Autopsy Findings and Venous Thromboembolism in Patients With COVID-19
Authors: Dominic Wichmann
Journal: Annals of Internal Medicine (2020)

Letters15 December 2020Autopsy Findings and Venous Thromboembolism in Patients With COVID-19FREEDominic Wichmann, MDDominic Wichmann, MDUniversity Medical Center Hamburg-Eppendorf, Hamburg, Germany (D.W.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/L20-1206 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail IN RESPONSE:Dr. Epelbaum raises concerns that focusing on VTE or PE in patients with COVID-19 may misdirect investigators' attention to an epiphenomenon. We strongly disagree, especially because we believe that the references he gives do not back up his statements.Dr. Epelbaum states that lack of VTE prophylaxis “remains a global deficiency,” citing a study by Kröger and colleagues (1). The main topic of this study was to investigate whether patients presenting with VTE/PE in Germany had a risk factor that could have been identified previously. Most of these patients had no medical condition and no identifiable risk factor. The algorithm consequently decided against prophylaxis, which can hardly be extrapolated to patients with COVID-19.It is correct that PE is a common (but rarely fatal) finding on computed tomography in critically ill patients (2), most likely because performance of this study has improved in recent years. In contrast, one third of our patients had a fatal PE. Furthermore, Dr. Epelbaum states that we used Bikdeli and associates' consensus statement to corroborate the demand for general anticoagulant treatment for patients with COVID-19 (3). This is not correct; instead, we stressed the need for further studies on this subject. The consensus statement focused largely on the effects of COVID-19–associated coagulopathies on anticoagulant strategies for cardiovascular interventions. A short paragraph cited by Dr. Epelbaum deals with empirical anticoagulant therapy in patients with COVID-19 and notes, “The majority of panel members consider prophylactic anticoagulation, although a minority consider intermediate-dose or therapeutic dose to be reasonable.” This statement was written before our study and others were published (4). The panel's decision was based mainly on a single retrospective study from China in which only laboratory abnormalities had been presented and no autopsies had been done (5). As such, our study and that by Baldi and coworkers add substantial value to the consensus statement's claim that the “optimal dosing [for anticoagulant treatment] in patients with severe COVID-19 remains unknown and warrants further prospective investigation.”References1. Kröger K, Moerchel C, Bus C, et al. Venous thromboembolism in Germany: results of the GermAn VTE registry (GATE-registry). Int J Clin Pract. 2014;68:1467-72. [PMID: 25333964] doi:10.1111/ijcp.12504 CrossrefMedlineGoogle Scholar2. Minet C, Lugosi M, Savoye PY, et al. Pulmonary embolism in mechanically ventilated patients requiring computed tomography: prevalence, risk factors, and outcome. Crit Care Med. 2012;40:3202-8. [PMID: 23164766] doi:10.1097/CCM.0b013e318265e461 CrossrefMedlineGoogle Scholar3. Bikdeli B, Madhavan MV, Jimenez D, et al; Global COVID-19 Thrombosis Collaborative Group, endorsed by the ISTH, NATF, ESVM, and the IUA, supported by the ESC Working Group on Pulmonary Circulation and Right Ventricular Function. COVID-19 and thrombotic or thromboembolic disease: implications for prevention, antithrombotic therapy, and follow-up: JACC state-of-the-art review. J Am Coll Cardiol. 2020;75:2950-73. [PMID: 32311448] doi:10.1016/j.jacc.2020.04.031 CrossrefMedlineGoogle Scholar4. Baldi E, Sechi GM, Mare C, et al; Lombardia CARe Researchers. Out-of-hospital cardiac arrest during the COVID-19 outbreak in Italy [Letter]. N Engl J Med. 2020;383:496-8. [PMID: 32348640] doi:10.1056/NEJMc2010418 CrossrefMedlineGoogle Scholar5. Tang N. Response to ‘Reply to Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy' [Letter]. J Thromb Haemost. 2020;18:1520-1. [PMID: 32302451] doi:10.1111/jth.14851 CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: Dominic Wichmann, MDAffiliations: University Medical Center Hamburg-Eppendorf, Hamburg, Germany (D.W.)Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-2003. 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