Anticoagulation for hypercoagulability in severe critical COVID-19: A case series of fading and fatal cycles of microthrombosis

The pathophysiology of the COVID-19 involves a systemic hypercoagulable state and systemic micro-thrombosis which can cause fatal consequences. Despite that anticoagulation seems an intuitive therapeutic option, the US National Institute of Health has issued a warning against its use in critically ill patients. We present five cases of imaging-proven or clinically suspected hypercoagulability with hemodynamic compromise despite therapeutic anticoagulation. We describe the patients with thoughts on links between pathophysiology and the laboratory values, clinical course, and imaging studies in each case. All patients presented to the hospital with symptoms and chest imaging suggestive of COVID-19 pneumonia. All patients presented with severe hypoxia requiring mechanical ventilation, and received full anticoagulation for treatment of hypercoagulable state suggested by elevated D-dimer. All but one patient received alteplase for thrombolytic therapy of suspected massive pulmonary embolism (PE). On the basis of this case series, hypercoagulability in COVID-19 is a late manifestation of the disease that persists despite anticoagulation, is cyclic in nature based on D-dimer despite thrombolysis, and is fatal if it rebounds. The use of anticoagulation and thrombolysis in these patients seemed harmful or non-beneficial. Early intervention before D-dimer elevation and hemodynamic compromise may benefit in preventing thromboembolic burden. <Learning objective: Fatal and hemodynamically significant hypercoagulability in COVID-19 patients is cyclic in nature as evident by re-elevation of D-dimer levels during hospitalization. As suggested by the US National Institute of Health, anti-coagulation in these patients does not seem to prevent mortality. Cyclic thromboembolsim seems to be a late manifestation of the disease during which stage it is already too late for the use of therapeutics. A signal of harm for anticoagulation in these patients may be related to a coagulopathy state.>