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Therapeutic Anticoagulation with Heparin in Critically Ill Patients with Covid-19.

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Date
2021-08-04
Authors
REMAP-CAP Investigators
ACTIV-4a Investigators
ATTACC Investigators
Goligher, Ewan C
Bradbury, Charlotte A
McVerry, Bryan J
Lawler, Patrick R
Berger, Jeffrey S
Gong, Michelle N
Carrier, Marc
Reynolds, Harmony R
Kumar, Anand
Turgeon, Alexis F
Kornblith, Lucy Z
Kahn, Susan R
Marshall, John C
Kim, Keri S
Houston, Brett L
Derde, Lennie PG
Cushman, Mary
Tritschler, Tobias
Angus, Derek C
Godoy, Lucas C
McQuilten, Zoe
Kirwan, Bridget-Anne
Farkouh, Michael E
Brooks, Maria M
Lewis, Roger J
Berry, Lindsay R
Lorenzi, Elizabeth
Gordon, Anthony C
Ahuja, Tania
Al-Beidh, Farah
Annane, Djillali
Arabi, Yaseen M
Aryal, Diptesh
Baumann Kreuziger, Lisa
Beane, Abi
Bhimani, Zahra
Bihari, Shailesh
Billett, Henny H
Bond, Lindsay
Bonten, Marc
Brunkhorst, Frank
Buxton, Meredith
Buzgau, Adrian
Castellucci, Lana A
Chekuri, Sweta
Chen, Jen-Ting
Cheng, Allen C
Chkhikvadze, Tamta
Coiffard, Benjamin
Contreras, Aira
Costantini, Todd W
de Brouwer, Sophie
Detry, Michelle A
Duggal, Abhijit
Džavík, Vladimír
Effron, Mark B
Eng, Heather F
Escobedo, Jorge
Estcourt, Lise J
Everett, Brendan M
Fergusson, Dean A
Fitzgerald, Mark
Fowler, Robert A
Froess, Joshua D
Fu, Zhuxuan
Galanaud, Jean P
Galen, Benjamin T
Gandotra, Sheetal
Girard, Timothy D
Goodman, Andrew L
Goossens, Herman
Green, Cameron
Greenstein, Yonatan Y
Gross, Peter L
Haniffa, Rashan
Hegde, Sheila M
Hendrickson, Carolyn M
Higgins, Alisa M
Hindenburg, Alexander A
Hope, Aluko A
Horowitz, James M
Horvat, Christopher M
Huang, David T
Hudock, Kristin
Hunt, Beverley J
Husain, Mansoor
Hyzy, Robert C
Jacobson, Jeffrey R
Jayakumar, Devachandran
Keller, Norma M
Khan, Akram
Kim, Yuri
Kindzelski, Andrei
King, Andrew J
Knudson, M Margaret
Kornblith, Aaron E
Kutcher, Matthew E
Laffan, Michael A
Lamontagne, Francois
Le Gal, Grégoire
Leeper, Christine M
Leifer, Eric S
Lim, George
Gallego Lima, Felipe
Linstrum, Kelsey
Litton, Edward
Lopez-Sendon, Jose
Lother, Sylvain A
Marten, Nicole
Saud Marinez, Andréa
Martinez, Mary
Mateos Garcia, Eduardo
Mavromichalis, Stavroula
McAuley, Daniel F
McDonald, Emily G
McGlothlin, Anna
McGuinness, Shay P
Middeldorp, Saskia
Montgomery, Stephanie K
Mouncey, Paul R
Murthy, Srinivas
Nair, Girish B
Nair, Rahul
Nichol, Alistair D
Nicolau, Jose C
Nunez-Garcia, Brenda
Park, John J
Park, Pauline K
Parke, Rachael L
Parker, Jane C
Parnia, Sam
Paul, Jonathan D
Pompilio, Mauricio
Quigley, John G
Rosenson, Robert S
Rost, Natalia S
Rowan, Kathryn
Santos, Fernanda O
Santos, Marlene
Santos, Mayler O
Satterwhite, Lewis
Saunders, Christina T
Schreiber, Jake
Schutgens, Roger EG
Seymour, Christopher W
Siegal, Deborah M
Silva, Delcio G
Singhal, Aneesh B
Slutsky, Arthur S
Solvason, Dayna
Stanworth, Simon J
Turner, Anne M
van Bentum-Puijk, Wilma
van de Veerdonk, Frank L
van Diepen, Sean
Vazquez-Grande, Gloria
Wahid, Lana
Wareham, Vanessa
Widmer, R Jay
Wilson, Jennifer G
Yuriditsky, Eugene
Zhong, Yongqi
Berry, Scott M
McArthur, Colin J
Neal, Matthew D
Hochman, Judith S
Webb, Steven A
Zarychanski, Ryan
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Abstract
<h4>Background</h4>Thrombosis and inflammation may contribute to morbidity and mortality among patients with coronavirus disease 2019 (Covid-19). We hypothesized that therapeutic-dose anticoagulation would improve outcomes in critically ill patients with Covid-19.<h4>Methods</h4>In an open-label, adaptive, multiplatform, randomized clinical trial, critically ill patients with severe Covid-19 were randomly assigned to a pragmatically defined regimen of either therapeutic-dose anticoagulation with heparin or pharmacologic thromboprophylaxis in accordance with local usual care. 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.<h4>Results</h4>The trial was stopped when the prespecified criterion for futility was met for therapeutic-dose anticoagulation. Data on the primary outcome were available for 1098 patients (534 assigned to therapeutic-dose anticoagulation and 564 assigned to usual-care thromboprophylaxis). The median value for organ support-free days was 1 (interquartile range, -1 to 16) among the patients assigned to therapeutic-dose anticoagulation and was 4 (interquartile range, -1 to 16) among the patients assigned to usual-care thromboprophylaxis (adjusted proportional odds ratio, 0.83; 95% credible interval, 0.67 to 1.03; posterior probability of futility [defined as an odds ratio <1.2], 99.9%). The percentage of patients who survived to hospital discharge was similar in the two groups (62.7% and 64.5%, respectively; adjusted odds ratio, 0.84; 95% credible interval, 0.64 to 1.11). Major bleeding occurred in 3.8% of the patients assigned to therapeutic-dose anticoagulation and in 2.3% of those assigned to usual-care pharmacologic thromboprophylaxis.<h4>Conclusions</h4>In critically ill patients with Covid-19, an initial strategy of therapeutic-dose anticoagulation with heparin did not result in a greater probability of survival to hospital discharge or a greater number of days free of cardiovascular or respiratory organ support than did usual-care pharmacologic thromboprophylaxis. (REMAP-CAP, ACTIV-4a, and ATTACC ClinicalTrials.gov numbers, NCT02735707, NCT04505774, NCT04359277, and NCT04372589.).
Type
Journal article
Subject
REMAP-CAP Investigators
ACTIV-4a Investigators
ATTACC Investigators
Permalink
https://hdl.handle.net/10161/23608
Published Version (Please cite this version)
10.1056/nejmoa2103417
Publication Info
REMAP-CAP Investigators; ACTIV-4a Investigators; ATTACC Investigators; Goligher, Ewan C; Bradbury, Charlotte A; McVerry, Bryan J; ... Zarychanski, Ryan (2021). Therapeutic Anticoagulation with Heparin in Critically Ill Patients with Covid-19. The New England journal of medicine. 10.1056/nejmoa2103417. Retrieved from https://hdl.handle.net/10161/23608.
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.
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Wahid

Lana Wahid

Medical Instructor in the Department of Medicine
Clinical researcher, trialist, hospitalist and educator.
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