• Hanny Al-Samkari, Shruti Gupta, Rebecca Karp Leaf, Wei Wang, Rachel P Rosovsky, Samantha K Brenner, Salim S Hayek, Hanna Berlin, Rajat Kapoor, Shahzad Shaefi, Michal L Melamed, Anne Sutherland, Jared Radbel, Adam Green, Brian T Garibaldi, Anand Srivastava, Amanda Leonberg-Yoo, Alexandre M Shehata, Jennifer E Flythe, Arash Rashidi, Nitender Goyal, Lili Chan, Kusum S Mathews, S Susan Hedayati, Rajany Dy, Stephanie M Toth-Manikowski, Jingjing Zhang, Mary Mallappallil, Roberta E Redfern, Amar D Bansal, Samuel A P Short, Mark G Vangel, Andrew J Admon, Matthew W Semler, Kenneth A Bauer, Miguel A Hernán, David E Leaf, and STOP-COVID Investigators.
• Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (H.A., R.K.L., R.P.R.).
• Ann. Intern. Med. 2021 May 1; 174 (5): 622632622-632.

BackgroundHypercoagulability may be a key mechanism of death in patients with coronavirus disease 2019 (COVID-19).ObjectiveTo evaluate the incidence of venous thromboembolism (VTE) and major bleeding in critically ill patients with COVID-19 and examine the observational effect of early therapeutic anticoagulation on survival.DesignIn a multicenter cohort study of 3239 critically ill adults with COVID-19, the incidence of VTE and major bleeding within 14 days after intensive care unit (ICU) admission was evaluated. A target trial emulation in which patients were categorized according to receipt or no receipt of therapeutic anticoagulation in the first 2 days of ICU admission was done to examine the observational effect of early therapeutic anticoagulation on survival. A Cox model with inverse probability weighting to adjust for confounding was used.Setting67 hospitals in the United States.ParticipantsAdults with COVID-19 admitted to a participating ICU.MeasurementsTime to death, censored at hospital discharge, or date of last follow-up.ResultsAmong the 3239 patients included, the median age was 61 years (interquartile range, 53 to 71 years), and 2088 (64.5%) were men. A total of 204 patients (6.3%) developed VTE, and 90 patients (2.8%) developed a major bleeding event. Independent predictors of VTE were male sex and higher D-dimer level on ICU admission. Among the 2809 patients included in the target trial emulation, 384 (11.9%) received early therapeutic anticoagulation. In the primary analysis, during a median follow-up of 27 days, patients who received early therapeutic anticoagulation had a similar risk for death as those who did not (hazard ratio, 1.12 [95% CI, 0.92 to 1.35]).LimitationObservational design.ConclusionAmong critically ill adults with COVID-19, early therapeutic anticoagulation did not affect survival in the target trial emulation.Primary Funding SourceNone.

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