In critically ill COVID-19 patients, an initial strategy of anticoagulation with heparin did not result in any benefit compared with standard prophylactic treatment.
Thrombosis and inflammation are the main issues when discussing COVID-19 related morbidity. This led to testing whether an anticoagulation scheme could improve prognosis in critically ill COVID-19 patients.
Given the dynamics of this virus, this trial had an adaptive and multiplatform design. Patients were randomized to a pragmatically defined scheme of heparin anticoagulation vs. a prophylactic scheme.
The primary endpoint was organ support–free days (like cardiovascular or respiratory organ support) and in-hospital mortality. The only difference between this trial and the one we previously discussed in another article is disease severity.
While this trial was also stopped early, in this case, the reason was that the anticoagulant range futility criteria was reached.
Data from 1098 patients (534 in the anticoagulation arm vs. 564 in the prophylactic arm) was analyzed.
The median respiratory or cardiovascular support–free days was similar between groups (adjusted proportional odds ratio: 0.83; 95% CI: 0.67 to 1.03).
The percentage of patients who survived to hospital discharge was also similar in both groups (62.7% vs. 64.5%).
Read also: Anticoagulation with Heparin in Non-Critical COVID-19.
As expected, the bleeding rate was higher in the anticoagulation arm (3.8% vs. 2.3%).
Conclusion
An initial strategy of anticoagulation with heparin is not useful for critically ill COVID-19 patients. Anticoagulation schemes with heparin did not decrease the need for life support or death vs. thrombo-prophylaxis.
nejmoa2103417Original Title: Therapeutic Anticoagulation with Heparin in Critically Ill Patients with Covid-19. The REMAP-CAP, ACTIV-4a, and ATTACC Investigators.
Reference: Ewan C Goligher et al. N Engl J Med. 2021 Aug 4. Online ahead of print.
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