Recent updates in the management of thromboembolism - MediBytes December 2021 newsletter

COVID-19 has been found to increase the incidence of thrombotic events; however, the need for an extended thromboprophylaxis in hospitalized patients has been debated widely. A cohort study data was published in November 2021, which evaluated 2,832 adult patients hospitalized with SARS-CoV-2.1 Patients with a history of venous thromboembolism, peak dimerized plasmin fragment D (D-dimer) level greater than 3 μg/mL and predischarge C-reactive protein level greater than 10 mg/dL were more likely to experience venous thromboembolism after discharge.

In critically ill patients with severe COVID-19, one of the challenges is to decide upon the dosing of low molecular weight heparin for thromboprophylaxis. In a retrospective study data published in November 2021, starting intermediate-dose thromboprophylaxis for critically ill patients with COVID-19 to achieve anti-FXa levels in the accepted thromboprophylactic range was supported.2

Venous thromboembolism is a leading cause of cardiovascular morbidity and mortality. The majority of venous thromboembolism events are hospital-associated. In a systematic review and meta-analysis published in November 20213, data from 27 studies from 20 countries with a total of 1,37,288 patients were screened. Overall, 50.5% of patients had an indication for thromboprophylaxis; of these, 54.5% received adequate thromboprophylaxis. The use of adequate thromboprophylaxis was 66.8% in Europe, 44.9% in Africa, 37.6% in Asia, 58.3% in South America, and 68.6% in North America. The use of anticoagulants for venous  thromboembolism prevention has been proven effective and safe; however, thromboprophylaxis prescriptions are still unsatisfactory among hospitalized medically ill patients around the globe.

In the only multicenter and prospective study of deep vein thrombosis in intensive care units in China that was published in December,4 54 hospitals evaluated 940 patients admitted in intensive care units. Deep vein thrombosis prophylaxis was found to be widely performed in intensive care unit patients. Prophylaxis is an independent protective factor for deep vein thrombosis occurrence. The most common treatment for patients with deep vein thrombosis is low molecular weight heparin. Moreover, D-dimer levels were independently associated with deep vein thrombosis in intensive care unit patients.

Patients with inflammatory bowel disease (IBD) are at an increased risk for thrombotic events. Therapies for IBD have the potential to modulate this risk. Consensus was reached among 14 international IBD experts and 3 thrombosis experts from 12 countries for 19 statements. Patients with IBD harbor an increased risk of venous and arterial thrombotic events. Thromboprophylaxis is indicated during hospitalization for any cause in patients with IBD.5

    1. Li P, Zhao W, Kaatz S, et al. Factors associated with risk of postdischarge thrombosis in patients with COVID-19. JAMA Netw Open. 2021 Nov 1;4(11):e2135397.
    2. Hamilton DO, Main-Ian A, Tebbutt J, et al. Standard- versus intermediate-dose enoxaparin for anti-factor Xa guided thromboprophylaxis in critically ill patients with COVID-19. Thromb J. 2021 Nov 15;19(1):87.
    3. Forgo G, Micieli E, Ageno W, et al. An update on the global use of risk assessment models and thromboprophylaxis in hospitalized patients with medical illnesses from the World Thrombosis Day steering committee: Systematic review and meta-analysis. J Thromb Haemost. 2021 Nov 25.
    4. Li L, Zhou J, Huang L, et al; Zhejiang Provincial Critical Care Clinical Research Group. Prevention, treatment, and risk factors of deep vein thrombosis in critically ill patients in Zhejiang province, China: A multicenter, prospective, observational study. Ann Med. 2021 Dec;53(1):2234–2245.
    5. Olivera PA, Zuily S, Kotze PG, et al. International consensus on the prevention of venous and arterial thrombotic events in patients with inflammatory bowel disease. Nat Rev Gastroenterol Hepatol. 2021 Dec;18(12):857–873.