key: cord-0857327-xt59hgid
authors: Gutierrez, J. Antonio; Samsky, Marc D.; Schulteis, Ryan D.; Gu, Lin; Swaminathan, Rajesh V.; Aday, Aaron W.; Rao, Sunil V.
title: Venous Thromboembolism Among Patients Hospitalized with COVID-19 at Veterans Health Administration Hospitals
date: 2021-03-18
journal: Am Heart J
DOI: 10.1016/j.ahj.2021.03.010
sha: 5e7cc9ec33b88ba5e91e047e06d590ba67da545a
doc_id: 857327
cord_uid: xt59hgid

Patients with coronavirus disease 2019 (COVID-19) are at heightened risk of venous thromboembolic events (VTE), though there is no data examining when these events occur following a COVID-19 diagnosis. We therefore sought to characterize the incidence, timecourse of events, and outcomes of VTE during the COVID-19 pandemic in a national healthcare system using data from Veterans Affairs Administration.

Patients with coronavirus disease 2019 (COVID-19) are at heightened risk of thromboembolic events, potentially resulting from propagation of a consumptive coagulopathy due to activation of inflammatory pathways or via endotheliitis. 1, 2 The reported incidence of COVID-19 associated venous thromboembolism (VTE) has varied, likely due to differences in populations studied, settings, patterns of screening, and diagnostic testing. Furthermore, there is no data examining when VTE events occur following a COVID-19 diagnosis. We therefore sought to characterize the incidence, timecourse of events, and outcomes of VTE during the COVID-19 pandemic in a national healthcare system using data from Veterans Affairs (VA) Administration.

We used the VA Data Warehouse to identify all hospitalized patients with a positive COVID-19 polymerase chain reaction (PCR) between 05/01/2020-08/01/2020. Patients were included if admitted from 48 hours prior to the positive PCR through 21 days following the positive PCR. In the event of multiple positive COVID-19 tests, only the first was considered.

Demographics were obtained using International Classification of Diseases 10 th Revision, Clinical Modification (ICD-10) codes at admission (Supplement).

The primary outcome was identified using VTE ICD-10 codes after admission through 10/31/2020 at VA hospitals. A propensity score matched, Cox proportional hazard estimate with COVID-19 negative patients was performed using nearest neighbor matching. Event free survival was estimated for COVID-19 positive vs. negative using Kaplan-Meier estimates. An adjusted Cox regression model was used to evaluate the association between COVID-19 and VTE. A P-value <0.05 was considered significant. This study was approved by the Durham VA Medical Center IRB. Analyses were performed using SAS 9.4 (Cary, NC).

During the study period, we found 4,461 hospitalized patients with a positive and 76,929 with negative COVID-19 PCR test(s). The median (25 th , 75 th percentiles) age of the overall COVID-19 positive cohort was 68 (58, 75) years, 93.3% were male, 52.6% white, 35.7% black, with a median (25 th , 75 th percentiles) length of stay of 6 (3,14) days ( Table 1) (Figure 1) . Following propensity score matching, the adjusted hazard for VTE associated with a positive COVID-19 test was 1.28 (95% CI 1.10-1.48; P=0.001).

This study of patients at U.S. VA hospitals demonstrates that patients hospitalized with COVID-19, despite thromboprophylaxis, are at increased risk of VTE during admission and following discharge. The rates reported in this large, national sample that includes patients admitted to intensive care, step-down care, and intermediate level care wards are consistent with smaller, regionally-based reports. 3 Previous reports have focused on non-critcally ill or symptomatic patients. [4] [5] [6] This analysis adds to the mounting evidence of increased VTE risk in hospitalized patients with COVID-19, and extends our knowledge to now include increased risk following discharge. Furthermore, these results provides additional justification for future randomized controlled trials studying use of antithrombotics in hospitalized and convalescing paitents with COVID-19. As stated by professional societies, there is no high quality data to guide thromboprophylaxis in patients with COVID-19. 7 No at Risk VTE rate COVID (+) 9.2% COVID (-) 6.8% P < 0.0001

Diagnosis, Management, and Pathophysiology of Arterial and Venous Thrombosis in COVID-19

Endothelial cell infection and endotheliitis in COVID-19

COVID-19 and coagulation: bleeding and thrombotic manifestations of SARS-CoV-2 infection

Frequency of venous thromboembolism in 6513 patients with COVID-19: a retrospective study

Pulmonary embolism in COVID-19 patients: a French multicentre cohort study

Thrombosis in Hospitalized Patients With COVID-19 in a New York City Health System

COVID-19 and Thrombotic or Thromboembolic Disease: Implications for Prevention, Antithrombotic Therapy, and Follow-Up: JACC State-of-the-Art Review

Prevention, Diagnosis, and Treatment of VTE in Patients With Coronavirus Disease

Albumin g/dL

Cerebrovascular Disease, n (%)

These results are observational and unmeasured confounders may exist. Furthermore, due to a lack of routine screening in the asymptomatic setting, the true