Low-molecular-weight heparin compared with unfractionated heparin in critically ill COVID-19 patients

Thrombosis in COVID-19 worsens mortality. In our study, we sought to investigate how the dose and type of anticoagulation (AC) can influence patient outcomes. This is a single-center retrospective analysis of critically ill intubated patients with COVID-19, comparing low-molecular-weight heparin (LM...

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Veröffentlicht in:Journal of vascular surgery. Venous and lymphatic disorders (New York, NY) NY), 2022-09, Vol.10 (5), p.1128-1136
Hauptverfasser: Volteas, Panagiotis, Drakos, Panagiotis, Alkadaa, Leor N., Cleri, Nathaniel A., Asencio, Anthony A., Oganov, Anthony, Giannopoulos, Stefanos, Saadon, Jordan R., Mikell, Charles B., Rubano, Jerry A., Labropoulos, Nicos, Tassiopoulos, Apostolos K., Mofakham, Sima, Bannazadeh, Mohsen
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container_end_page 1136
container_issue 5
container_start_page 1128
container_title Journal of vascular surgery. Venous and lymphatic disorders (New York, NY)
container_volume 10
creator Volteas, Panagiotis
Drakos, Panagiotis
Alkadaa, Leor N.
Cleri, Nathaniel A.
Asencio, Anthony A.
Oganov, Anthony
Giannopoulos, Stefanos
Saadon, Jordan R.
Mikell, Charles B.
Rubano, Jerry A.
Labropoulos, Nicos
Tassiopoulos, Apostolos K.
Mofakham, Sima
Bannazadeh, Mohsen
description Thrombosis in COVID-19 worsens mortality. In our study, we sought to investigate how the dose and type of anticoagulation (AC) can influence patient outcomes. This is a single-center retrospective analysis of critically ill intubated patients with COVID-19, comparing low-molecular-weight heparin (LMWH) and unfractionated heparin (UFH) at therapeutic and prophylactic doses. Of 218 patients, 135 received LMWH (70 prophylactic, 65 therapeutic) and 83 UFH (11 prophylactic, 72 therapeutic). The primary outcome was mortality. Secondary outcomes were thromboembolic complications confirmed on imaging and major bleeding complications. Cox proportional-hazards regression models were used to determine whether the type and dose of AC were independent predictors of survival. We performed Kaplan-Meier survival analysis to compare the cumulative survivals. Overall, therapeutic AC, with either LMWH (65% vs 79%, P = .09) or UFH (32% vs 46%, P = .73), conveyed no survival benefit over prophylactic AC. UFH was associated with a higher mortality rate than LMWH (66% vs 28%, P = .001), which was also evident in the multivariable analysis (LMWH vs UFH mortality, hazard ratio: 0.47, P = .001) and in the Kaplan-Meier survival analysis. Thrombotic and bleeding complications did not depend on the AC type (prophylactic LMWH vs UFH: thrombosis P = .49, bleeding P = .075; therapeutic LMWH vs UFH: thrombosis P = .5, bleeding P = .17). When comparing prophylactic with therapeutic AC, the rate of both thrombotic and bleeding complications was higher with the use of LMWH compared with UFH. In addition, transfusion requirements were significantly higher with both therapeutic LMWH and UFH. Among intubated critically ill COVID-19 intensive care unit patients, therapeutic AC, with either LMWH or UFH, conveyed no survival benefit over prophylactic AC. AC with LMWH was associated with higher cumulative survival compared with AC with UFH. •Type of Research: Single-center retrospective cohort study•Key Findings: Of 218 patients, 135 received low-molecular-weight heparin (LMWH) and 83 received unfractionated heparin. Among intubated critically ill COVID-19 intensive care unit patients, therapeutic anticoagulation (AC), with either LMWH or unfractionated heparin, conveyed no survival benefit over prophylactic AC. AC with LMWH was associated with higher cumulative survival compared with AC with unfractionated heparin.•Take Home Message: In intubated, critically ill, COVID-19 adult ICU patients, thera
doi_str_mv 10.1016/j.jvsv.2022.04.019
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In our study, we sought to investigate how the dose and type of anticoagulation (AC) can influence patient outcomes. This is a single-center retrospective analysis of critically ill intubated patients with COVID-19, comparing low-molecular-weight heparin (LMWH) and unfractionated heparin (UFH) at therapeutic and prophylactic doses. Of 218 patients, 135 received LMWH (70 prophylactic, 65 therapeutic) and 83 UFH (11 prophylactic, 72 therapeutic). The primary outcome was mortality. Secondary outcomes were thromboembolic complications confirmed on imaging and major bleeding complications. Cox proportional-hazards regression models were used to determine whether the type and dose of AC were independent predictors of survival. We performed Kaplan-Meier survival analysis to compare the cumulative survivals. Overall, therapeutic AC, with either LMWH (65% vs 79%, P = .09) or UFH (32% vs 46%, P = .73), conveyed no survival benefit over prophylactic AC. UFH was associated with a higher mortality rate than LMWH (66% vs 28%, P = .001), which was also evident in the multivariable analysis (LMWH vs UFH mortality, hazard ratio: 0.47, P = .001) and in the Kaplan-Meier survival analysis. Thrombotic and bleeding complications did not depend on the AC type (prophylactic LMWH vs UFH: thrombosis P = .49, bleeding P = .075; therapeutic LMWH vs UFH: thrombosis P = .5, bleeding P = .17). When comparing prophylactic with therapeutic AC, the rate of both thrombotic and bleeding complications was higher with the use of LMWH compared with UFH. In addition, transfusion requirements were significantly higher with both therapeutic LMWH and UFH. Among intubated critically ill COVID-19 intensive care unit patients, therapeutic AC, with either LMWH or UFH, conveyed no survival benefit over prophylactic AC. AC with LMWH was associated with higher cumulative survival compared with AC with UFH. •Type of Research: Single-center retrospective cohort study•Key Findings: Of 218 patients, 135 received low-molecular-weight heparin (LMWH) and 83 received unfractionated heparin. Among intubated critically ill COVID-19 intensive care unit patients, therapeutic anticoagulation (AC), with either LMWH or unfractionated heparin, conveyed no survival benefit over prophylactic AC. AC with LMWH was associated with higher cumulative survival compared with AC with unfractionated heparin.•Take Home Message: In intubated, critically ill, COVID-19 adult ICU patients, therapeutic AC, with either LMWH or UFH, had no survival benefit or greater organ-support-free days over prophylactic AC. This finding is in concordance with the NIH (National Institutes of Health) guidelines supporting the use of prophylactic AC over therapeutic AC in those critically ill unless AC is contraindicated or there is a documented VTE. It seems that the initiation of therapeutic AC after severe COVID-19 has developed may be too late to alter the consequences of established disease processes. Furthermore, AC with LMWH is preferable as it was shown to be associated with higher cumulative survival than AC with UFH.</description><identifier>ISSN: 2213-333X</identifier><identifier>EISSN: 2213-3348</identifier><identifier>DOI: 10.1016/j.jvsv.2022.04.019</identifier><identifier>PMID: 35716998</identifier><language>eng</language><publisher>Elsevier Inc</publisher><subject>Anticoagulation (AC) ; Clinical Research Study ; COVID-19 ; Low-molecular-weight heparin (LMWH) ; SARS-CoV-2 ; Thromboprophylaxis ; Unfractionated heparin (UFH)</subject><ispartof>Journal of vascular surgery. 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Venous and lymphatic disorders (New York, NY)</title><description>Thrombosis in COVID-19 worsens mortality. In our study, we sought to investigate how the dose and type of anticoagulation (AC) can influence patient outcomes. This is a single-center retrospective analysis of critically ill intubated patients with COVID-19, comparing low-molecular-weight heparin (LMWH) and unfractionated heparin (UFH) at therapeutic and prophylactic doses. Of 218 patients, 135 received LMWH (70 prophylactic, 65 therapeutic) and 83 UFH (11 prophylactic, 72 therapeutic). The primary outcome was mortality. Secondary outcomes were thromboembolic complications confirmed on imaging and major bleeding complications. Cox proportional-hazards regression models were used to determine whether the type and dose of AC were independent predictors of survival. We performed Kaplan-Meier survival analysis to compare the cumulative survivals. Overall, therapeutic AC, with either LMWH (65% vs 79%, P = .09) or UFH (32% vs 46%, P = .73), conveyed no survival benefit over prophylactic AC. UFH was associated with a higher mortality rate than LMWH (66% vs 28%, P = .001), which was also evident in the multivariable analysis (LMWH vs UFH mortality, hazard ratio: 0.47, P = .001) and in the Kaplan-Meier survival analysis. Thrombotic and bleeding complications did not depend on the AC type (prophylactic LMWH vs UFH: thrombosis P = .49, bleeding P = .075; therapeutic LMWH vs UFH: thrombosis P = .5, bleeding P = .17). When comparing prophylactic with therapeutic AC, the rate of both thrombotic and bleeding complications was higher with the use of LMWH compared with UFH. In addition, transfusion requirements were significantly higher with both therapeutic LMWH and UFH. Among intubated critically ill COVID-19 intensive care unit patients, therapeutic AC, with either LMWH or UFH, conveyed no survival benefit over prophylactic AC. AC with LMWH was associated with higher cumulative survival compared with AC with UFH. •Type of Research: Single-center retrospective cohort study•Key Findings: Of 218 patients, 135 received low-molecular-weight heparin (LMWH) and 83 received unfractionated heparin. Among intubated critically ill COVID-19 intensive care unit patients, therapeutic anticoagulation (AC), with either LMWH or unfractionated heparin, conveyed no survival benefit over prophylactic AC. AC with LMWH was associated with higher cumulative survival compared with AC with unfractionated heparin.•Take Home Message: In intubated, critically ill, COVID-19 adult ICU patients, therapeutic AC, with either LMWH or UFH, had no survival benefit or greater organ-support-free days over prophylactic AC. This finding is in concordance with the NIH (National Institutes of Health) guidelines supporting the use of prophylactic AC over therapeutic AC in those critically ill unless AC is contraindicated or there is a documented VTE. It seems that the initiation of therapeutic AC after severe COVID-19 has developed may be too late to alter the consequences of established disease processes. Furthermore, AC with LMWH is preferable as it was shown to be associated with higher cumulative survival than AC with UFH.</description><subject>Anticoagulation (AC)</subject><subject>Clinical Research Study</subject><subject>COVID-19</subject><subject>Low-molecular-weight heparin (LMWH)</subject><subject>SARS-CoV-2</subject><subject>Thromboprophylaxis</subject><subject>Unfractionated heparin (UFH)</subject><issn>2213-333X</issn><issn>2213-3348</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2022</creationdate><recordtype>article</recordtype><recordid>eNp9UU1LxDAQDaKoqH_AU49eWvPRpi2IIOsnLHhR8RayydTNkjZrku6y_94sq4IXw0BmkvfeDPMQOie4IJjwy0WxWIVVQTGlBS4LTNo9dEwpYTljZbP_m7P3I3QWwgKn03Be1fgQHbGqJrxtm2MEU7fOe2dBjVb6fA3mYx6zOSylN0OmXJ8S0NnaxHk2Dp2XKho3yJjefkBbnDfRKGntJjPWZpPnt6fbnLTZUkYDQwyn6KCTNsDZ932CXu_vXiaP-fT54WlyM80V4zTmui55pVOwFkuaZpyxFjoFnDLeNZrLllR1hzudSi2brqo5x5izGSkrzjmwE3S9012Osx60Sr29tGLpTS_9RjhpxN-fwczFh1uJlhJa1k0SuPgW8O5zhBBFb4ICa-UAbgyC8ropGcasTlC6gyrvQvDQ_bYhWGwtEguxtUhsLRK4FMmiRLrakSBtYWXAi6DShhRo40FFoZ35j_4FTCyabw</recordid><startdate>20220901</startdate><enddate>20220901</enddate><creator>Volteas, Panagiotis</creator><creator>Drakos, Panagiotis</creator><creator>Alkadaa, Leor N.</creator><creator>Cleri, Nathaniel A.</creator><creator>Asencio, Anthony A.</creator><creator>Oganov, Anthony</creator><creator>Giannopoulos, Stefanos</creator><creator>Saadon, Jordan R.</creator><creator>Mikell, Charles B.</creator><creator>Rubano, Jerry A.</creator><creator>Labropoulos, Nicos</creator><creator>Tassiopoulos, Apostolos K.</creator><creator>Mofakham, Sima</creator><creator>Bannazadeh, Mohsen</creator><general>Elsevier Inc</general><scope>AAYXX</scope><scope>CITATION</scope><scope>7X8</scope><scope>5PM</scope></search><sort><creationdate>20220901</creationdate><title>Low-molecular-weight heparin compared with unfractionated heparin in critically ill COVID-19 patients</title><author>Volteas, Panagiotis ; Drakos, Panagiotis ; Alkadaa, Leor N. ; Cleri, Nathaniel A. ; Asencio, Anthony A. ; Oganov, Anthony ; Giannopoulos, Stefanos ; Saadon, Jordan R. ; Mikell, Charles B. ; Rubano, Jerry A. ; Labropoulos, Nicos ; Tassiopoulos, Apostolos K. ; Mofakham, Sima ; Bannazadeh, Mohsen</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c362t-d7465d65d390a2571b39efce6236f8d6a9157f0fd36fda8f57660063b145666e3</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2022</creationdate><topic>Anticoagulation (AC)</topic><topic>Clinical Research Study</topic><topic>COVID-19</topic><topic>Low-molecular-weight heparin (LMWH)</topic><topic>SARS-CoV-2</topic><topic>Thromboprophylaxis</topic><topic>Unfractionated heparin (UFH)</topic><toplevel>online_resources</toplevel><creatorcontrib>Volteas, Panagiotis</creatorcontrib><creatorcontrib>Drakos, Panagiotis</creatorcontrib><creatorcontrib>Alkadaa, Leor N.</creatorcontrib><creatorcontrib>Cleri, Nathaniel A.</creatorcontrib><creatorcontrib>Asencio, Anthony A.</creatorcontrib><creatorcontrib>Oganov, Anthony</creatorcontrib><creatorcontrib>Giannopoulos, Stefanos</creatorcontrib><creatorcontrib>Saadon, Jordan R.</creatorcontrib><creatorcontrib>Mikell, Charles B.</creatorcontrib><creatorcontrib>Rubano, Jerry A.</creatorcontrib><creatorcontrib>Labropoulos, Nicos</creatorcontrib><creatorcontrib>Tassiopoulos, Apostolos K.</creatorcontrib><creatorcontrib>Mofakham, Sima</creatorcontrib><creatorcontrib>Bannazadeh, Mohsen</creatorcontrib><collection>CrossRef</collection><collection>MEDLINE - Academic</collection><collection>PubMed Central (Full Participant titles)</collection><jtitle>Journal of vascular surgery. Venous and lymphatic disorders (New York, NY)</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Volteas, Panagiotis</au><au>Drakos, Panagiotis</au><au>Alkadaa, Leor N.</au><au>Cleri, Nathaniel A.</au><au>Asencio, Anthony A.</au><au>Oganov, Anthony</au><au>Giannopoulos, Stefanos</au><au>Saadon, Jordan R.</au><au>Mikell, Charles B.</au><au>Rubano, Jerry A.</au><au>Labropoulos, Nicos</au><au>Tassiopoulos, Apostolos K.</au><au>Mofakham, Sima</au><au>Bannazadeh, Mohsen</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Low-molecular-weight heparin compared with unfractionated heparin in critically ill COVID-19 patients</atitle><jtitle>Journal of vascular surgery. Venous and lymphatic disorders (New York, NY)</jtitle><date>2022-09-01</date><risdate>2022</risdate><volume>10</volume><issue>5</issue><spage>1128</spage><epage>1136</epage><pages>1128-1136</pages><issn>2213-333X</issn><eissn>2213-3348</eissn><abstract>Thrombosis in COVID-19 worsens mortality. In our study, we sought to investigate how the dose and type of anticoagulation (AC) can influence patient outcomes. This is a single-center retrospective analysis of critically ill intubated patients with COVID-19, comparing low-molecular-weight heparin (LMWH) and unfractionated heparin (UFH) at therapeutic and prophylactic doses. Of 218 patients, 135 received LMWH (70 prophylactic, 65 therapeutic) and 83 UFH (11 prophylactic, 72 therapeutic). The primary outcome was mortality. Secondary outcomes were thromboembolic complications confirmed on imaging and major bleeding complications. Cox proportional-hazards regression models were used to determine whether the type and dose of AC were independent predictors of survival. We performed Kaplan-Meier survival analysis to compare the cumulative survivals. Overall, therapeutic AC, with either LMWH (65% vs 79%, P = .09) or UFH (32% vs 46%, P = .73), conveyed no survival benefit over prophylactic AC. UFH was associated with a higher mortality rate than LMWH (66% vs 28%, P = .001), which was also evident in the multivariable analysis (LMWH vs UFH mortality, hazard ratio: 0.47, P = .001) and in the Kaplan-Meier survival analysis. Thrombotic and bleeding complications did not depend on the AC type (prophylactic LMWH vs UFH: thrombosis P = .49, bleeding P = .075; therapeutic LMWH vs UFH: thrombosis P = .5, bleeding P = .17). When comparing prophylactic with therapeutic AC, the rate of both thrombotic and bleeding complications was higher with the use of LMWH compared with UFH. In addition, transfusion requirements were significantly higher with both therapeutic LMWH and UFH. Among intubated critically ill COVID-19 intensive care unit patients, therapeutic AC, with either LMWH or UFH, conveyed no survival benefit over prophylactic AC. AC with LMWH was associated with higher cumulative survival compared with AC with UFH. •Type of Research: Single-center retrospective cohort study•Key Findings: Of 218 patients, 135 received low-molecular-weight heparin (LMWH) and 83 received unfractionated heparin. Among intubated critically ill COVID-19 intensive care unit patients, therapeutic anticoagulation (AC), with either LMWH or unfractionated heparin, conveyed no survival benefit over prophylactic AC. AC with LMWH was associated with higher cumulative survival compared with AC with unfractionated heparin.•Take Home Message: In intubated, critically ill, COVID-19 adult ICU patients, therapeutic AC, with either LMWH or UFH, had no survival benefit or greater organ-support-free days over prophylactic AC. This finding is in concordance with the NIH (National Institutes of Health) guidelines supporting the use of prophylactic AC over therapeutic AC in those critically ill unless AC is contraindicated or there is a documented VTE. It seems that the initiation of therapeutic AC after severe COVID-19 has developed may be too late to alter the consequences of established disease processes. Furthermore, AC with LMWH is preferable as it was shown to be associated with higher cumulative survival than AC with UFH.</abstract><pub>Elsevier Inc</pub><pmid>35716998</pmid><doi>10.1016/j.jvsv.2022.04.019</doi><tpages>9</tpages><oa>free_for_read</oa></addata></record>
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identifier ISSN: 2213-333X
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issn 2213-333X
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subjects Anticoagulation (AC)
Clinical Research Study
COVID-19
Low-molecular-weight heparin (LMWH)
SARS-CoV-2
Thromboprophylaxis
Unfractionated heparin (UFH)
title Low-molecular-weight heparin compared with unfractionated heparin in critically ill COVID-19 patients
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