warfarin and Coronavirus-Infections

Many healthcare resources have been and continue to be allocated to the management of patients with COVID-19. Therefore, the ongoing care of patients receiving oral anticoagulation with warfarin is likely to be compromised amid this unprecedented crisis. This article discusses a stepwise algorithm for the management of outpatient warfarin therapy. Alternative management strategies are presented and discussed, including alternative pharmacological therapy options and self-monitoring. Our algorithm aims to help clinicians safely optimize the treatment of patients requiring anticoagulation therapy in the context of the global response to the current pandemic.

Topics: Ambulatory Care; Anticoagulants; Coronavirus Infections; COVID-19; Drug Monitoring; Humans; Pandemics; Patient Care Management; Pneumonia, Viral; Warfarin

The global COVID-19 pandemic is caused by the SARS-CoV-2 virus entering human cells using angiotensin-converting enzyme 2 (ACE2) as a cell surface receptor. ACE2 is shed to the circulation, and a higher plasma level of soluble ACE2 (sACE2) might reflect a higher cellular expression of ACE2. The present study explored the associations between sACE2 and clinical factors, cardiovascular biomarkers, and genetic variability.. Plasma and DNA samples were obtained from two international cohorts of elderly patients with atrial fibrillation (n = 3999 and n = 1088). The sACE2 protein level was measured by the Olink Proteomics® Multiplex CVD II96 × 96 panel. Levels of the biomarkers high-sensitive cardiac troponin T (hs-cTnT), N-terminal probrain natriuretic peptide (NT-proBNP), growth differentiation factor 15 (GDF-15), C-reactive protein, interleukin-6, D-dimer, and cystatin-C were determined by immunoassays. Genome-wide association studies were performed by Illumina chips. Higher levels of sACE2 were statistically significantly associated with male sex, cardiovascular disease, diabetes, and older age. The sACE2 level was most strongly associated with the levels of GDF-15, NT-proBNP, and hs-cTnT. When adjusting for these biomarkers, only male sex remained associated with sACE2. We found no statistically significant genetic regulation of the sACE2 level.. Male sex and clinical or biomarker indicators of biological ageing, cardiovascular disease, and diabetes are associated with higher sACE2 levels. The levels of GDF-15 and NT-proBNP, which are associated both with the sACE2 level and a higher risk for mortality and cardiovascular disease, might contribute to better identification of risk for severe COVID-19 infection.

Topics: Aged; Angiotensin-Converting Enzyme 2; Antithrombins; Atrial Fibrillation; Betacoronavirus; Biomarkers; Cohort Studies; Coronavirus Infections; COVID-19; Dabigatran; Female; Humans; Male; Middle Aged; Pandemics; Peptidyl-Dipeptidase A; Pneumonia, Viral; Pyrazoles; Pyridones; Risk Factors; SARS-CoV-2; Stroke; Warfarin

Coronavirus disease 2019 (COVID-19) is a viral infection that can, in severe cases, result in cytokine storm, systemic inflammatory response and coagulopathy that is prognostic of poor outcomes. While some, but not all, laboratory findings appear similar to sepsis-associated disseminated intravascular coagulopathy (DIC), COVID-19- induced coagulopathy (CIC) appears to be more prothrombotic than hemorrhagic. It has been postulated that CIC may be an uncontrolled immunothrombotic response to COVID-19, and there is growing evidence of venous and arterial thromboembolic events in these critically ill patients. Clinicians around the globe are challenged with rapidly identifying reasonable diagnostic, monitoring and anticoagulant strategies to safely and effectively manage these patients. Thoughtful use of proven, evidence-based approaches must be carefully balanced with integration of rapidly emerging evidence and growing experience. The goal of this document is to provide guidance from the Anticoagulation Forum, a North American organization of anticoagulation providers, regarding use of anticoagulant therapies in patients with COVID-19. We discuss in-hospital and post-discharge venous thromboembolism (VTE) prevention, treatment of suspected but unconfirmed VTE, laboratory monitoring of COVID-19, associated anticoagulant therapies, and essential elements for optimized transitions of care specific to patients with COVID-19.

Topics: Anticoagulants; Coronavirus Infections; COVID-19; Heparin; Humans; Pandemics; Patient Discharge; Patient Transfer; Pneumonia, Viral; Thrombolytic Therapy; Venous Thromboembolism; Warfarin

Topics: Adult; Anticoagulants; Basal Ganglia Hemorrhage; Betacoronavirus; Brain; Cerebral Angiography; Cerebral Hemorrhage; Comorbidity; Computed Tomography Angiography; Coronavirus Infections; COVID-19; Diabetes Mellitus, Type 2; Endothelium, Vascular; Female; Frontal Lobe; Heparin, Low-Molecular-Weight; Humans; Hypertension; Magnetic Resonance Imaging; Male; Middle Aged; Myocardial Ischemia; Pandemics; Pneumonia, Viral; Pulmonary Embolism; Retrospective Studies; Risk Factors; SARS-CoV-2; Severity of Illness Index; Tomography, X-Ray Computed; Venous Thrombosis; Warfarin

We describe a patient with COVID-19 who developed simultaneous pulmonary, intracardiac and peripheral arterial thrombosis. A 58-year-old man, without major comorbidity, was admitted with a 14-day history of breathlessness. Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection was confirmed by laboratory testing. Initial imaging revealed COVID-19 pneumonia but no pulmonary thromboembolism (PTE) on CT pulmonary angiography (CTPA). The patient subsequently developed respiratory failure and left foot ischaemia associated with a rising D-dimer. Repeat CTPA and lower limb CT angiography revealed simultaneous bilateral PTE, biventricular cardiac thrombi and bilateral lower limb arterial occlusions. This case highlights a broad range of vascular sequalae associated with COVID-19 and the fact that these can occur despite a combination of prophylactic and treatment dose anticoagulation.

Topics: Anticoagulants; Betacoronavirus; Clinical Deterioration; Computed Tomography Angiography; Coronavirus Infections; COVID-19; Enoxaparin; Heart Diseases; Heart Ventricles; Humans; Male; Middle Aged; Pandemics; Peripheral Arterial Disease; Pneumonia, Viral; Pulmonary Embolism; SARS-CoV-2; Thrombosis; Treatment Outcome; Warfarin

Topics: Aged, 80 and over; Anticoagulants; Autoantibodies; Betacoronavirus; Combined Modality Therapy; Coronavirus Infections; COVID-19; COVID-19 Drug Treatment; Enoxaparin; Fatal Outcome; Humans; International Normalized Ratio; Male; Pandemics; Platelet Count; Platelet Transfusion; Pneumonia, Viral; Purpura, Thrombocytopenic, Idiopathic; SARS-CoV-2; Thrombophlebitis; Warfarin

Topics: Adult; Analgesics; Anticoagulants; Betacoronavirus; Coronavirus; Coronavirus Infections; COVID-19; Enoxaparin; Humans; Mesenteric Veins; Pandemics; Pneumonia, Viral; Portal Vein; SARS-CoV-2; Thrombosis; Tomography, X-Ray Computed; Treatment Outcome; Warfarin

Currently, there is minimal data available highlighting the prevalence of venous thromboembolism in patients infected with coronavirus disease 2019 (COVID-19). This case report with a literature review emphasizes a unique presentation of COVID-19 that is highly important for health care providers to consider when treating their patients.. A 65-year-old Caucasian male patient presented to the emergency department with a 2-day history of dyspnea on exertion after his wife's recent diagnosis of COVID-19. He additionally had experienced a couple of episodes of self-resolving diarrhea a few days before presentation. Based on the patient's clinical presentation and the laboratory workup identifying an elevated D-dimer, a computed tomography angiogram of the chest was obtained, which was significant for moderately large, bilateral pulmonary emboli with a saddle embolus, and an associated small, left lower lobe, pulmonary infarct. Ultrasound of the lower extremity showed non-occlusive deep vein thrombosis at the distal left femoral vein to the left popliteal vein. The patient was additionally diagnosed with COVID-19 when the results of the COVID-19 polymerase chain reaction test returned as positive. The patient was admitted to the COVID unit, and he was started on an intravenously administered, unfractionated heparin drip for management of his bilateral pulmonary emboli and deep vein thrombosis. The patient's clinical condition improved significantly with anticoagulation, and he was observed in the hospital for 3 days, after which he was discharged home on the enoxaparin bridge with warfarin. Post-discharge telephone calls at day 10 and week 4 revealed that the patient was appropriately responding to anticoagulation treatment and had no recurrence of his symptoms related to venous thromboembolism and COVID-19.. As COVID-19 continues to lead to significant mortality, more data is emerging that is exposing its perplexing pathogenicity. Meanwhile, the presentation of venous thromboembolism in patients with COVID-19 remains an unusual finding. It is imperative for health care providers to be mindful of this unique association to make necessary diagnostic evaluations and provide appropriate treatment for the patients.

Topics: Aged; Anticoagulants; Betacoronavirus; Computed Tomography Angiography; Coronavirus Infections; COVID-19; Enoxaparin; Femoral Vein; Fibrin Fibrinogen Degradation Products; Heparin; Hospitalization; Humans; Lung; Male; Pandemics; Pneumonia, Viral; Pulmonary Embolism; SARS-CoV-2; Treatment Outcome; Ultrasonography; Venous Thromboembolism; Warfarin