VTE rate, 'COVID toes,' and Virchow's triad: What you need to know about COVID and coagulation
05/21/20 • 32 min
Adam C. Cuker, MD, joins host David H. Henry, MD, to discuss recent findings regarding coagulation in COVID-19 patients. Both 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 notes that high D-dimer correlates with disease severity and prognosis in COVID-19 patients. He also compares 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 says 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 discusses 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.
Disclosures:
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.
* *
For more MDedge Podcasts, go to mdedge.com/podcasts
Email the show: [email protected]
Interact with us on Twitter: @MDedgehemonc
David Henry on Twitter: @davidhenrymd
Adam C. Cuker, MD, joins host David H. Henry, MD, to discuss recent findings regarding coagulation in COVID-19 patients. Both 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 notes that high D-dimer correlates with disease severity and prognosis in COVID-19 patients. He also compares 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 says 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 discusses 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.
Disclosures:
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.
* *
For more MDedge Podcasts, go to mdedge.com/podcasts
Email the show: [email protected]
Interact with us on Twitter: @MDedgehemonc
David Henry on Twitter: @davidhenrymd
Previous Episode
Curbsiders Host Dr. Matt Watto on being an internist in the COVID-19 pandemic
In this episode, Matthew Watto, MD, an internist at Pennsylvania Hospital in Philadelphia, tells host David H. Henry, MD, also of Pennsylvania Hospital, how the COVID-19 pandemic has affected him personally and professionally.
Dr. Watto recounts how COVID-19 has impacted patient volume, shifts, teaching, and interactions between patients and staff. Dr. Watto also discusses his internal medicine podcast, The Curbsiders, which, he says, provides listeners with “clinical pearls, practice-changing knowledge, and bad puns.”
Disclosures:
Dr. Henry has no financial disclosures relevant to this episode. Dr. Watto has no financial disclosures relevant to this episode.
* *
For more MDedge Podcasts, go to mdedge.com/podcasts
Email the show: [email protected]
Interact with us on Twitter: @MDedgehemonc
David Henry on Twitter: @davidhenrymd
Ilana Yurkiewicz on Twitter: @ilanayurkiewicz
Next Episode
Would you choose oncology again? Plus, breast cancer research: HER2CLIMB, KEYNOTE 522, and DESTINY BREAST01 with Dr. Bill Gradishar
David H. Henry, MD, answers the question, "Would you choose oncology again?" This question was asked of oncologists surveyed for the Medscape Oncologist Compensation Report 2020, and 96% of oncologists said they would still choose oncology as their specialty.
Later, William J. Gradishar, MD, of Northwestern University in Chicago, joined Dr. Henry to discuss recent developments in breast cancer. Dr. Gradishar reviewed three trials presented at the 2019 San Antonio Breast Cancer Symposium (SABCS), two of which will be updated at the ASCO Annual Meeting.
* *
SABCS highlights
HER2CLIMB trial:
- This trial led to the recent U.S. approval of tucatinib in combination with trastuzumab and capecitabine.
- The phase 2 trial enrolled patients with heavily pretreated, HER2-positive, metastatic breast cancer (N Engl J Med. 2020 Feb 13; 382:597-609).
- Patients who received tucatinib plus trastuzumab and capecitabine had superior progression-free and overall survival, compared with patients who received placebo plus trastuzumab and capecitabine. Tucatinib even improved outcomes in patients with brain metastasis, Dr. Gradishar noted.
- Additional results from HER2CLIMB are scheduled to be presented at ASCO in Abstract 1005.
DESTINY-BREAST01 trial:
- This trial led to the U.S. approval of trastuzumab deruxtecan.
- Trastuzumab deruxtecan produced durable responses and a median progression-free survival of 16.4 months in patients with HER2-positive, metastatic breast cancer who had previously received trastuzumab emtansine (N Engl J Med 2020; 382:610-621).
- A key side effect of trastuzumab deruxtecan is interstitial lung disease, which led to deaths in the trial and a black box warning for the antibody-drug conjugate.
- A subgroup analysis of data from DESTINY-BREAST01 is scheduled to be presented at ASCO in Abstract 1036.
KEYNOTE-522 trial:
- The phase 3 trial enrolled patients with early triple-negative breast cancer (N Engl J Med 2020; 382:810-821).
- The rate of pathologic complete response (pCR) was significantly higher in patients who received pembrolizumab plus neoadjuvant chemotherapy than in patients who received placebo plus neoadjuvant chemotherapy.
- Although it is clear that pembrolizumab improves pCR, it isn’t clear if the checkpoint inhibitor will improve long-term outcomes, Dr. Gradishar said.
Disclosures:
Dr. Henry reported having no financial disclosures relevant to this episode.
Dr. Gradishar reported financial relationships with AstraZeneca, Celltrion, Genentech, MacroGenics, Merck, Pfizer, and Seattle Genetics.
* *
For more MDedge Podcasts, go to mdedge.com/podcasts
Email the show: [email protected]
Interact with us on Twitter: @MDedgehemonc
David Henry on Twitter: @davidhenrymd
If you like this episode you’ll love
Episode Comments
Generate a badge
Get a badge for your website that links back to this episode
<a href="https://goodpods.com/podcasts/blood-and-cancer-197219/vte-rate-covid-toes-and-virchows-triad-what-you-need-to-know-about-cov-19337338"> <img src="https://storage.googleapis.com/goodpods-images-bucket/badges/generic-badge-1.svg" alt="listen to vte rate, 'covid toes,' and virchow's triad: what you need to know about covid and coagulation on goodpods" style="width: 225px" /> </a>
Copy