of the patients on admission. Conclusions During the first 2 months of the current outbreak, Covid-19 spread rapidly throughout China and caused varying degrees of illness. Patients often presented without fever, and many did not have abnormal radiologic findings. (Funded by the National Health Commission of China and others.)

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Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

Fei Zhou, Ting Yu, Ronghui Du … (2020)

Summary Background Since December, 2019, Wuhan, China, has experienced an outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Epidemiological and clinical characteristics of patients with COVID-19 have been reported but risk factors for mortality and a detailed clinical course of illness, including viral shedding, have not been well described. Methods In this retrospective, multicentre cohort study, we included all adult inpatients (≥18 years old) with laboratory-confirmed COVID-19 from Jinyintan Hospital and Wuhan Pulmonary Hospital (Wuhan, China) who had been discharged or had died by Jan 31, 2020. Demographic, clinical, treatment, and laboratory data, including serial samples for viral RNA detection, were extracted from electronic medical records and compared between survivors and non-survivors. We used univariable and multivariable logistic regression methods to explore the risk factors associated with in-hospital death. Findings 191 patients (135 from Jinyintan Hospital and 56 from Wuhan Pulmonary Hospital) were included in this study, of whom 137 were discharged and 54 died in hospital. 91 (48%) patients had a comorbidity, with hypertension being the most common (58 [30%] patients), followed by diabetes (36 [19%] patients) and coronary heart disease (15 [8%] patients). Multivariable regression showed increasing odds of in-hospital death associated with older age (odds ratio 1·10, 95% CI 1·03–1·17, per year increase; p=0·0043), higher Sequential Organ Failure Assessment (SOFA) score (5·65, 2·61–12·23; p<0·0001), and d-dimer greater than 1 μg/mL (18·42, 2·64–128·55; p=0·0033) on admission. Median duration of viral shedding was 20·0 days (IQR 17·0–24·0) in survivors, but SARS-CoV-2 was detectable until death in non-survivors. The longest observed duration of viral shedding in survivors was 37 days. Interpretation The potential risk factors of older age, high SOFA score, and d-dimer greater than 1 μg/mL could help clinicians to identify patients with poor prognosis at an early stage. Prolonged viral shedding provides the rationale for a strategy of isolation of infected patients and optimal antiviral interventions in the future. Funding Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences; National Science Grant for Distinguished Young Scholars; National Key Research and Development Program of China; The Beijing Science and Technology Project; and Major Projects of National Science and Technology on New Drug Creation and Development.

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GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.

Gordon Guyatt, Andrew D Oxman, Gunn E. Vist … (2008)

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Author and article information

Journal

Journal ID (nlm-ta): Blood Adv

Journal ID (iso-abbrev): Blood Adv

Title: Blood Advances

Publisher: The American Society of Hematology

ISSN (Print): 2473-9529

ISSN (Electronic): 2473-9537

Publication date PMC-release: 8 February 2021

Publication date (Print): 9 February 2021

Publication date (Electronic): 8 February 2021

Volume: 5

Issue: 3

Pages: 872-888

Affiliations

[1 ]Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA;

[2 ]St. Michael's Hospital, Division of Hematology/Oncology, University of Toronto, Toronto, ON, Canada;

[3 ]Michael G. DeGroote Cochrane Canada Centre, McMaster University, Hamilton, ON, Canada

[4 ]McGRADE Centre, and McMaster University, Hamilton, ON, Canada

[5 ]Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada;

[6 ]Division of Hematology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand;

[7 ]Department of Pharmacy, The Johns Hopkins Hospital, Union, NJ;

[8 ]Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD;

[9 ]Children's Hospital at Montefiore, Division of Pediatric Hematology, Oncology, and Cellular Therapies, Albert Einstein College of Medicine, Bronx, NY;

[10 ]Division of Hematology-Oncology, Department of Medicine, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, NY;

[11 ]Department of Medicine, College of Physicians and Surgeons and Columbia University, New York, NY

[12 ]Division of Infectious Diseases, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY;

[13 ]Research and Development at United Health Group, Minnetonka, MN;

[14 ]Prohealth NY, Lake Success, NY;

[15 ]Department of Medicine, McGill University, Montreal, QC, Canada;

[16 ]Thrombosis and Hemostasis, Department of Medicine, Leiden University Medical Center, Leiden, The Netherlands;

[17 ]Section of Hematology, School of Medicine, Yale University, New Haven, CT;

[18 ]Department of Internal Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile;

[19 ]Division of Hematology and Oncology, Kaiser Permanente, Oakland/Richmond, CA;

[20 ]Department of Medicine, McMaster University, Hamilton, ON, Canada;

[21 ]Division of Angiology and Hemostasis, Faculty of Medicine, Geneva University Hospitals, University of Geneva, Geneva, Switzerland;

[22 ]Department of Medicine, Washington University School of Medicine St. Louis, St. Louis, MO;

[23 ]Department of Medicine and University of Ottawa, Ottawa, ON, Canada

[24 ]Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada;

[25 ]Cottage Grove, MN;

[26 ]Toronto, ON, Canada;

[27 ]Department of Internal Medicine, American University of Beirut, Beirut, Lebanon;

[28 ]Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada;

[29 ]Clinical Research Institute, American University of Beirut, Beirut, Lebanon;

[30 ]Library Services, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada;

[31 ]Department of Clinical Medicine, Health Science Center, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico;

[32 ]Office of Scientific Affairs and Research, King Hussein Cancer Center, Amman, Jordan;

[33 ]Department of Neurology, University of Chicago, Chicago, IL;

[34 ]The Michael G. DeGroote National Pain Center, McMaster University, Hamilton, ON, Canada;

[35 ]Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Germany;

[36 ]Department of Internal Medicine, Division of Nephrology, University of Kansas Medical Center, Kansas City, KS; and

[37 ]Institute for Evidence in Medicine, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany

Author notes

[ ^∗ ]Adam Cuker, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104;

[*]

A.C. and E.K.T. are joint first authors.

Article

Publisher Item ID: S2473-9529(21)00113-0

DOI: 10.1182/bloodadvances.2020003763

PMC ID: 7869684

PubMed ID: 33560401

SO-VID: e4548254-00da-4cb4-895d-5b615c65d142

License:

Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

History

Date received : 5 November 2020

Date accepted : 18 December 2020

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American Society of Hematology 2021 guidelines on the use of anticoagulation for thromboprophylaxis in patients with COVID-19

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Abstract

Background:

Objective:

Methods:

Results:

Conclusions:

Abstract

Related collections

Novel Coronavirus Disease COVID-19

Most cited references 90

Clinical Characteristics of Coronavirus Disease 2019 in China

Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.

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Cited by 189

Most referenced authors 4,129