This systematic review highlights the therapeutic trends and outcomes of VTE survivors compared with those who died. The main observations were: First, unfractionated and low-molecular-weight heparin was the cornerstone in the VTE treatment. Also, the Food and Drug Administration-approved systemic alteplase regimen drives advanced therapy in PE patients. Second, we identified high mortality in the ICU associated with severe COVID-19 with a low incidence of bleeding complications in massive PE. Third, the original PESI score II-III recognized patients who survived, suggesting its usefulness in the risk stratification in COVID-19 patients. Fourth, elevated C reactive protein and D dimer measurements and right ventricular dysfunction identified poor in-hospital outcomes. Finally, the exploratory analysis showed the same high ICH incidence in CVT mild COVID-19 patients than non-COVID-19 patients.
Recent systematic reviews and meta-analyses focused on the incidence, primary and secondary VTE prevention, bleeding complications (23–26), and the association of D-dimer with mortality (27, 28). Therefore, therapeutic approaches, outcomes, clinical presentation, risk stratification, and patient characteristics are not well defined.
Patients with severe COVID-19 disease are at high risk for thromboinflammation since they have SARS-CoV-2 infection, risk factors, cardiovascular, renal, or chronic pulmonary inflammatory comorbidities (2). An increased frequency of arterial and venous thrombosis at the beginning of the pandemic was remarkable (29). VTE is now recognized as among the predominant cardiovascular hazards (29), with the highest incidence in the intensive care unit setting (25%), increasing to 69% after surveillance venous ultrasonography (29). Also, thromboprophylaxis, the foundation to prevent in-hospital VTE, fails in a subset of COVID-19 patients (29). Additionally, quantifying the risk of thrombosis and cardiovascular complications is complicated in this heterogeneous population by reports of limited sample size, restriction of assessments to the ICU setting, outcome definitions, and differing thromboprophylaxis strategies (29).
Our findings suggest that intravenous or subcutaneous anticoagulation remains the cornerstone of therapy in deep venous thrombosis and PE COVID-19 patients. Strategies for reperfusion therapy included the thrombolysis regimen recommended for international guidelines (22) or "safe dose" in PE patients (30–32) (Table 1). The rationale for systemic fibrinolysis in PE is to avert or improve impending clinical instability secondary to right ventricular dysfunction to improve the outcome. Several pulmonary hypertension mechanisms (PE, hypoxic vasoconstriction, pulmonary microthrombi, ACE2 dysregulation, and cytokine storm) inducing right ventricular dysfunction demand a CTPA before clinical decision-making in this population (33). Despite systemic thrombolysis, bleeding complication incidence was lower (0.9% vs. 3.2%; Table 1) than recent evidence (21.4%) using intermediate- or full-heparin dose without advanced treatment and bleeding definitions according to the individual studies (26). This difference in the incidence of bleeding complications is unclear because relevant clinical or significant bleedings are usually reported. We showed high mortality (21.6%) in massive PE in SARS-CoV-2 infected individuals with severe COVID-19 (Table 1). However, it is lower than observed in massive PE non-COVID-19 patients (33%) (34); the mortality rates observed are also related to severe COVID-19 and higher than previous other viral pandemics experienced in the past (35).
The original PESI score is a helpful tool for immediate and bedside risk stratification (22); whether this score helps COVID-19 patients is unanswered. The original PESI risk score had greater precision in identifying low and intermediate PE risks and identified a high proportion of high-risk patients with very high risk (19) (Table 2). Current COVID-19 restrictions delay or avoid all recommended diagnostic approaches in high clinical suspicion PE patients (22); thus, the original PESI score could be helpful in high clinical suspicion COVID-19 patients. Clinicians should also consider that the simplified PESI score may fail (36), and a multimodal approach use improves the accuracy of risk stratification. (PESI score definition is available in the e-Appendix).
The main characteristics of patients who died included hypertension, a high inflammatory, and prothrombotic state, severe COVID-19 associated with massive PE, ICU admission, and low use of VTE primary prevention (Tables 2, 3, and 4). Another remarkable finding shows VTE events despite thromboprophylaxis. Current evidence suggests administering heparin at standard doses in non-critically ill patients without risk factor for thrombosis or at a high dose for critically ill patients (intermediate or therapeutic dose) (37). Additionally, high dose thromboprophylaxis might be adjusted according to inflammation's progression without increasing bleeding risk in critically ill COVID-19 patients (38). Randomized controlled trials comparing different thromboprophylaxis doses are needed to establish the best therapeutic approach (38). The most consistent biomarker abnormalities related to mortality were higher C-reactive protein and D-dimer measurement levels, both associated with ICU admission and death (15). Patients with severe COVID-19 are at increased risk of thromboinflammation as they have pro-inflammatory risk factors, cardiopulmonary comorbidities related to inflammation, and cytokine storm (33). Additionally, there are several plausible reasons for elevated D-dimer in patients with SARS-CoV-2: severe infection, VTE, pulmonary and coronary microthrombus, acute kidney, cardiac injury, and pro-inflammatory cytokines (28).
Overlapping severe COVID-19 pneumonia and PE is a challenge, and any pneumonia increases the risk of VTE (33). A higher D-dimer measurement and severe oxygen desaturation are possible clinical markers to establish high clinical suspicion and PE severity. Recently, in a case series, the clinical presentation was similar: persistent or worsening respiratory symptoms increased oxygen requirements and DD levels that were several-fold higher (39). We suggest that physicians in charge should consider these clinical variables and never ignore abnormal or significantly elevated D-dimer because it is an expression of the coagulation system and secondary fibrinolysis activity, suggesting a high risk of acute thrombosis or, at least, VTE (33). Sudden hypotension could be another clinical element for PE suspicion in the setting of pneumonia COVID-19 (33).
We identified differences in the baseline characteristics reported previously in CVT patients (40–42). Only two patients had a history of oral contraceptives and no history of hereditary prothrombotic factors. These findings suggest an essential role of SARS-CoV-2 in pathogenicity as a trigger of thrombosis. Although early ICH (present at the time of diagnosis) is a frequent complication (40%) (41, 42), current evidence demonstrates a low incidence of new ICH after initiating treatment with anticoagulation (40–43). This analysis identified a high ICH incidence (four early and six after treatment), secondary to a high pro-inflammatory state induced by SARS-CoV-2. Although anticoagulation is the standard of care in CVT patients (avoid thrombus growth, prevent VTE), the high prevalence of ICH suggests that physicians in charge have to be warning for early detection of this feared complication (42).
The significant limitations of the study included a potential loss of case reports from search engines. There is a trend not to report patients with poor in-hospital outcomes or serious adverse events. It was not possible to obtain information on the timing of the D-dimer measurements and other biomarkers. We got the most information from case reports, and we did not contact any author. As for any systematic review, our results should be considered hypothesis-generating; prospective studies are mandatory to confirm our findings.