Registry of Arterial and Venous Thromboembolic Complications in Patients With COVID-19

Abstract

Background: Cardiovascular complications, including myocardial infarction, ischemic stroke, and pulmonary embolism, represent an important source of adverse outcomes in coronavirus disease-2019 (COVID-19).

Objectives: To assess the frequency of arterial and venous thromboembolic disease, risk factors, prevention and management patterns, and outcomes in patients with COVID-19, the authors designed a multicenter, observational cohort study.

Methods: We analyzed a retrospective cohort of 1,114 patients with COVID-19 diagnosed through our Mass General Brigham integrated health network. The total cohort was analyzed by site of care: intensive care (n = 170); hospitalized nonintensive care (n = 229); and outpatient (n = 715). The primary study outcome was a composite of adjudicated major arterial or venous thromboembolism.

Results: Patients with COVID-19 were 22.3% Hispanic/Latinx and 44.2% non-White. Cardiovascular risk factors of hypertension (35.8%), hyperlipidemia (28.6%), and diabetes (18.0%) were common. Prophylactic anticoagulation was prescribed in 89.4% of patients with COVID-19 in the intensive care cohort and 84.7% of those in the hospitalized nonintensive care setting. Frequencies of major arterial or venous thromboembolism, major cardiovascular adverse events, and symptomatic venous thromboembolism were highest in the intensive care cohort (35.3%, 45.9%, and 27.0 %, respectively) followed by the hospitalized nonintensive care cohort (2.6%, 6.1%, and 2.2%, respectively) and the outpatient cohort (0% for all).

Conclusions: Major arterial or venous thromboembolism, major adverse cardiovascular events, and symptomatic venous thromboembolism occurred with high frequency in patients with COVID-19, especially in the intensive care setting, despite a high utilization rate of thromboprophylaxis.

Keywords: COVID-19; anticoagulation; cardiovascular disease; coronavirus; deep venous thrombosis; myocardial infarction; pulmonary embolism; stroke; thromboembolism.

Graphical abstract

Figure 1

Time From COVID-19 PCR Diagnosis to Major Composite Outcomes Kaplan-Meier plots demonstrating time from coronavirus disease-2019 (COVID-19) polymerase chain reaction (PCR) diagnosis to each of the 3 major composite outcomes. Major arterial and venous thromboembolism (A), major cardiovascular events (B), and symptomatic venous thromboembolism (VTE) (C) were more frequent in intensive care unit (ICU) patients than in hospitalized non-ICU patients. Adjusting for competing risk of death, estimated cumulative incidences at 30 days for major arterial and venous thromboembolism, major cardiovascular events, and symptomatic VTE in the ICU cohort were 0.34 (95% confidence interval [CI]: 0.28 to 0.42), 0.44 (95% CI: 0.38 to 0.52), and 0.24 (95% CI: 0.19 to 0.31), respectively. The estimated cumulative incidences at 30 days for major arterial and venous thromboembolism, major cardiovascular events, and symptomatic VTE in the hospitalized non-ICU cohort were 0.03 (95% CI: 0.01 to 0.06), 0.06 (95% CI: 0.03 to 0.1), and 0.02 (95% CI: 0.01 to 0.05), respectively. Three patients had outcomes prior to PCR diagnosis and were excluded from the plots.

Figure 1

Time From COVID-19 PCR Diagnosis to Major Composite Outcomes Kaplan-Meier plots demonstrating time from coronavirus disease-2019 (COVID-19) polymerase chain reaction (PCR) diagnosis to each of the 3 major composite outcomes. Major arterial and venous thromboembolism (A), major cardiovascular events (B), and symptomatic venous thromboembolism (VTE) (C) were more frequent in intensive care unit (ICU) patients than in hospitalized non-ICU patients. Adjusting for competing risk of death, estimated cumulative incidences at 30 days for major arterial and venous thromboembolism, major cardiovascular events, and symptomatic VTE in the ICU cohort were 0.34 (95% confidence interval [CI]: 0.28 to 0.42), 0.44 (95% CI: 0.38 to 0.52), and 0.24 (95% CI: 0.19 to 0.31), respectively. The estimated cumulative incidences at 30 days for major arterial and venous thromboembolism, major cardiovascular events, and symptomatic VTE in the hospitalized non-ICU cohort were 0.03 (95% CI: 0.01 to 0.06), 0.06 (95% CI: 0.03 to 0.1), and 0.02 (95% CI: 0.01 to 0.05), respectively. Three patients had outcomes prior to PCR diagnosis and were excluded from the plots.

Central Illustration

Cardiovascular Complications in Patients With Coronavirus Disease-2019 at 30 Days From Diagnosis Cardiovascular complications, including major arterial or venous thromboembolism, in 1,114 patients with coronavirus disease-2019 (COVID-19) at 30 days from diagnosis. Adjudicated major arterial (including myocardial infarction, stroke/transient ischemic attack, systemic embolism, and major adverse limb events) or venous thromboembolism, major adverse cardiovascular events, and symptomatic venous thromboembolism (VTE) (including catheter- and device-related deep vein thrombosis [DVT]) were frequent in patients with COVID-19 admitted to the intensive care unit (ICU) setting (n = 170). Among those admitted to the non-ICU setting (n = 229), the frequency of major arterial or venous thromboembolism, major adverse cardiovascular events, and symptomatic VTE was also elevated but lower than for those with critical illness. The increased frequency of thromboembolic complications occurred in the context of a relative high rate of thromboprophylaxis prescription. Outpatients (n = 715) were considered to be low risk for major arterial or venous thromboembolism, major adverse cardiovascular events, and symptomatic VTE.