Can we manage prophylactic therapy in COVID-19 patients to prevent severe illness complications?

Paulo Eduardo Ocke Reis Marcos Cesar Braga Lima About the authors

Resumo

Muitos pacientes com COVID-19 apresentam complicações tromboembólicas que acabam piorando seu prognóstico. Os autores propõem uma modificação no escore CHA2DS2-VASc, incluindo 1 ponto para COVID-19, para, desse modo, indicar profilaxia de eventos tromboembólicos antes do agravamento do quadro. As vantagens dessa modificação seriam evitar a piora do paciente por problemas tromboembólicos, bem como a necessidade de internação em unidade de tratamento intensivo e de ventilação mecânica, e diminuir a mortalidade.

Palavras-chave:
COVID-19; coronavirus; anticoagulantes; trombose; prevenção; mortalidade hospitalar

Abstract

Many patients with COVID-19 have thromboembolic complications that worsen their prognosis. Herein, the authors propose a modified version of the CHA2DS2-VASc score, including 1 point for COVID-19, so that prophylaxis to protect against thromboembolic events would be indicated before the condition becomes severe. The advantages of this modification would be prevention of the patient’s condition worsening due to thromboembolic problems and reduction of the likelihood of a need for intensive care and mechanical ventilation, reducing mortality.

Keywords:
COVID-19; coronavirus; anticoagulants; thrombosis; prevention; hospital mortality

INTRODUCTION

Since infection by COVID-19 was first described, the severe respiratory syndrome associated with the disease has caused rapid increases in admissions to intensive care units (ICUs) and elevated mortality of a group of patients.11 Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Whuam, China. Lancet. 2020;395(10223):497-506. http://dx.doi.org/10.1016/S0140-6736(20)30183-5. PMid:31986264.
http://dx.doi.org/10.1016/S0140-6736(20)...
During a pandemic, it is necessary to avoid saturation of health systems, both public and private, and in particular of ICUs. The principal relevant finding in the lungs is presence of platelet thrombi and fibrin in small arterial vessels, which fits perfectly with a clinical scenario of coagulopathy.22 Casarna L, Sonzogni A, Nasr A, et al. Pulmonary post-mortem findings in a large series of COVID-19 cases from Northern Italy. medRxiv; 2020 [citado 2020 abr 28]. https://www.medrxiv.org/content/10.1101/2020.04.19.20054262v1
https://www.medrxiv.org/content/10.1101/...

Since there is no consensus-approved treatment in this situation and considering the possibility of thrombosis associated with infection by coronavirus in certain cases, recently-acquired experience and findings of still-embryonic scientific studies has shown that effective anticoagulation can prevent or reverse the prothrombotic state in some patients.22 Casarna L, Sonzogni A, Nasr A, et al. Pulmonary post-mortem findings in a large series of COVID-19 cases from Northern Italy. medRxiv; 2020 [citado 2020 abr 28]. https://www.medrxiv.org/content/10.1101/2020.04.19.20054262v1
https://www.medrxiv.org/content/10.1101/...
,33 Obi AT, Barnes GD, Wakefield TW, et al. Practical diagnosis and treatment of suspected venous thromboembolism during COVID-19 Pandemic. J Vasc Surg Venous Lymphat Disord. 2020. http://dx.doi.org/10.1016/j.jvsv.2020.04.009. PMid:32305585.
http://dx.doi.org/10.1016/j.jvsv.2020.04...

PROPOSAL

We have observed that, coincidentally, the group of patients who respond poorly to the COVID-19 infection (Figure 1)44 Cuffe R. Coronavírus: quais as chances de morrer por causa da covid-19. Brasil: BBC News; 2020 [citado 2020 abr 28]. https://www.bbc.com/portuguese/internacional-51703189
https://www.bbc.com/portuguese/internaci...
and die are the same patients whose CHA2DS2-VASc scores indicate risk of stroke, transitory ischemic episode, peripheral emboli, and pulmonary thromboembolism (Table 1).55 Sá T, Sargento-Freitas J, Pinheiro V, et al. CHADS2 e CHA2DS2VASc como preditores de fonte cardioembólica em prevenção secundária cerebrovascular. Rev Port Cardiol. 2013;32(5):373-8. http://dx.doi.org/10.1016/j.repc.2012.09.007. PMid:23566635.
http://dx.doi.org/10.1016/j.repc.2012.09...
,66 Habboushe J, Altman C, Lip GYH. Time trends in use of the CHADS2 and CHA2 DS2 VASc scores, and the geographical and specialty uptake of these scores from a popular online clinical decision tool and medical reference. Int J Clin Pract. 2019;73(2):e13280. http://dx.doi.org/10.1111/ijcp.13280. PMid:30281876.
http://dx.doi.org/10.1111/ijcp.13280...
According to this score, a patient is considered high risk if they score 2 points or more, intermediate risk if they score 1, and low risk if they do not have risk factors.66 Habboushe J, Altman C, Lip GYH. Time trends in use of the CHADS2 and CHA2 DS2 VASc scores, and the geographical and specialty uptake of these scores from a popular online clinical decision tool and medical reference. Int J Clin Pract. 2019;73(2):e13280. http://dx.doi.org/10.1111/ijcp.13280. PMid:30281876.
http://dx.doi.org/10.1111/ijcp.13280...
Our proposal, therefore, is to add 1 point to the CHA2DS2-VASc score (Table 1) for patients who have COVID-19 and use the new score to indicate prophylactic anticoagulation for patients with a high risk of thrombosis according to the score, in phase 2 of the disease (Table 2). The objective is to prevent the patient’s condition from worsening because of thromboembolic problems, avoiding the need for ICU admission and mechanical ventilation.77 Bikdeli B, Madhavan MV, Jimenez D, et al. COVID-19 and thrombotic or thromboembolic disease: implications for prevention, antithrombotic therapy, and follow-up. J Am Coll Cardiol. 2020;17:272-84. PMid:32311448.

Figure 1
Mortality from COVID-19 varies by age and health status.44 Cuffe R. Coronavírus: quais as chances de morrer por causa da covid-19. Brasil: BBC News; 2020 [citado 2020 abr 28]. https://www.bbc.com/portuguese/internacional-51703189
https://www.bbc.com/portuguese/internaci...
Table 1
Structure of the CHA2DS2-VASc score after addition of 1 point for COVID-19 (CHA2DS2-VASc-C19).
Table 2
Phases of COVID-19 infection and treatment.

The idea is to proceed in a similar manner as with risk of thromboses and emboli according to the existing scores and initiate prophylaxis to attempt to avert occurrence of events that have contributed to the worsening clinical status of these patients.11 Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Whuam, China. Lancet. 2020;395(10223):497-506. http://dx.doi.org/10.1016/S0140-6736(20)30183-5. PMid:31986264.
http://dx.doi.org/10.1016/S0140-6736(20)...

2 Casarna L, Sonzogni A, Nasr A, et al. Pulmonary post-mortem findings in a large series of COVID-19 cases from Northern Italy. medRxiv; 2020 [citado 2020 abr 28]. https://www.medrxiv.org/content/10.1101/2020.04.19.20054262v1
https://www.medrxiv.org/content/10.1101/...
-33 Obi AT, Barnes GD, Wakefield TW, et al. Practical diagnosis and treatment of suspected venous thromboembolism during COVID-19 Pandemic. J Vasc Surg Venous Lymphat Disord. 2020. http://dx.doi.org/10.1016/j.jvsv.2020.04.009. PMid:32305585.
http://dx.doi.org/10.1016/j.jvsv.2020.04...
In this communication, the authors propose modifying the scoring of the CHA2DS2-VASc score and studying its validity, with the objective of reducing the number of critically patients who progress to phase 3.

  • How to cite: Reis PEO, Lima MCB. Can we manage prophylactic therapy in COVID-19 patients to prevent severe illness complications? J Vasc Bras. 2020;19:e20200057. https://doi.org/10.1590/1677-5449.200057
  • Financial support: None.
  • The study was carried out at Hospital Universitário Antônio Pedro (HUAP), Universidade Federal Fluminense (UFF), Niterói, RJ, Brazil.

References

  • 1
    Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Whuam, China. Lancet. 2020;395(10223):497-506. http://dx.doi.org/10.1016/S0140-6736(20)30183-5 PMid:31986264.
    » http://dx.doi.org/10.1016/S0140-6736(20)30183-5
  • 2
    Casarna L, Sonzogni A, Nasr A, et al. Pulmonary post-mortem findings in a large series of COVID-19 cases from Northern Italy. medRxiv; 2020 [citado 2020 abr 28]. https://www.medrxiv.org/content/10.1101/2020.04.19.20054262v1
    » https://www.medrxiv.org/content/10.1101/2020.04.19.20054262v1
  • 3
    Obi AT, Barnes GD, Wakefield TW, et al. Practical diagnosis and treatment of suspected venous thromboembolism during COVID-19 Pandemic. J Vasc Surg Venous Lymphat Disord. 2020. http://dx.doi.org/10.1016/j.jvsv.2020.04.009 PMid:32305585.
    » http://dx.doi.org/10.1016/j.jvsv.2020.04.009
  • 4
    Cuffe R. Coronavírus: quais as chances de morrer por causa da covid-19. Brasil: BBC News; 2020 [citado 2020 abr 28]. https://www.bbc.com/portuguese/internacional-51703189
    » https://www.bbc.com/portuguese/internacional-51703189
  • 5
    Sá T, Sargento-Freitas J, Pinheiro V, et al. CHADS2 e CHA2DS2VASc como preditores de fonte cardioembólica em prevenção secundária cerebrovascular. Rev Port Cardiol. 2013;32(5):373-8. http://dx.doi.org/10.1016/j.repc.2012.09.007 PMid:23566635.
    » http://dx.doi.org/10.1016/j.repc.2012.09.007
  • 6
    Habboushe J, Altman C, Lip GYH. Time trends in use of the CHADS2 and CHA2 DS2 VASc scores, and the geographical and specialty uptake of these scores from a popular online clinical decision tool and medical reference. Int J Clin Pract. 2019;73(2):e13280. http://dx.doi.org/10.1111/ijcp.13280 PMid:30281876.
    » http://dx.doi.org/10.1111/ijcp.13280
  • 7
    Bikdeli B, Madhavan MV, Jimenez D, et al. COVID-19 and thrombotic or thromboembolic disease: implications for prevention, antithrombotic therapy, and follow-up. J Am Coll Cardiol. 2020;17:272-84. PMid:32311448.

Publication Dates

  • Publication in this collection
    20 May 2020
  • Date of issue
    2020

History

  • Received
    28 Apr 2020
  • Accepted
    04 May 2020
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