no slide title cme-covid... · 2020/5/6 · title no slide title author thomas deloughery created...
TRANSCRIPT
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COVID!
Tom DeLoughery, MD MACP FAWM
Oregon Health & Science University
@bloodman
OHSU
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DISCLOSURE
Current Relevant Financial Relationship(s)
NoneOHSU
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Talk
• Thrombosis incidence
• Mechanisms of thrombosis
• Testing
• Treatment
• Convalescent plasma
• Blood groups
OHSU
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COVID
• New infection
• Pneumonia primary feature
• Coagulation issues soon
recognized as a major featureOHSU
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Coagulopathy in COVID-19
• Very common!
• Most patients with
–Abnormal coagulation
–Very high D-dimers
–Very high fibrinogen
• Thrombosis >>> bleeding
OHSU
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D-Dimer
• Marked elevation in all patients
• Major prognostic indicator
• May be a sign of thrombosis
• Cause
–Widespread coagulation activation
–Pulmonary thrombosis
OHSU
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D-Dimer
D
E
D
D
E
D
D
E
D
D
E
D
FPA
FPB
E
D
D
Thrombin Plasmin
X-Linked
Fibrin
Fibrinogen Fibrin
Monomer
D-Dimer
OHSU
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Zhang, J Throm Haemo 18:1324, 2020
OHSU
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Zhang, J Throm Haemo 18:1324, 2020
OHSU
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OHSU
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Thrombosis
• Rates of 17-69% reported even
with prophylaxis
–Much higher than literature
–Venous thrombosis
–Arterial thrombosis
–Microthrombosis
OHSU
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Cui
• VTE = 25%
• Unknown prophylaxis
• D-Dimer predictive
• J Throm Hem 2020OHSU
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Chu J Thromb Haemo 2020
OHSU
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Klok
• VTE = 27->49% (87% PE)
• Arterial = 3.7%
• All getting prophylaxis
• Coagulation abnormities predicted
thrombosis
• Thrombosis HR 5.4 death
• Throm Research 2020
OHSU
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OHSU
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France
• 16.7% thrombosis rate
• 96% CRRT thrombosis rate
–< 24 hours!
• All getting prophylaxes
• ICU medicine in press
OHSU
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France II
• 26 consecutive ICU patients
• 69% thrombosis
–PE 23% patients
• No benefit of standard
prophylaxs
• JTH in press
OHSU
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Middledorpf
• N = 199
• ICU: 26% @ 1wk, 47% @ 2 wks,
and 59%@ 3 wks
– ICU vs ward: 7.1
• 2.8%/day of ICU stay
• History of DVT not a risk factor
JTH
OHSU
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Venous Thrombosis Rates
• COVID: 17-65%
– Increases with duration of ICU stay
• Non-COVID ICU
–14.6% Controls (2% PE)
–7.5% Prophylaxis (1%)
OHSU
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OHSU
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Wichmann• First 12 mandated COVID
autopsy
• Consecutive series
• Age -73
• 75% male
• 4 (25%) die massive PE
• 3 more with DVT
OHSU
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From: Autopsy Findings and Venous Thromboembolism in Patients With COVID-19A Prospective Cohort Study
Ann Intern Med. Published online May 06, 2020. doi:10.7326/M20-2003
OHSU
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Autopsy/Pathology
• Uniformly show
–Micro/macrovascular thrombosis
in multiple organs
–Minimal microangiopathy
–Megakaryocytes in lungsOHSU
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The Lancet Respiratory Medicine DOI: (10.1016/S2213-2600(20)30243-5)
Copyright © 2020 Elsevier Ltd Terms and Conditions
OHSU
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Arterial Thrombosis
• Increasing reports in young
patients without risk factors
• Stroke, MI, aortic or visceral
arterial thrombosisOHSU
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OHSU
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Arterial Thrombosis
• Typical presentation – arterial
event in young person
• Minimal to no respiratory
symptoms
• Positive COVID testing
OHSU
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Stroke
• Increased incidence reported
• Rates of 1-2% in COVID patients
–Higher on MRI??
• Unclear epidemiologyOHSU
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NYC Stroke
• 1.6% COVID patients with stroke
• 24% presented with stroke
• Mean age 69, 50% men
• OR 7.8 compared to flu patients
• Mortality 34% vs 14% no stroke
• JAMA Neurology 2020
OHSU
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COVID Toes
OHSU
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Heparin Resistance
• Increasing reports of high
heparin requirements
–> 4000u/hr
• Breakthrough thrombosis
• High rates of CRRT/dialysis
thrombosis
–> 90% in one study
OHSU
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Summary
• Thrombosis
–Much increased in ICU patients
• 7x
–Mainly venous but arterial reported
–Occurs despite standard prophylaxis
–Widespread
OHSU
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OHSU
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Etiology
• Intense inflammation
–Raises procoagulants
–Convert endothelium to
prothrombotic state
• Pulmonary inflammation
• Viral attack on endothelial cells
• Platelets
• Other cascades
OHSU
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Inflammation
• IL-6 stimulates prothrombotic
changes
– Increased fibrinogen
– Increased factor 8
– Increased VWF
• TNF/IL-1 convert endothelium to
prothrombotic state
OHSU
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OHSU
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Evidence for Inflammation
• Antivirals +/- effectiveness
• Dexamethasone very effective
–Only in patients requiring oxygen
• But maybe some inflammation
good
–Early dex harmful
– Increasing reports of adverse
outcomes with anti IL-6 therapy
OHSU
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OHSU
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Potential Drivers
• Polyphosphates
– Initiate contact pathway
• NETs
–Powerful initiator of coagulation
• PAMP (Pathogen-associated
molecular patterns)
OHSU
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NET
• Neutrophil extracellular traps
• DNA/Histones extruded from
neutrophils
• Very prothrombotic
• Increased in sepsis, DIC, COVID
OHSU
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OHSU
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Rao World J Cardiol. 7: 829-842, 2015
OHSU
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OHSU
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Middleton, Blood 2020
OHSU
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Antiphospholipid
Antibodies• Increased incidence in COVID
patients
–Up to 90% lupus inhibitors
• Pathogenic or false positives?
• Further muddies waters on PTT
monitoring of heparin
OHSU
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OHSU
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Pulmonary Inflammation
• Virus infection at alveolar level
leads to local inflammation
• This spreads throughout the
lung and system vasculature
• Path
–Pulmonary inflammation with
microthrombi
OHSU
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OHSU
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Rebel EM
OHSU
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OHSU
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OHSU
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Endothelial Infection
• Increasing evidence virus can
attack vascular endothelium
• Converts antithrombotic surface
to prothrombotic OHSU
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Lancet: in press
OHSU
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OHSU
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TMTM TF TF
Activation of Coagulation
PC--->aPC
VII--->VIIa VII--->VIIaInactivation of CoagulationOHSU
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VWF
VWF GPIb
GPIb
GPIb
GPIb
GPIb
TXA2
ADP
ADP
ADP
ADP
TXA2
TXA2
TXA2ADP
IIa
IIa
IIa
IIa
OHSU
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Endothelial Damage
• ICU vs Ward patients
• vWF: 565% vs 278%
• P-selectin: 15.9 vs 11.2 ng/ml
• Mortality associated with
increased thrombomodulin
• Goshua Lancet Haem 2020
OHSU
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Figure 1
The Lancet Haematology DOI: (10.1016/S2352-3026(20)30216-7)
Copyright © 2020 Elsevier Ltd Terms and Conditions
OHSU
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Figure 2
The Lancet Haematology DOI: (10.1016/S2352-3026(20)30216-7)
Copyright © 2020 Elsevier Ltd Terms and Conditions
OHSU
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OHSU
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Platelets
• COVID platelets
–Unique transcriptome
– Increased P-selectin/PDGF
– Increased aggregation
– Increased thrombopoietin
OHSU
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Novel Findings
• Transcriptome changes same in
all COVID patient but different
than other viral infections
• Platelets not decreased
• Antiplatelet agents being studied
OHSU
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Manne Blood 2020
OHSU
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Complement
• Complicated inflammatory cascade
• Active proteins lead to tissue
damage
–Lung, microvascular
• Increase C5a seen in COVID
• Early work with complement
blockers
OHSU
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J Clin Invest DOI: 10.1172/JCI140183
OHSU
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Contact Pathway
• Coagulation/inflammation
overlap
• Contact blocker effective in
sepsis
• Low risk of side effects
OHSU
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Raghunathan Res Pract Thromb Haemost. 3:331, 2019
OHSU
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DeLoughery, EP Semin Thromb Hemost 45:502, 2019
OHSU
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Bottom Line
• COVID leads to a prothrombotic
state via multiple mechanisms
• Unique compare to other
infectionsOHSU
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OHSU
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Testing
• Admit: INR, aPTT, platelets, D-
dimer, fibrinogen,
• Daily platelets, D-dimers,
fibrinogenOHSU
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TEG
• Consistent findings
–Shorten r time
– Increase K time
– Increased MA
–Decreased lysis
• Hypercoagulability
OHSU
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Yuriditsky CCM 2020
OHSU
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Anticoagulation
• Consensus
–Everyone in hospital for COVID
gets thromboprophylaxis with
LMWH (UFH if renal failure)
• Controversy
–Everything else
OHSU
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Is Heparin Beneficial?
• Teng study showed heparin
associated with increase survival
esp with high d-dimers
• Prophylaxis not standard in
China
• Unclear doses used
• Ayerbe showed RR of 0.55
OHSU
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OHSU
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Heparin
• Observational data
• But
–Antithrombotic?
–Antiinflammatory?
–Antiviral?
• Italian studies underway
OHSU
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Heparin as Antiviral
• Heparin can be a decoy for virus
binding
• Heparin binds to spike protein
• Heparin has anti-inflammatory
properties
OHSU
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Lie
Liu, RPTH 2020
OHSU
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Pre-Existing
Anticoagulation• Circulation study suggested
being on anticoagulation at
admission beneficial
• Studies controlling for baseline
conditions no benefit OHSU
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Increase Dosing?
• Many protocols increase heparin
dosing for
– ICU patients
–D-Dimers 1.5- 3 x normal
• LMWH 40mg bid
• Multiple RCT in process
OHSU
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Therapeutic Dosing
• Some centers starting
therapeutic dosing with D-Dimer
3-6x normal
–High pretest probability of
thrombosisOHSU
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Thrombotic Risk
• Low – not in hospital
• Intermediate – in hospital but not
requiring oxygen/vent
• High –obese or requires oxygen/vent
• Very high risk – obese + oxygen/vent,
ECMO, high D-dimers or fibrinogen
• Susan, Crit Care 2020
OHSU
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Risk
• Low – nothing
• Intermediate – standard LMWH
• High – double LMWH
• Very high – therapeutic LMWH
• Susan, Crit Care 2020
OHSU
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Outpatient Prophylaxis
• Some advocate after discharge
prophylaxis for 30-45 days due
to perceived high risk of
thrombosis
• 10% readmissions for
thrombosis
OHSU
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Heparin Resistance
• Etiology
• Increased inflammatory proteins
– Increased fibrinogen, etc absorb
heparin
– Interference with PTT
–Heparinase?
• Prothrombotic drive
OHSU
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Heparin Resistance
• Solution
–Use LMWH as much as possible
– If using UFH, use heparin levels
–Breakthrough: increase LMWH by
25% or use argatrobanOHSU
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OHSU
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Suggested Protocol
1. Prophylaxis for everyone with COVID
admitted to hospital –
- LMWH preferred
- Enoxaparin 40mg daily is standard
- BMI >40, enoxaparin 40mg BID
- For renal failure
- Unfractionated heparin 5000u BID or
- Enoxaparin 30mg daily
OHSU
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Suggest Protocol
2. Screen for DVT at admit to ICU and every 4-5
days in ICU
- Low threshold for empiric treatment of
thrombosis (sudden deterioration, D-Dimer >
3.0)
- Enoxaparin 1mg/kg BID (preferred)
- Renal failure: unfractionated heparin with goal
0.35-0.7
3. Double Prophylaxis for ICU patients
– Enoxaparin 40mg bid
OHSU
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Suggested Protocol
4. Outpatient prophylaxis for patients who are
likely to be immobile for a month either:
- 40mg enoxaparin or
- 10mg rivaroxaban OHSU
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Guidelines• Multiple ones!
–ACCP, ISTH, AC Forum, BSH, etc
• Contentious issues:
–Dosing of prophylaxis
– Initiation of therapeutic dosing
–Screening
OHSU
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Dosing of Prophylaxis
• Pro increase dosing:
–High rates of thrombosis on standard
dosing
–Low risk of bleeding
• Con
–No data
– Is thrombosis driven by inflammation?
–Not risk free
OHSU
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Initiation of Therapeutic
Anticoagulation• Pro
–High rates of thrombosis
–Difficult to get sick people to imaging
• Con
–No data
–Risk of bleeding
–Can obtain testing if you try hard
enough
OHSU
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Screening Dopplers
• Pro
–High rates of thrombosis
–Patients are unable to complain of
symptoms
• Con
–No data for screening
–Exposes patients to risk of
anticoagulation
OHSU
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OHSU
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Use of Convalescent Plasma
• Incredible hope and speculation
about this
• Multiple trials/protocols in
processOHSU
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Convalescent Plasma
• Very old idea
• Antibodies in donor
convalescent plasma can
decrease infection in recipient
• Two types
–Plasma
–Hyperimmune globulin
OHSU
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Hyperimmune Globulin
• Long track records of
effectiveness
• Process
–Patients know to have high titers
–Plasmapheresis
–Fractionation to isolate IGG
–Concentrate given to patient
OHSU
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Convalescent Plasma
• Patient documented to have
infection
– Ideally with high titers of ab
• Unit of whole blood drawn or
plasmapheresis
• Plasma spun off and frozen
OHSU
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Issues
• Plasma raises IgG by ~5%
• Lack of antibody testing
–Are high titers neutralizing?
• Many anecdotes but negative RCT
studies in other disease
• One trial stopped because
patients already had antibodies
OHSU
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Netherland Trial
• 86 patients (~ 10 days into illness,
~ 2 days in hospital)
–79% already had neutralizing
antibodies
–Titers same as plasma
–Trial stopped
OHSU
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Plasma: Bottom Line
• ~ 10,000 received plasma outside
of trials
• Many units no titer testing was
done
• Need RCT data OHSU
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OHSU
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Blood Groups
• Multiple (7) studies showing
–Group O protective: 0.80
–Group A risk factor: 1.20
–Both serology and genetic studies OHSU
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Blood Groups
• Type O protective?
–Lower levels of von Willebrand
factor
• Anti-A binds virus spike protein
–Group A at risk
OHSU
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COVID Thrombosis
• Very high rate of thrombosis
– ICU patients
• Venous thrombosis
–Arterial thrombosis
• Low suspicion for diagnosis and
treatment
• Need RCT to report!
OHSU
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OHSU