Discussion:
Novel COVID-19 first originated from Wuhan, China and has spread rapidly
to all over the world.1 It spreads via respiratory
droplets between close contacts and patients usually present with
respiratory symptoms although atypical symptoms like altered mental
status in elderly patients have been reported.2 There
have been increased evidence of hypercoagulability seen in patients
infected with COVID-19. Venous thromboembolism (VTE) is common in
acutely ill patients with COVID-19 and has been termed as
COVID-19-associated coagulopathy (CAC).3 An autopsy
study showed as high as 58% incidence of VTE.4 The
pathogenesis of CAC is incompletely understood. All three categories of
‘Virchow’s triad’ appears to be implicated including, endothelial
injury as evident by direct invasion of endothelial cells by the virus
along with increased cytokines and complements, stasis due to
immobilization in hospitalized patients and hypercoagulable state due to
changes in circulating prothrombotic factors such as D-dimer and
fibrinogen.5 Risk factors for CAC are males with
obesity and other chronic medical comorbidities, especially
cardiovascular disease, hypertension, diabetes mellitus and
ESRD.4 Common laboratory findings include high D-dimer
and fibrinogen, mildly prolonged PT and aPTT and mild
thrombocytopenia.4 Elevated D-dimer levels appears to
correlate with illness severity as well as increased mortality.
CAC appears to clinically behave differently from disseminated
intravascular coagulation (DIC).3 The major clinical
finding in CAC is thrombosis and high fibrinogen, whereas acute DIC
often presents with bleeding and low fibrinogen.3Management can be challenging due to absence of high-quality data.
Whether therapeutic dose anticoagulation should be offered to everyone
with COVID-19 remains unclear. Some authors have suggested using
intermediate dose of low molecular weight heparin in patients with
significantly elevated d-dimer levels due to the high percentage of
patients with VTE despite receiving prophylactic
anticoagulation.6,7 Full-dose anticoagulation is
recommended for individuals with documented VTE or with recurrent
clotting of intravascular access devices unless contraindicated.