Hypercoagulation Detected by Rotational Thromboelastometry Predicts Mortality in COVID-19: A Risk Model Based on a Prospective Observational Study

Lou M Almskog; Agneta Wikman; Jonas Svensson; Matteo Bottai; Mariann Kotormán; Carl-Magnus Wahlgren; Michael Wanecek; Jan van der Linden; Anna Ågren

doi:10.1055/a-1725-9221

Hypercoagulation Detected by Rotational Thromboelastometry Predicts Mortality in COVID-19: A Risk Model Based on a Prospective Observational Study

TH Open. 2021 Dec 21;6(1):e50-e59. doi: 10.1055/a-1725-9221. eCollection 2022 Jan.

Authors

Lou M Almskog^{1

2}, Agneta Wikman^{3

4}, Jonas Svensson⁵, Matteo Bottai⁶, Mariann Kotormán¹, Carl-Magnus Wahlgren^{2

7}, Michael Wanecek^{1

8}, Jan van der Linden^{2

9}, Anna Ågren^{2

10

11}

Affiliations

¹ Department of Anaesthesiology and Intensive Care, Capio St. Göran's Hospital, Stockholm, Sweden.
² Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
³ Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden.
⁴ Department of CLINTEC, Karolinska Institutet, Stockholm, Sweden.
⁵ Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Karolinska University Hospital, Stockholm, Sweden.
⁶ Division of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
⁷ Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden.
⁸ Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.
⁹ Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.
¹⁰ Coagulation Unit, Hematology Centre, Karolinska University Hospital, Stockholm, Sweden.
¹¹ Department of Clinical Sciences, Danderyd Hospital and Karolinska Institutet, Stockholm, Sweden.

Abstract

Background Severe disease due to the novel coronavirus disease 2019 (COVID-19) has been shown to be associated with hypercoagulation. The aim of this study was to assess the Rotational Thromboelastometry (ROTEM) as a marker of coagulopathy in hospitalized COVID-19 patients. Methods This was a prospective, observational study where patients hospitalized due to a COVID-19 infection were eligible for inclusion. Conventional coagulation tests and ROTEM were taken after hospital admission, and patients were followed for 30 days. A prediction model, including variables ROTEM EXTEM-MCF (Maximum Clot Firmness) which in previous data has been suggested a suitable marker of hypercoagulation, age, and respiratory frequency, was developed using logistic regression to evaluate the probability of death. Results Out of the 141 patients included, 18 (13%) died within 30 days. In the final prediction model, the risk of death within 30 days for a patient hospitalized due to COVID-19 was increased with increased EXTEM-MCF, age, and respiratory frequency. Longitudinal ROTEM data in the severely ill subpopulation showed enhanced hypercoagulation. In an in vitro analysis, no heparin effect on EXTEM-coagulation time (CT) was observed, supporting a severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) effect on prolonged initiation of coagulation. Conclusion Here, we show that hypercoagulation measured with ROTEM predicts 30-day mortality in COVID-19. Longitudinal ROTEM data strengthen the hypothesis of hypercoagulation as a driver of severe disease in COVID-19. Thus, ROTEM may be a useful tool to assess disease severity in COVID-19 and could potentially guide anticoagulation therapy.

Keywords: COVID-19; coagulopathy; mortality; thromboelastometry; thrombosis.

The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. ( https://creativecommons.org/licenses/by/4.0/ ).

Grants and funding

Funding This work was supported by a grant from the Swedish Society of Thrombosis and Haemostasis (L.M.A.), an unrestricted grant from CSL Behring (A.W.), grants from Karolinska Institutet (J.v.d.L.), a grant from the Swedish Society of Medicine (A.Å.), and a grant from the Tetra Laval Group through the Development Office of Karolinska Institutet (A.Å.).