Abstract
AbstractObjective To evaluate whether early initiation of prophylactic anticoagulation compared with no anticoagulation was associated with decreased risk of death among patients admitted to hospital with coronavirus disease 2019 (covid-19) in the United States. Design Observational cohort study. Setting Nationwide cohort of patients receiving care in the Department of Veterans Affairs, a large integrated national healthcare system. Participants All 4297 patients admitted to hospital from 1 March to 31 July 2020 with laboratory confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and without a history of anticoagulation. Main outcome measures The main outcome was 30 day mortality. Secondary outcomes were inpatient mortality, initiating therapeutic anticoagulation (a proxy for clinical deterioration, including thromboembolic events), and bleeding that required transfusion. Results Of 4297 patients admitted to hospital with covid-19, 3627 (84.4%) received prophylactic anticoagulation within 24 hours of admission. More than 99% (n=3600) of treated patients received subcutaneous heparin or enoxaparin. 622 deaths occurred within 30 days of hospital admission, 513 among those who received prophylactic anticoagulation. Most deaths (510/622, 82%) occurred during hospital stay. Using inverse probability of treatment weighted analyses, the cumulative incidence of mortality at 30 days was 14.3% (95% confidence interval 13.1% to 15.5%) among those who received prophylactic anticoagulation and 18.7% (15.1% to 22.9%) among those who did not. Compared with patients who did not receive prophylactic anticoagulation, those who did had a 27% decreased risk for 30 day mortality (hazard ratio 0.73, 95% confidence interval 0.66 to 0.81). Similar associations were found for inpatient mortality and initiation of therapeutic anticoagulation. Receipt of prophylactic anticoagulation was not associated with increased risk of bleeding that required transfusion (hazard ratio 0.87, 0.71 to 1.05). Quantitative bias analysis showed that results were robust to unmeasured confounding (e-value lower 95% confidence interval 1.77 for 30 day mortality). Results persisted in several sensitivity analyses. Conclusions Early initiation of prophylactic anticoagulation compared with no anticoagulation among patients admitted to hospital with covid-19 was associated with a decreased risk of 30 day mortality and no increased risk of serious bleeding events. These findings provide strong real world evidence to support guidelines recommending the use of prophylactic anticoagulation as initial treatment for patients with covid-19 on hospital admission.
| Original language | English |
|---|---|
| Article number | n311 |
| Journal | The BMJ |
| Volume | 372 |
| DOIs | |
| State | Published - Feb 11 2021 |
Funding
Funding: This work was supported by the National Institute on Alcohol Abuse and Alcoholism (U01-AA026224, U24-AA020794, U01-AA020790, U10-AA013566) and by the Department of Veterans Affairs Health Services Research and Development (C19 20-405) and Office of Research and Development (MVP000). Research was also sponsored by the Laboratory Directed Research and Development Program (LOIS:10074) of Oak Ridge National Laboratory, managed by UT-Battelle, LLC for the US Department of Energy under contract DE-AC05-00OR22725. The funders had no role in considering the study design or in the collection, analysis, interpretation of data, writing of the report, or decision to submit the article for publication. The views and opinions expressed in this manuscript are those of the authors and do not necessarily represent those of the Department of Veterans Affairs or the United States government. disclosure form at www.icmje.org/coi_disclosure.pdf and declare: This work was supported by the National Institute on Alcohol Abuse and Alcoholism (U01-AA026224, U24-AA020794, U01-AA020790, U10-AA013566) and by the Department of Veterans Affairs Health Services Research and Development (C19 20-405) and Office of Research and Development (MVP000). Research was also sponsored by the Laboratory Directed Research and Development Program (LOIS:10074) of Oak Ridge National Laboratory, managed by UT-Battelle, LLC for the US Department of Energy under contract DE-AC05-00OR22725. JAB reports consulting with Amgen, Bayer, JanOne, and Janssen. He serves on the data safety monitoring committee for Novartis. PMH is supported by grants from National Heart, Lung, and Blood Institute, VA Health Services Research & Development, and University of Colorado School of Medicine. He has a research agreement with Bristol-Myers Squibb through the University of Colorado. He serves as the deputy editor for Circulation: Cardiovascular Quality and Outcomes. IJD reports grants from UK National Health Service National Institute for Health Research and has received unrestricted research grants and holds shares in GlaxoSmithKline, outside of the submitted work. All other authors declare no financial relationships with any organizations that might have an interest in the submitted work in the previous three years, and no other relationships or activities that could appear to have influenced the submitted work.
