Early initiation of prophylactic anticoagulation for prevention of COVID-19 mortality: a nationwide cohort study of hospitalized patients in the United States.

Autor:	Rentsch CT; Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK, WC1E 7HT.; VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, 06516., Beckman JA; Cardiovascular Division, Vanderbilt University Medical Center and Vanderbilt Translational and Clinical Cardiovascular Research Center, Nashville, TN, 37232., Tomlinson L; Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK, WC1E 7HT., Gellad WF; Center for Pharmaceutical Policy and Prescribing, Health Policy Institute, University of Pittsburgh, Pittsburgh, PA, 15261.; Division of General Internal Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, 15213.; Veterans Affairs Pittsburgh Healthcare System, US Department of Veterans Affairs, Pittsburgh, PA, 15240., Alcorn C; Center for Occupational Biostatistics and Epidemiology, Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, 15260., Kidwai-Khan F; VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, 06516.; Department of Internal Medicine, Yale School of Medicine, New Haven, CT, 06510., Skanderson M; VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, 06516., Brittain E; Department of Medicine, Vanderbilt University Medical Center and Vanderbilt Translational and Clinical Cardiovascular Research Center, Nashville, TN, 37232., King JT Jr; VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, 06516.; Department of Neurosurgery, Yale School of Medicine, New Haven, CT, 06510., Ho YL; Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, MA., Eden S; Faculty of Biostatistics, Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, 37212., Kundu S; Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, 37232., Lann MF; Center for Occupational Biostatistics and Epidemiology, Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, 15260., Greevy RA Jr; Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, 37232., Ho PM; Rocky Mountain Regional VA Medical Center, US Department of Veterans Affairs, Aurora, CO, 80045., Heidenreich PA; VA Palo Alto Healthcare System, US Department of Veterans Affairs, Palo Alto, CA 94304.; Department of Medicine, Stanford University School of Medicine, Stanford, CA 94304., Jacobson DA; Oak Ridge National Laboratory, Biosciences Division, Oak Ridge, TN, 37831., Douglas IJ; Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK, WC1E 7HT., Tate JP; VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, 06516.; Department of Internal Medicine, Yale School of Medicine, New Haven, CT, 06510., Evans SJ; Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK, WC1E 7HT., Atkins D; Health Services Research and Development, US Department of Veterans Affairs, Washington, DC, 20420., Justice AC; VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, 06516.; Department of Internal Medicine, Yale School of Medicine, New Haven, CT, 06510.; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, 06510., Freiberg MS; Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, 37232.; Geriatric Research Education and Clinical Center, Tennessee Valley Healthcare System, US Department of Veterans Affairs, Nashville, TN, 37212.
Jazyk:	angličtina
Zdroj:	MedRxiv : the preprint server for health sciences [medRxiv] 2020 Dec 11. Date of Electronic Publication: 2020 Dec 11.
DOI:	10.1101/2020.12.09.20246579
Abstrakt:	Importance: Deaths among patients with coronavirus disease 2019 (COVID-19) are partially attributed to venous thromboembolism and arterial thromboses. Anticoagulants prevent thrombosis formation, possess anti-inflammatory and anti-viral properties, and may be particularly effective for treating patients with COVID-19. Objective: To evaluate whether initiation of prophylactic anticoagulation within 24 hours of admission is associated with decreased risk of death among patients hospitalized with COVID-19. Design: Observational cohort study. Setting: Nationwide cohort of patients receiving care in the Department of Veterans Affairs, the largest integrated healthcare system in the United States. Participants: All patients hospitalized with laboratory-confirmed SARS-CoV-2 infection March 1 to July 31, 2020, without a history of therapeutic anticoagulation. Exposures: Prophylactic doses of subcutaneous heparin, low-molecular-weight heparin, or direct oral anticoagulants. Main Outcomes and Measures: 30-day mortality. Secondary outcomes: inpatient mortality and initiating therapeutic anticoagulation. Results: Of 4,297 patients hospitalized with COVID-19, 3,627 (84.4%) received prophylactic anticoagulation within 24 hours of admission. More than 99% (n=3,600) received subcutaneous heparin or enoxaparin. We observed 622 deaths within 30 days of admission, 513 among those who received prophylactic anticoagulation. Most deaths (510/622, 82%) occurred during hospitalization. In inverse probability of treatment weighted analyses, cumulative adjusted incidence of mortality at 30 days was 14.3% (95% CI 13.1-15.5) among those receiving prophylactic anticoagulation and 18.7% (95% CI 15.1-22.9) among those who did not. Compared to patients who did not receive prophylactic anticoagulation, those who did had a 27% decreased risk for 30-day mortality (HR 0.73, 95% CI 0.66-0.81). Similar associations were found for inpatient mortality and initiating therapeutic anticoagulation. Quantitative bias analysis demonstrated that results were robust to unmeasured confounding (e-value lower 95% CI 1.77). Results persisted in a number of sensitivity analyses. Conclusions and Relevance: Early initiation of prophylactic anticoagulation among patients hospitalized with COVID-19 was associated with a decreased risk of mortality. These findings provide strong real-world evidence to support guidelines recommending the use of prophylactic anticoagulation as initial therapy for COVID-19 patients upon hospital admission.
Databáze:	MEDLINE
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