key: cord-0845823-xdk2ugpm
authors: Rustgi, Sheila D.; Yang, Jeong Yun; Luther, Sanjana; David, Yakira; Dixon, Rebekah E.; Simoes, Priya K.; Kumta, Nikhil A.
title: Anticoagulation Does Not Increase Risk of Mortality or ICU Admission in Hospitalized COVID-19 Patients with Gastrointestinal Bleeding: Results from a New York Health System
date: 2020-12-15
journal: Clin Res Hepatol Gastroenterol
DOI: 10.1016/j.clinre.2020.101602
sha: 5ac28926530f095cda43b68b859b96e2891486d6
doc_id: 845823
cord_uid: xdk2ugpm

nan

This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

The novel coronavirus disease 2019 (COVID-19) has spread rapidly around the globe, leading to numerous hospitalizations and deaths worldwide. Although initially described as a respiratory disease, subsequent studies have demonstrated its impact on other organ systems including the gastrointestinal tract. 1 Gastrointestinal bleeding (GIB) has been reported in 4-13.7% of patients. 2 Furthermore, COVID-19 has been found to promote a prothrombotic state, resulting in guidelines recommending anticoagulation (AC) for these patients to reduce the risk of thromboembolic events, including pulmonary embolism, myocardial infarction or cerebrovascular accident. 3, 4 These findings and practices led to the implementation of J o u r n a l P r e -p r o o f a system-wide AC protocol within our hospital system. AC is a well-established risk for GIB. 5 This study aims to assess the impact of AC for COVID-19 on GIB by comparing patient characteristics and outcomes before and after the implementation of a systemwide AC protocol in a health care system at the pandemic epicenter.

System between February 29 th and May 15 th , 2020 and International Classification of Diseases (ICD-10) code for anemia or GIB were reviewed. Patients were excluded if they did not have overt GIB (hematemesis, melena or hematochezia). Charts were reviewed for demographic information, length of stay (LOS), ICU admission, laboratory test results, medications, COVID-19 severity and GIB management. April 10, 2020 was identified as the date when a system-wide AC protocol was initiated, wherein COVID-19

patients who met certain clinical criteria were recommended to start AC on admission and continue for two weeks after discharge. Patients were included in the pre and post AC cohorts by date of hospital discharge.

There were 146 patients admitted with a positive SARS-CoV2 test and GIB during admission (Table 1) . 38 (26.0%) were discharged prior to AC protocol initiation.

Patient age, sex, race and body mass index (BMI) were not significantly different between the two groups. The mean BMI was 28.5 ± 6.9, and 63% were never smokers.

The most common comorbidities were hypertension (62%), diabetes mellitus (35.6%), and chronic kidney disease (30.1%). There were no significant differences in comorbidities between the two groups. 22.6% of patients were on AC prior to admission.

There were no differences between the two groups in terms of prehospitalization AC, 

To our knowledge, this is the first study comparing outcomes of COVID-19

patients and GIB before and after the initiation of a system-wide AC protocol. Initiation of this protocol was not associated with increased mortality or ICU admission among J o u r n a l P r e -p r o o f hospitalized patients with GIB. However, hospital LOS was longer for those in the post AC protocol group. Although endoscopy is usually standard of care for hospitalized patients with GIB, it was frequently deferred in endoscopy suites internationally. 6,7. Most patients were treated medically with PPI therapy. Among the small number of patients (n=17) who did undergo endoscopy, few required therapeutic intervention.

The mortality rate in our cohort was high (35.6%). On multivariable analysis controlling for other factors, age was the only independent risk factor associated with mortality, consistent with other studies of COVID-19 hospitalized patients. 8 Interestingly, discharge after initiation of the AC protocol was protective against mortality in our study, consistent with previous studies. 9 This finding may be limited by unobserved confounding factors, including improved knowledge in caring for COVID-19 patients later in the pandemic.

Our study has multiple strengths. We report the clinical characteristics of a diverse patient population in a large NYC health system. The initiation of a system-wide AC protocol in the midst of the NYC COVID-19 pandemic allows us to directly compare two otherwise similar cohorts. Another strength of our study is that we only included patients with overt GIB.

Limitations include that this was a retrospective, single hospital system study,

where practices were evolving. Elective endoscopies were cancelled and staff were redeployed to care for COVID patients. The patient population for this study was identified using ICD-10 codes, which is limited by physician coding and risks underselection of patients. However, all charts were manually reviewed for accuracy.

Finally, due to the short time period we did not evaluate outcomes after discharge.

Our study suggests that initiation of treatment dose AC to minimize COVID-19 related thromboembolic complications does not result in increased mortality for patients J o u r n a l P r e -p r o o f 

Comorbidities and multi-organ injuries in the treatment of COVID-19

Review article: gastrointestinal features in COVID-19 and the possibility of faecal transmission

Coagulation abnormalities and thrombosis in patients with COVID-19

ISTH interim guidance on recognition and management of coagulopathy in COVID-19

Association of Oral Anticoagulants and Proton Pump Inhibitor Cotherapy With Hospitalization for Upper Gastrointestinal Tract Bleeding

Global Impact of the COVID-19 Pandemic on Endoscopy: An International Survey of 252 Centers from 55 Countries

Characteristics and Outcomes of Patients Undergoing Endoscopy During the COVID-19 Pandemic: A Multicenter Study from New York City

Risk Factors for Intensive Care Unit Admission and In-hospital Mortality among Hospitalized Adults Identified through the U.S. Coronavirus Disease 2019 (COVID-19)-Associated Hospitalization Surveillance Network (COVID-NET)

Association of Treatment Dose Anticoagulation With In-Hospital Survival Among Hospitalized Patients With COVID-19