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Article pour les cliniciens

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A Systematic Review and a Meta-Analysis Comparing Prophylactic and Therapeutic Low Molecular Weight Heparins for Mortality Reduction in 32,688 COVID-19 Patients.

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• Giossi R
• Menichelli D
• Pani A
• Tratta E
• Romandini A
• Roncato R, et al.

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Commentaires cliniques (en anglais)

Hemostasis and Thrombosis

There were only two RCTs included. Furthermore, the results of the two RCTs did not compare anticoagulation with no anticoagulation. Therefore, the results of the SR still should be confirmed by future high-quality studies.

Hospital Doctor/Hospitalists

This meta-analysis included 2 randomized and 31 observational comparisons of prophylactic vs therapeutic dosing with a heparin or fondaparinux in COVID-19 patients, published before 22 June 2021. The authors conclude that prophylactic and full dose treatment both reduced all cause mortality but not length of stay, and that major bleeding was more likely with full dose heparin. The overview is limited by its heavy weighting for observational studies (only 5/31 were 'good quality') and the few randomized trials (n=2). Pubmed lists 4 major randomized trials published since their cut-off date. Conclusions are, therefore, preliminary.

Hospital Doctor/Hospitalists

This metanalysis based on the existing evidence so far, (and before two recent RCT) comparing prophylactic versus full dose anticoagulation in hospitalized COVID-19 patients confirms that heparin (mostly LMWH) at both full and prophylactic dose is effective in reducing mortality in this subset of patients. D-dimers were expressed only in a subset of studies. Confounding biases were frequent on most of observational studies included, but not in the 2 RCT. There were 32688 patients evaluated, and 33.5% of the hospitalized did not receive any anticoagulant. Heparin reduced risk of all-cause mortality at 28 days, both on prophylactic and full dose. As other studies that came after this, the data does not support an extensive use of full dose anticoagulation in all hospitalized subjects (significant bleeding risk) except in specific cases. Prophylactic should represent first choice.

Infectious Disease

This systematic review includes predominantly observational studies with high risk of bias, but the evidence suggests a robust effect in favour of prophylactic Low Molecular Weight Heparins in terms of mortality.