Clinicians are becoming increasingly concerned about evidence that COVID-19 could also be a thromboembolic disease.
Although the coronavirus disease 2019 (COVID-19) is primarily viewed as a pulmonary disease, clinicians are becoming increasingly concerned about evidence that it could also be a thromboembolic disease.
In addition to acute respiratory distress syndrome and its effects on patients with respiratory failure, some evidence now suggests that microvascular thrombotic processes may play a role in patients’ respiratory failure.
A report from the National Institute for Public Health of the Netherlands found a potential link between mortality, D-dimer values, and a prothrombotic syndrome among patients with COVID-19. They noted that although there are no publications on the incidence of venous thromboembolism, the authors noted that there are case reports on thromboembolic disease, stroke, and myocarditis.
A single-center retrospective cohort study in China investigated disseminated intravascular coagulation (DIC) and found that 71% of 21 non-survivors were classified as having overt DIC any time during follow-up, compared with just 0.6% of 162 survivors of the COVID-19 infection.
Complications with the coagulation system have also been noted, as is common in a variety of different viruses. Vascular endothelial damage in both small- and mid-sized pulmonary vessels has been noted in previous outbreaks of severe acute respiratory syndrome-coronavirus (SARS-CoV). Based on these observations, the authors said similar complications are likely to be found in patients with COVID-19.
In light of these observations among patients with COVID-19, the authors recommended initiation of several diagnostic and preventive actions.
Antithrombotic therapy has been found to lower mortality rates in some studies. Most notably, a single-center retrospective cohort study of 449 consecutive patients diagnosed with severe COVID-19 in China found that prophylactic doses of heparins might be associated with improved survival in patients with evidence of sepsis-induced coagulopathy (SIC).
Of the 449 patients, 99 received heparin for 7 days or longer. The drug was associated with lower 28-day mortality among 97 patients with a SIC score of 4 or greater, but not among the patients with a score less than 4.
Chest CT scans have also been proposed in order to enable standardized reporting. According to the authors, the typical CT pattern of a patient with COVID-19 pneumonia in Rome, Italy, was characterized by the consistent presence of peripheral ground glass opacities associated with multi-lobar and posterior involvement, bilateral distribution, and subsegmental vessel enlargement.
A recent retrospective study of 1008 patients in which 25 underwent CT pulmonary angiography found acute pulmonary embolism (PE) in 10 patients (40%), which were mainly located in subsegmental vessels.
The authors concluded with several basic recommendations for the diagnostic and therapeutic management of patients with suspected or confirmed COVID-19:
Ourkerk M, Buller H, Kuijpers D, van Es N, et al. Diagnosis, Prevention, and Treatment of Thromboembolic Complications in COVID-19: Report of the National Institute for Public Health of the Netherlands. Radiology; April 23, 2020. https://pubs.rsna.org/doi/10.1148/radiol.2020201629. Accessed May 6, 2020.