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Systematic ReviewSystematic Review
Open Access

Role of anticoagulation in lowering the mortality in hospitalized covid-19 patients

Meta-analysis of available literature

Muhammad Aamir Waheed, Khalid Rashid, Tawfik Rajab, Ahmad Rajab, Adnan H. Adnan, Harris Fayyaz, Ahmad A. Ibad, Rabia Basri, Yahya Khan, Habib I. Alhabib and Abdelnaser Elzouki
Saudi Medical Journal June 2022, 43 (6) 541-550; DOI: https://doi.org/10.15537/smj.2022.43.6.20220046
Muhammad Aamir Waheed
From the Department of Acute Medicine (Waheed, Rajab, Adnan, Fayyaz) University Hospitals Northampton, Northampton; from the Department of Cardioloogy (Rashid), James Cook University Hospital, Middlesbrough; from the Department of Internal Medicine (Rajab), Calderdale and Huddersfield NHS Foundation Trust, England, United Kingdom; from the Department of Pathology (Ibad), Bannu Medical College, Khyber Medical University, Bannu; from the Department of Medical Education (Khan), Pak International Medical College, Peshawar, Pakistan; from the Department of Anesthesia (Basri), Hamad Medical Corporation; from the Department of Internal Medicine (Elazouki), Hamad Medical Corporation and Weill Cornell Medical College of Qatar, Doha, Qatar; from the Department of Internal Medicine (Alhabib), Dr. Mahasen’s Medical Complex, Al Qassim, Kingdom of Saudi Arabia.
FRCP, CABIM
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  • For correspondence: [email protected]
Khalid Rashid
From the Department of Acute Medicine (Waheed, Rajab, Adnan, Fayyaz) University Hospitals Northampton, Northampton; from the Department of Cardioloogy (Rashid), James Cook University Hospital, Middlesbrough; from the Department of Internal Medicine (Rajab), Calderdale and Huddersfield NHS Foundation Trust, England, United Kingdom; from the Department of Pathology (Ibad), Bannu Medical College, Khyber Medical University, Bannu; from the Department of Medical Education (Khan), Pak International Medical College, Peshawar, Pakistan; from the Department of Anesthesia (Basri), Hamad Medical Corporation; from the Department of Internal Medicine (Elazouki), Hamad Medical Corporation and Weill Cornell Medical College of Qatar, Doha, Qatar; from the Department of Internal Medicine (Alhabib), Dr. Mahasen’s Medical Complex, Al Qassim, Kingdom of Saudi Arabia.
MBBS
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Tawfik Rajab
From the Department of Acute Medicine (Waheed, Rajab, Adnan, Fayyaz) University Hospitals Northampton, Northampton; from the Department of Cardioloogy (Rashid), James Cook University Hospital, Middlesbrough; from the Department of Internal Medicine (Rajab), Calderdale and Huddersfield NHS Foundation Trust, England, United Kingdom; from the Department of Pathology (Ibad), Bannu Medical College, Khyber Medical University, Bannu; from the Department of Medical Education (Khan), Pak International Medical College, Peshawar, Pakistan; from the Department of Anesthesia (Basri), Hamad Medical Corporation; from the Department of Internal Medicine (Elazouki), Hamad Medical Corporation and Weill Cornell Medical College of Qatar, Doha, Qatar; from the Department of Internal Medicine (Alhabib), Dr. Mahasen’s Medical Complex, Al Qassim, Kingdom of Saudi Arabia.
MBBS
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Ahmad Rajab
From the Department of Acute Medicine (Waheed, Rajab, Adnan, Fayyaz) University Hospitals Northampton, Northampton; from the Department of Cardioloogy (Rashid), James Cook University Hospital, Middlesbrough; from the Department of Internal Medicine (Rajab), Calderdale and Huddersfield NHS Foundation Trust, England, United Kingdom; from the Department of Pathology (Ibad), Bannu Medical College, Khyber Medical University, Bannu; from the Department of Medical Education (Khan), Pak International Medical College, Peshawar, Pakistan; from the Department of Anesthesia (Basri), Hamad Medical Corporation; from the Department of Internal Medicine (Elazouki), Hamad Medical Corporation and Weill Cornell Medical College of Qatar, Doha, Qatar; from the Department of Internal Medicine (Alhabib), Dr. Mahasen’s Medical Complex, Al Qassim, Kingdom of Saudi Arabia.
MBBS
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Adnan H. Adnan
From the Department of Acute Medicine (Waheed, Rajab, Adnan, Fayyaz) University Hospitals Northampton, Northampton; from the Department of Cardioloogy (Rashid), James Cook University Hospital, Middlesbrough; from the Department of Internal Medicine (Rajab), Calderdale and Huddersfield NHS Foundation Trust, England, United Kingdom; from the Department of Pathology (Ibad), Bannu Medical College, Khyber Medical University, Bannu; from the Department of Medical Education (Khan), Pak International Medical College, Peshawar, Pakistan; from the Department of Anesthesia (Basri), Hamad Medical Corporation; from the Department of Internal Medicine (Elazouki), Hamad Medical Corporation and Weill Cornell Medical College of Qatar, Doha, Qatar; from the Department of Internal Medicine (Alhabib), Dr. Mahasen’s Medical Complex, Al Qassim, Kingdom of Saudi Arabia.
MBBS
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Harris Fayyaz
From the Department of Acute Medicine (Waheed, Rajab, Adnan, Fayyaz) University Hospitals Northampton, Northampton; from the Department of Cardioloogy (Rashid), James Cook University Hospital, Middlesbrough; from the Department of Internal Medicine (Rajab), Calderdale and Huddersfield NHS Foundation Trust, England, United Kingdom; from the Department of Pathology (Ibad), Bannu Medical College, Khyber Medical University, Bannu; from the Department of Medical Education (Khan), Pak International Medical College, Peshawar, Pakistan; from the Department of Anesthesia (Basri), Hamad Medical Corporation; from the Department of Internal Medicine (Elazouki), Hamad Medical Corporation and Weill Cornell Medical College of Qatar, Doha, Qatar; from the Department of Internal Medicine (Alhabib), Dr. Mahasen’s Medical Complex, Al Qassim, Kingdom of Saudi Arabia.
MBBS, MRCP
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Ahmad A. Ibad
From the Department of Acute Medicine (Waheed, Rajab, Adnan, Fayyaz) University Hospitals Northampton, Northampton; from the Department of Cardioloogy (Rashid), James Cook University Hospital, Middlesbrough; from the Department of Internal Medicine (Rajab), Calderdale and Huddersfield NHS Foundation Trust, England, United Kingdom; from the Department of Pathology (Ibad), Bannu Medical College, Khyber Medical University, Bannu; from the Department of Medical Education (Khan), Pak International Medical College, Peshawar, Pakistan; from the Department of Anesthesia (Basri), Hamad Medical Corporation; from the Department of Internal Medicine (Elazouki), Hamad Medical Corporation and Weill Cornell Medical College of Qatar, Doha, Qatar; from the Department of Internal Medicine (Alhabib), Dr. Mahasen’s Medical Complex, Al Qassim, Kingdom of Saudi Arabia.
MBBS
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Rabia Basri
From the Department of Acute Medicine (Waheed, Rajab, Adnan, Fayyaz) University Hospitals Northampton, Northampton; from the Department of Cardioloogy (Rashid), James Cook University Hospital, Middlesbrough; from the Department of Internal Medicine (Rajab), Calderdale and Huddersfield NHS Foundation Trust, England, United Kingdom; from the Department of Pathology (Ibad), Bannu Medical College, Khyber Medical University, Bannu; from the Department of Medical Education (Khan), Pak International Medical College, Peshawar, Pakistan; from the Department of Anesthesia (Basri), Hamad Medical Corporation; from the Department of Internal Medicine (Elazouki), Hamad Medical Corporation and Weill Cornell Medical College of Qatar, Doha, Qatar; from the Department of Internal Medicine (Alhabib), Dr. Mahasen’s Medical Complex, Al Qassim, Kingdom of Saudi Arabia.
MBBS, CABAIC
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Yahya Khan
From the Department of Acute Medicine (Waheed, Rajab, Adnan, Fayyaz) University Hospitals Northampton, Northampton; from the Department of Cardioloogy (Rashid), James Cook University Hospital, Middlesbrough; from the Department of Internal Medicine (Rajab), Calderdale and Huddersfield NHS Foundation Trust, England, United Kingdom; from the Department of Pathology (Ibad), Bannu Medical College, Khyber Medical University, Bannu; from the Department of Medical Education (Khan), Pak International Medical College, Peshawar, Pakistan; from the Department of Anesthesia (Basri), Hamad Medical Corporation; from the Department of Internal Medicine (Elazouki), Hamad Medical Corporation and Weill Cornell Medical College of Qatar, Doha, Qatar; from the Department of Internal Medicine (Alhabib), Dr. Mahasen’s Medical Complex, Al Qassim, Kingdom of Saudi Arabia.
MBBS
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Habib I. Alhabib
From the Department of Acute Medicine (Waheed, Rajab, Adnan, Fayyaz) University Hospitals Northampton, Northampton; from the Department of Cardioloogy (Rashid), James Cook University Hospital, Middlesbrough; from the Department of Internal Medicine (Rajab), Calderdale and Huddersfield NHS Foundation Trust, England, United Kingdom; from the Department of Pathology (Ibad), Bannu Medical College, Khyber Medical University, Bannu; from the Department of Medical Education (Khan), Pak International Medical College, Peshawar, Pakistan; from the Department of Anesthesia (Basri), Hamad Medical Corporation; from the Department of Internal Medicine (Elazouki), Hamad Medical Corporation and Weill Cornell Medical College of Qatar, Doha, Qatar; from the Department of Internal Medicine (Alhabib), Dr. Mahasen’s Medical Complex, Al Qassim, Kingdom of Saudi Arabia.
BDMS
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Abdelnaser Elzouki
From the Department of Acute Medicine (Waheed, Rajab, Adnan, Fayyaz) University Hospitals Northampton, Northampton; from the Department of Cardioloogy (Rashid), James Cook University Hospital, Middlesbrough; from the Department of Internal Medicine (Rajab), Calderdale and Huddersfield NHS Foundation Trust, England, United Kingdom; from the Department of Pathology (Ibad), Bannu Medical College, Khyber Medical University, Bannu; from the Department of Medical Education (Khan), Pak International Medical College, Peshawar, Pakistan; from the Department of Anesthesia (Basri), Hamad Medical Corporation; from the Department of Internal Medicine (Elazouki), Hamad Medical Corporation and Weill Cornell Medical College of Qatar, Doha, Qatar; from the Department of Internal Medicine (Alhabib), Dr. Mahasen’s Medical Complex, Al Qassim, Kingdom of Saudi Arabia.
FRCP, PhD
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Article Figures & Data

Figures

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  • Figure 1
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    Figure 1

    - Flow chart of database search and studies selection.

  • Figure 2
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    Figure 2

    - Mortality in patients using prophylactic anticoagulants versus therapeutic anticoagulants.

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    Figure 3

    - Mortality in patients not using any anticoagulants versus prophylactic anticoagulants.

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    Figure 4

    - Funnel plot of standard error by log odds ration. Studies with anticoagulation versus no anticoagulation.

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    Figure 5

    - Funnel plot of standard error by log odds ration. Mortality in patients using prophylactic anticoagulants versus therapeutic anticoagulants.

Tables

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    Table 1

    - Study inclusion and exclusion criteria.

    Inclusion criteriaExclusion criteria
    Randomized controlled trials, controlled (non-randomized) clinical trials or cluster trials, prospective and retrospective comparative cohort studies, and case-control or nested case-control studies.Cross-sectional studies, case series, and case reports.
    Studies involving the general adult human population who are 18 years of age or older.
    Studies that involve COVID-19 patients who are receiving anticoagulation as an intervention during their hospital stay to affect mortality.Studies with a population of non-COVID-19 hospitalizations.
    Studies in the English language.
    • View popup
    Table 2

    - The main characteristics of the included studies.

    Study name, author, year and countryTotal number of patientsMalesMean ageNo anticoagulation groupProphylactic anticoagulation
    1. D-dimer-driven anticoagulation reduces mortality in intubated COVID-19 patients: A cohort study with a propensity matched analysis (Tassiopoulos et al, 2021, USA)2919514159.50104
    2. Preliminary experience with low molecular weight heparin strategy in COVID-19 patients (Paolisso et al, 2020, USA)304506874 361
    3. Therapeutic versus prophylactic anticoagulation for severe COVID-19: A randomized phase II clinical trial (HESACOVID) (Lemos et al, 2020, Iran)31562325620220
    4. Higher anticoagulation targets and risk of thrombotic events in severe COVID-19 patients: bi-center cohort study (Helms 2020, France)32179130620108
    5. Optimizing management to reduce the mortality of COVID-19: Experience from a designated hospital for severely and critically Ill patients in China (Zhu 2021, China)3322121047340220
    6. Empiric use of anticoagulation in hospitalized patients with COVID-19: a propensity score-matched study of risk and benefits (Yu et al, 2021, USA)342356060NA115
    7. Beneficial effects of intermediate dosage of anticoagulation treatment on the prognosis of hospitalized covid 19 patients. (Poulakou, 2021, Greece)351212126
    8. Effect of intermediate-dose vs standard-dose prophylactic anticoagulation on thrombotic events ECMO or mortality among patients with covid-19 admitted to the intensive care unit (Sadeghipour et al, 2021, Iran)36222117119NA220
    9. Intermediate dose anticoagulation aspirin and in-hospital mortality in covid 19: A propensity score-matched analysis (Meizlish et al, 2021, USA)3753110414546536
    10. Therapeutic anticoagulation with Heparin in critically ill patients with covid-19 (Goliggher et al, 2021, United Kingdom, USA, Canada, Brazil)38200567200NA70
    11. Clinical presentation, course, and risk factors associated with mortality in a severe outbreak of covid-19 in Rhode Island, USA, April-June 2020 (Atalla et al, 2020, USA)39NA18NA73627
    12. Early initiation of prophylactic anticoagulation for prevention of Coronavisrus disease 2019 mortality in patients admitted to the hospital in the United States: cochort study (Rentsch et al, 2021, USA)40NA678NA961395
    USA: United States of America, Yrs: years, NA: not available
    • View popup
    Table 2

    - The main characteristics of the included studies (continuation).

    Study name, author, year and countryTherapeutic anticoagulationMortality in prophylactic anticoagulation groupMortality in therapeutic anticoagulation groupMortality in no anticoagulation group
    1. D-dimer-driven anticoagulation reduces mortality in intubated COVID-19 patients: A cohort study with a propensity matched analysis (Tassiopoulos et al, 2021, USA)299127.458.6NA
    2. Preliminary experience with low molecular weight heparin strategy in COVID-19 patients (Paolisso et al, 2020, USA)3089674NA
    3. Therapeutic versus prophylactic anticoagulation for severe COVID-19: A randomized phase II clinical trial (HESACOVID) (Lemos et al, 2020, Iran)31222117119NA
    4. Higher anticoagulation targets and risk of thrombotic events in severe COVID-19 patients: bi-center cohort study (Helms 2020, France)32712011NA
    5. Optimizing management to reduce the mortality of COVID-19: Experience from a designated hospital for severely and critically Ill patients in China (Zhu 2021, China)33 64.6 3.7
    6. Empiric use of anticoagulation in hospitalized patients with COVID-19: a propensity score-matched study of risk and benefits (Yu et al, 2021, USA)342356060NA
    7. Beneficial effects of intermediate dosage of anticoagulation treatment on the prognosis of hospitalized covid 19 patients. (Poulakou, 2021, Greece)3512121
    8. Effect of intermediate-dose vs standard-dose prophylactic anticoagulation on thrombotic events ECMO or mortality among patients with covid-19 admitted to the intensive care unit (Sadeghipour et al, 2021, Iran)36222117119NA
    9. Intermediate dose anticoagulation aspirin and in-hospital mortality in covid 19: A propensity score-matched analysis (Meizlish et al, 2021, USA)3753110414546
    10. Therapeutic anticoagulation with Heparin in critically ill patients with covid-19 (Goliggher et al, 2021, United Kingdom, USA, Canada, Brazil)38200567200NA
    11. Clinical presentation, course, and risk factors associated with mortality in a severe outbreak of covid-19 in Rhode Island, USA, April-June 2020 (Atalla et al, 2020, USA)39NA18NA7
    12. Early initiation of prophylactic anticoagulation for prevention of Coronavisrus disease 2019 mortality in patients admitted to the hospital in the United States: cochort study (Rentsch et al, 2021, USA)40NA678NA96
    USA: United States of America, vs: versus, REMAP-CAP: Randomized Embedded Multifactorial Adaptive Platform for Community-acquired Pneumonia, NA: not available
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Saudi Medical Journal: 43 (6)
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Role of anticoagulation in lowering the mortality in hospitalized covid-19 patients
Muhammad Aamir Waheed, Khalid Rashid, Tawfik Rajab, Ahmad Rajab, Adnan H. Adnan, Harris Fayyaz, Ahmad A. Ibad, Rabia Basri, Yahya Khan, Habib I. Alhabib, Abdelnaser Elzouki
Saudi Medical Journal Jun 2022, 43 (6) 541-550; DOI: 10.15537/smj.2022.43.6.20220046

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Role of anticoagulation in lowering the mortality in hospitalized covid-19 patients
Muhammad Aamir Waheed, Khalid Rashid, Tawfik Rajab, Ahmad Rajab, Adnan H. Adnan, Harris Fayyaz, Ahmad A. Ibad, Rabia Basri, Yahya Khan, Habib I. Alhabib, Abdelnaser Elzouki
Saudi Medical Journal Jun 2022, 43 (6) 541-550; DOI: 10.15537/smj.2022.43.6.20220046
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