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Jornal Vascular Brasileiro

Print version ISSN 1677-5449On-line version ISSN 1677-7301

J. vasc. bras. vol.19  Porto Alegre  2020  Epub May 20, 2020

https://doi.org/10.1590/1677-5449.200057 

INNOVATIONS

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

Paulo Eduardo Ocke Reis1 
http://orcid.org/0000-0001-5450-6806

Marcos Cesar Braga Lima1 

1Universidade Federal Fluminense – UFF, Departamento de Cirurgia Geral e Especializada, Niterói, RJ, Brasil.


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

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

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.1 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.2

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.2,3

PROPOSAL

We have observed that, coincidentally, the group of patients who respond poorly to the COVID-19 infection (Figure 1)4 and die are the same patients whose CHA2DS2-VASc scores indicate risk of stroke, transitory ischemic episode, peripheral emboli, and pulmonary thromboembolism (Table 1).5,6 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.6 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.7

Figure 1 Mortality from COVID-19 varies by age and health status.4  

Table 1 Structure of the CHA2DS2-VASc score after addition of 1 point for COVID-19 (CHA2DS2-VASc-C19). 

CHA2DS2-VASc Description Points
C Heart failure 1
H Hypertension 1
A2 Age (≥ 75 years) 2
D Diabetes mellitus 1
S2 Prior TIA or stroke 2
V Vascular disease (prior AMI, aortic plaque, peripheral arterial disease) 1
A Age (65-74 years) 1
C19 Suspected or confirmed COVID-19 1

TIA = transient ischemic attack; AMI = acute myocardial infarction.

Table 2 Phases of COVID-19 infection and treatment. 

Phases Clinical status Treatment
Phase 1 Flu-like respiratory infection Avoid contagion, reduce symptoms, reduce viral load with medications in use
Phase 2 (see Table 1) High risk of thrombosis Prophylaxis, avoid intra pulmonary thrombosis, prophylactic anticoagulation
Phase 3 Critical patient in ICU Full therapeutic anticoagulation

ICU = intensive care unit.

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.1-3 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. [ Links ]

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/10.1101/2020.04.19.20054262v1Links ]

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. [ Links ]

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-51703189Links ]

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. [ Links ]

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. [ Links ]

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. [ Links ]

Received: April 28, 2020; Accepted: May 04, 2020

Conflicts of interest: No conflicts of interest declared concerning the publication of this article.

Correspondence Paulo Eduardo Ocke Reis Universidade Federal Fluminense – UFF, Departamento de Cirurgia Geral e Especializada Rua Marques de Paraná, 303 – Centro CEP 24033-900 - Niterói (RJ), Brasil Tel.: +55 (21) 2629-5000 E-mail: vascular@pauloocke.com.br; ockereis@yahoo.com

Author information PEOR - MD; PhD; Board certified in Cirurgia Vascular e Endovascular; Adjunct professor of Cirurgia Vascular, Universidade Federal Fluminense (UFF); PhD, Universidade Federal do Rio de Janeiro (UFRJ). MCBL - MD; Board certified in Cardiologia, Universidade Federal Fluminense (UFF); Director, Clínica Cardiológica Dr. Marcos Cesar Braga Lima.

Author contributions Conception and design: PEOR, MCBL Analysis and interpretation: PEOR, MCBL Data collection: PEOR Writing the article: PEOR, MCBL Critical revision of the article: PEOR, MCBL Final approval of the article*: PEOR, MCBL Statistical analysis: MCBL Overall responsibility: PEOR, MCBL *All authors have read and approved of the final version of the article submitted to J Vasc Bras.

Creative Commons License Este é um artigo publicado em acesso aberto (Open Access) sob a licença Creative Commons Attribution, que permite uso, distribuição e reprodução em qualquer meio, sem restrições desde que o trabalho original seja corretamente citado.