Hypercoagulation detected by Rotational Thromboelastometry predicts mortality in COVID-19: A risk model based on a prospective observational study.

Almskog, L. M.; Wikman, A.; Svensson, J.; Bottai, M.; Kotorman, M.; Wahlgren, C.-M.; Wanecek, M.; van der Linden, J.; Agren, A.

ABSTRACT Background: Severe disease due to COVID-19 has been shown to be associated with hypercoagulation. Early identification of prothrombotic patients may help guiding anticoagulant treatment and improve survival. The aim of this study was to assess Rotational Thromboelastmetry (ROTEM) as a marker of coagulopathy in hospitalized COVID-19 patients. Methods: This was a prospective, observational study. 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. Patient characteristics and outcome variables were collected, and a prediction model including variables age, respiratory frequency and ROTEM EXTEM-MCF, was developed using logistic regression to evaluate the probability of death. Results: Out of the 141 patients included, 18 (13%) died within 30 days. D-dimer (p=0.01) and Activated Partial Thromboplastin Time (APTT) (p=0.002) were increased, and ROTEM EXTEM-/INTEM-CT (p<0.001) were prolonged in non-survivors. In the final prediction model, the risk of death within 30 days for a patient hospitalized due to COVID-19 was increased with increased age, respiratory frequency and EXTEM-MCF. Longitudinal ROTEM data in the severely ill subpopulation showed enhanced hypercoagulation. In our in vitro analysis, no heparin effect on EXTEM-CT was observed, supporting a SARS-CoV-2 effect on initiation of coagulation. Conclusions: 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.