ALERT: This system is being upgraded on Tuesday December 12. It will not be available
for use for several hours that day while the upgrade is in progress. Deposits to DukeSpace
will be disabled on Monday December 11, so no new items are to be added to the repository
while the upgrade is in progress. Everything should be back to normal by the end of
day, December 12.
Therapeutic Anticoagulation with Heparin in Noncritically Ill Patients with Covid-19.
Abstract
<h4>Background</h4>Thrombosis and inflammation may contribute to the risk of death
and complications among patients with coronavirus disease 2019 (Covid-19). We hypothesized
that therapeutic-dose anticoagulation may improve outcomes in noncritically ill patients
who are hospitalized with Covid-19.<h4>Methods</h4>In this open-label, adaptive, multiplatform,
controlled trial, we randomly assigned patients who were hospitalized with Covid-19
and who were not critically ill (which was defined as an absence of critical care-level
organ support at enrollment) to receive pragmatically defined regimens of either therapeutic-dose
anticoagulation with heparin or usual-care pharmacologic thromboprophylaxis. The primary
outcome was organ support-free days, evaluated on an ordinal scale that combined in-hospital
death (assigned a value of -1) and the number of days free of cardiovascular or respiratory
organ support up to day 21 among patients who survived to hospital discharge. This
outcome was evaluated with the use of a Bayesian statistical model for all patients
and according to the baseline d-dimer level.<h4>Results</h4>The trial was stopped
when prespecified criteria for the superiority of therapeutic-dose anticoagulation
were met. Among 2219 patients in the final analysis, the probability that therapeutic-dose
anticoagulation increased organ support-free days as compared with usual-care thromboprophylaxis
was 98.6% (adjusted odds ratio, 1.27; 95% credible interval, 1.03 to 1.58). The adjusted
absolute between-group difference in survival until hospital discharge without organ
support favoring therapeutic-dose anticoagulation was 4.0 percentage points (95% credible
interval, 0.5 to 7.2). The final probability of the superiority of therapeutic-dose
anticoagulation over usual-care thromboprophylaxis was 97.3% in the high d-dimer cohort,
92.9% in the low d-dimer cohort, and 97.3% in the unknown d-dimer cohort. Major bleeding
occurred in 1.9% of the patients receiving therapeutic-dose anticoagulation and in
0.9% of those receiving thromboprophylaxis.<h4>Conclusions</h4>In noncritically ill
patients with Covid-19, an initial strategy of therapeutic-dose anticoagulation with
heparin increased the probability of survival to hospital discharge with reduced use
of cardiovascular or respiratory organ support as compared with usual-care thromboprophylaxis.
(ATTACC, ACTIV-4a, and REMAP-CAP ClinicalTrials.gov numbers, NCT04372589, NCT04505774,
NCT02735707, and NCT04359277.).
Type
Journal articlePermalink
https://hdl.handle.net/10161/23607Published Version (Please cite this version)
10.1056/nejmoa2105911Publication Info
ATTACC Investigators; ACTIV-4a Investigators; REMAP-CAP Investigators; Lawler, Patrick
R; Goligher, Ewan C; Berger, Jeffrey S; ... Zarychanski, Ryan (2021). Therapeutic Anticoagulation with Heparin in Noncritically Ill Patients with Covid-19.
The New England journal of medicine. 10.1056/nejmoa2105911. Retrieved from https://hdl.handle.net/10161/23607.This is constructed from limited available data and may be imprecise. To cite this
article, please review & use the official citation provided by the journal.
Collections
More Info
Show full item recordScholars@Duke
Lana Wahid
Assistant Professor of Medicine
Health Services Researcher, Clinical TrialistMedical Director of Duke's Early Phase
Research Unit (DEPRU)Associate Chief, Hospital-Based Clinical Trials & Research Program

Articles written by Duke faculty are made available through the campus open access policy. For more information see: Duke Open Access Policy
Rights for Collection: Scholarly Articles
Works are deposited here by their authors, and represent their research and opinions, not that of Duke University. Some materials and descriptions may include offensive content. More info
Related items
Showing items related by title, author, creator, and subject.
-
Prospective Investigation of Markers of Elevated Delirium Risk (PRIMED Risk) study protocol: a prospective, observational cohort study investigating blood and cerebrospinal fluid biomarkers for delirium and cognitive dysfunction in older patients
Whitby, Jonathan; Bampoe, Sohail; Fullerton, James N; Smaje, Ashley; Hornby, Joanna; Hajdu, Bence; Schofield, Nick; ... (15 authors)<ns4:p><ns4:bold>Background:</ns4:bold> Delirium is a common post-operative complication, particularly in older adults undergoing major or emergency procedures. It is associated with increased length of intensive care and ... -
The Mediating Role of Emotion Regulation Within the Relationship Between Neuroticism and Misophonia: A Preliminary Investigation.
Cassiello-Robbins, Clair; Anand, Deepika; McMahon, Kibby; Guetta, Rachel; Trumbull, Jacqueline; Kelley, Lisalynn; Rosenthal, M Zachary (Frontiers in psychiatry, 2020-01)Misophonia is a newly described condition characterized by heightened emotional reactivity (e.g., anger, anxiety, and disgust) to common repetitive sounds (e.g., oral or nasal sounds made by others), accompanied by difficulties ... -
A Preliminary Investigation of the Association Between Misophonia and Symptoms of Psychopathology and Personality Disorders.
Cassiello-Robbins, Clair; Anand, Deepika; McMahon, Kibby; Brout, Jennifer; Kelley, Lisalynn; Rosenthal, M Zachary (Frontiers in psychology, 2020-01)Misophonia is a condition characterized by defensive motivational system emotional responding to repetitive and personally relevant sounds (e.g., eating, sniffing). Preliminary research suggests misophonia may be associated ...