Coagulation in the COVID-19 patient

Thursday, May 21, 2020

Adam C. Cuker, MD, joined host David H. Henry, MD, to discuss recent findings regarding coagulation in COVID-19 patients. Dr. Cuker and Dr. Henry both practice at the Hospital of the University of Pennsylvania in Philadelphia.

Dr. Cuker cited data suggesting at least 25%-30% of patients with COVID-19 develop venous thromboembolism (VTE), despite receiving prophylactic anticoagulation. Furthermore, COVID-19 patients have presented with “lots of different thrombotic manifestations,” he said. This includes stroke and “COVID toes syndrome,” a condition in which patients present with ischemic toes, which appears to have a thromboembolic etiology.

Dr. Cuker suggested that all three aspects of Virchow’s triad may be at play in patients with COVID-19 who have thrombotic manifestations, including:

  • Circulatory stasis (in patients who are immobilized/sedated/prone/paralyzed).
  • Hypercoagulability (inflammation, high levels of factor VIII and fibrinogen, neutrophil extracellular traps).
  • Endothelial injury (SARS-CoV-2 may infect endothelial cells via ACE2).

Dr. Cuker noted that high D-dimer correlates with disease severity and prognosis in COVID-19 patients. He also compared COVID-19 to heparin-induced thrombocytopenia (HIT), noting that both are associated with venous and arterial thromboses. And, like HIT patients, those with COVID-19 may require therapeutic-intensity anticoagulation to prevent clots.

Dr. Cuker said his hospital’s recommendations for anticoagulation in COVID-19 patients are as follows:

  • Stable hospitalized patients should receive standard-intensity prophylaxis.
  • ICU patients should receive intermediate- or therapeutic-intensity anticoagulation (at the discretion of the provider).
  • On discharge, patients should receive low-dose rivaroxaban (Xarelto) at 10 mg daily for 30 days as prophylaxis.
  • A nonhospitalized patient who has no risk factors for thrombotic events should not receive thromboprophylaxis.

Dr. Cuker also discussed two recent publications on thrombosis and anticoagulation in COVID-19 patients. In one study, thrombotic events occurred in 31% of COVID-19 patients admitted to the ICU at three Dutch hospitals (Thromb Res. 2020 Apr 10. pii: S0049-3848(20)30120-1).

Another study suggested that systemic anticoagulation may improve outcomes of patients hospitalized with COVID-19 (J Am Coll Cardiol. 2020 May 5. pii: S0735-1097(20)35218-9).

Show notes by Emily Bryer, DO, resident in the department of internal medicine, University of Pennsylvania, Philadelphia.


Dr. Henry has no financial disclosures relevant to this episode.

Dr. Cuker has served as a consultant for Synergy CRO. His institution has received research support on his behalf from Alexion, Bayer, Pfizer, Novo Nordisk, Sanofi, Spark, and Takeda.

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David Henry, MD
David Henry, MD, FACP, is a clinical professor of medicine at the University of Pennsylvania and vice chairman of the department of medicine at Pennsylvania Hospital in Philadelphia. He received his bachelor’s degree from Princeton University and his MD from the University of Pennsylvania, then completed his internship, residency, and fellowship at the Hospital of the University of Pennsylvania. After 2 years as an attending in the U.S. Air Force, he was drawn to practicing as a hem-onc because of the close patient contact and interaction, and his belief that, win or lose with each patient, one can always make a difference in their care and lives. Follow Dr. Henry on Twitter: @davidhenrymd. Dr. Henry reported being on the advisory board for Amgen, AMAG Pharmaceuticals, and Pharmacosmos. He reported institutional funding from the National Institutes of Health and FibroGen.