Thrombotic Complications in Patients with COVID-19: Pathophysiological Mechanisms, Diagnosis, and Treatment
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REVIEW ARTICLE
Thrombotic Complications in Patients with COVID-19: Pathophysiological Mechanisms, Diagnosis, and Treatment Aleksandra Gąsecka 1 & Josip A. Borovac 2 & Rui Azevedo Guerreiro 3 Daniel Caldeira 6,7 & Gemma Chiva-Blanch 8,9
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Michela Giustozzi 4
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William Parker 5
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Accepted: 16 September 2020 # The Author(s) 2020
Abstract Introduction Emerging evidence points to an association between severe clinical presentation of COVID-19 and increased risk of thromboembolism. One-third of patients hospitalized due to severe COVID-19 develops macrovascular thrombotic complications, including venous thromboembolism, myocardial injury/infarction and stroke. Concurrently, the autopsy series indicate multiorgan damage pattern consistent with microvascular injury. Prophylaxis, diagnosis and treatment COVID-19 associated coagulopathy has distinct features, including markedly elevated Ddimers concentration with nearly normal activated partial thromboplastin time, prothrombin time and platelet count. The diagnosis may be challenging due to overlapping features between pulmonary embolism and severe COVID-19 disease, such as dyspnoea, high concentration of D-dimers, right ventricle with dysfunction or enlargement, and acute respiratory distress syndrome. Both macro- and microvascular complications are associated with an increased risk of in-hospital mortality. Therefore, early recognition of coagulation abnormalities among hospitalized COVID-19 patients are critical measures to identify patients with poor prognosis, guide antithrombotic prophylaxis or treatment, and improve patients’ clinical outcomes. Recommendations for clinicians Most of the guidelines and consensus documents published on behalf of professional societies focused on thrombosis and hemostasis advocate the use of anticoagulants in all patients hospitalized with COVID-19, as well as 2-6 weeks post hospital discharge in the absence of contraindications. However, since there is no guidance for deciding the intensity and duration of anticoagulation, the decision-making process should be made in individual-case basis. Conclusions Here, we review the mechanistic relationships between inflammation and thrombosis, discuss the macrovascular and microvascular complications and summarize the prophylaxis, diagnosis and treatment of thromboembolism in patients affected by COVID-19. Keywords COVID-19 . SARS-CoV-2 . Thrombosis . Inflammation . Venous thromboembolism . Prophylaxis Aleksandra Gąsecka and Josip A. Borovac share joint first authorship—these authors contributed equally to this work. Key Features - There is a strong association between severe COVID-19 and thromboembolism. - COVID-19-associated coagulopathy has distinct features. - Symptoms of severe COVID-19 disease and pulmonary embolism overlap. - Early recognition of thrombotic complications is critical to improve outcomes. - Anticoagulation should be used in most patients hospitalized with COVID-19. - There is no consensus regarding the anticoagulation intensity and duration. * Aleksandra Gąsecka alek
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