This document describes the case of a 46-year-old male with no prior medical history who presented with chest pain and was found to have an ST elevation myocardial infarction (STEMI). He underwent treatment including thrombolysis and stenting, with resolution of symptoms. Two days later, he tested positive for COVID-19. Despite being asymptomatic, his D-dimer level rose significantly, indicating a COVID-19 associated coagulopathy. He was discharged on rivaroxaban for 3 weeks to prevent thrombosis given his elevated risk. The document then reviews the coagulopathy seen in COVID-19 patients and guidelines for extended thromboprophylaxis on discharge for high-risk medical patients.

1. A Case of COVID-19 Coagulopathy

2. Case History
• 46 year old male. No comorbidities.
• Wt 68 kg
• Acute chest pain – 5 hr duration
• ECG – ST elevation in inferior leads
• No h/o fever / cough. No h/o Red zone residence
• Echo
• Global hypokinesia
• No distinct RWMA.
• EF 50%
• Labs – Creatinine 0.9 mg% CBC Hb 13.2 Plt 255
HS trop I = 190 pg/ml (Males = 28.9 – 39.2 /Females = 13.8 – 17.5)

3. Case History
• Treated as STEMI Aspirin + Clopidogrel
Lysed Tenectaplase
• STs resolved in 2 hrs
• Chest pain resolved in 2 hrs Saturations 94% on RA
• RTPCR sent
• Stable overnight
• Day 2 – RTPCR +ve!
X-ray chest (N)
D-Dimer 2.0
• Clexane (0.6 ml) SC bid – given for 4 days

4. Case History
• 5th day – D – Dimer 6.0 mg/lit !!
• No symptoms
• On discharge antithrombotic therapy as:
Rivoroxaban 10 mg Daily For 3 Weeks
With Antiplatelet Therapy

5. COVID-19–associated Coagulopathy
• Coagulopathy is manifest as elevated fibrinogen, elevated D-dimers, and minimal change
in PT, aPTT, and platelet count in early stages of infection
• Disease severity is variably associated with prolongation of the prothrombin time (PT)
and international normalized ratio (INR) and thrombin time (TT) and variably by a trend
toward shortened activated partial thromboplastin time (aPTT)
• Increasing IL-6 levels are correlated with increasing fibrinogen levels
• Coagulopathy appears to be related to severity of illness and resultant
thromboinflammation and not intrinsic viral activity
• Elevated D-dimer at admission is associated with increased mortality
• Rising D-dimer after admission precedes multiorgan failure and overt DIC
• Noted to start at 4 d after admission in nonsurvivors
• Longer duration of hospital stay associated with increasing D-dimer and development
of sepsis physiology
• Bleeding manifestations are not common despite coagulopathy

7. Postulated Mechanisms of Coagulopathy and Pathogenesis of
Thrombosis in COVID-19
/Stroke

9. SCCM
GuidelinesFor
Prophylactic
Anticoagulation
On Discharge
(For COVID 19
Patients Only)
*The Society of Critical Care Medicine (SCCM), US
https://www.sccm.org

11. Cohen AT,et al.. Rivaroxaban for thromboprophylaxis in acutely ill medical patients. N Engl j Med. 2013 Feb 7;368:513-23.
N=8101
In acutely ill medical patients, Rivaroxaban was noninferior to enoxaparin for standard-duration thromboprophylaxis.
Extended-duration rivaroxaban reduced the risk of venous thromboembolism.
Rivaroxaban for thromboprophylaxis in acutely ill medical patients
Rivaroxaban vs Enoxaparin (MAGELLAN Study)

12. Rivaroxaban Reduces Thromboembolic Events in
Medically Ill Patients
• MARINER study demonstrated efficacy of post-hospital rivaroxaban use for preventing VTE in
medically ill patients.
• Post-discharge use of rivaroxaban for medically illpatients resulted in a 28% reduction in fatal and
major thromboembolic events without a significant increase in major bleeding.
J Am Coll Cardiol 2020;75:3140-3147.
MARINER (A Study of Rivaroxaban on the Venous Thromboembolic Risk in Post-Hospital Discharge Patients)
Medically Ill Patient Assessment of Rivaroxaban Versus Placebo IN Reducing Post-Discharge Venous Thrombo-Embolism Risk
(MARINER) Trial

13. Extended (Post-discharge) VTE Prophylaxis
• Although no data specific to COVID-19 exist, it is reasonable to employ individualized risk
stratification for thrombotic and hemorrhagic risk, followed by consideration of extended
prophylaxis (for up to 45 days) for patients with elevated risk of VTE (e.g., reduced
mobility/ 2 or more comorbidities /active cancer, and elevated Ddimer >3 times the
upper limit of normal at discharge) who have low risk of bleeding.
• Here again NOACs ( Rivaroxaban 10 mg OD ) will be preffered for given reasons:
Fixed dosing oral drugs
No need to monitor INR
Improved compliance

14. THANK YOU!