Venous Thromboembolism in COVID-19

Abstract

The coronavirus disease 2019 (COVID-19) is our latest pandemic, preceded by the H1N1 swine flu in 2009, which lasted approximately 19 months. One of the special characteristics of COVID-19 is the propensity to cause venous thromboembolism (VTE). Thromboinflammation seems to play a prominent role in the pathogenesis. We will here review some mechanisms in the pathogenesis and discuss some hematological biomarkers, and also whether they serve as useful risk factors for VTE. The role of general risk assessment models for medically ill patients specifically in COVID-19 is appraised. The type of prophylaxis and particularly whether standard or augmented doses of chemoprophylaxis should be used is reviewed based on available evidence. We are also comparing recommendations from 10 different guidance or position/consensus statements. Treatment recommendations for patients with COVID-19 and pulmonary embolism are discussed with current general treatment guidelines as reference. Specifics for patients with COVID-19 are pointed out and the potential role of thrombolytic treatment is explored.

Fig. 1

Risk factors for venous thromboembolism in patients with COVID-19.

Fig. 2

Reported incidence of venous thromboembolism in hospitalized patients with COVID-19 according to different selection criteria. Data are from 20 studies included in a meta-analysis. Each dot represents the mean incidence in one study.

Fig. 3

Proposed risk-adjusted management of patients with acute pulmonary embolism, including those infected with SARS-CoV-2. CTPA, computed tomography pulmonary angiography/angiogram; PE, pulmonary embolism; PESI, Pulmonary Embolism Severity Index; RV, right ventricular; sPESI, simplified Pulmonary Embolism Severity Index; TTE, transthoracic echocardiogram. Cancer, heart failure, and chronic lung disease are the comorbidities included in the PESI and sPESI. A cardiac troponin test may already have been performed during initial diagnostic work-up (e.g., in the chest pain unit). Troponin is proposed as the preferred biomarker, because it is the only one to have been used in an interventional trial. It is also included in the Hestia criteria. (Adapted from Konstantinides et al with permission from Oxford University Press.)