Letter to the Editor
COVID-19 and thrombosis: Beyond a casual association
COVID-19 y trombosis: más que una asociación
José López Castro
Internal Medicine Dep., Monforte Public Hospital, Lugo, Spain
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"documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Med Clin. 2020;155:42-3" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific letter</span>" "titulo" => "Iatrogenic hyperthyroidism can be a triggering factor for takotsubo cardiomyopathy" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "42" "paginaFinal" => "43" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hipertiroidismo iatrogénico como factor desencadenante de miocardiopatía de estrés" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Eva Cervilla-Muñoz, Marianela Bringas-Beranek, Pablo Demelo-Rodríguez" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Eva" "apellidos" => "Cervilla-Muñoz" ] 1 => array:2 [ "nombre" => "Marianela" "apellidos" => "Bringas-Beranek" ] 2 => array:2 [ "nombre" => "Pablo" "apellidos" => "Demelo-Rodríguez" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S238702062030245X?idApp=UINPBA00004N" "url" => "/23870206/0000015500000001/v1_202007040744/S238702062030245X/v1_202007040744/en/main.assets" ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "COVID-19 and thrombosis: Beyond a casual association" "tieneTextoCompleto" => true "saludo" => "Dear Editor:" "paginas" => array:1 [ 0 => array:1 [ "paginaInicial" => "44" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "José López Castro" "autores" => array:1 [ 0 => array:3 [ "nombre" => "José" "apellidos" => "López Castro" "email" => array:1 [ 0 => "jlcastro126@hotmail.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Internal Medicine Dep., Monforte Public Hospital, Lugo, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "COVID-19 y trombosis: más que una asociación" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Despite various therapeutic schemes used since the onset of the SARS-CoV2 pandemic of COVID-19, mortality remains around 3–5% in the different countries that have reported cases.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> After the knowledge that the virus enters the cell through the union of its protein S with the receptor for ACE2 (angiotensin converting enzyme type 2)<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> has been speculated with the suspension of certain pharmacological groups that due to their mechanism of action increase the presence of these receptors and therefore could increase the passage of virus into the alveolar cells, this point remaining in controversy. On the other hand, in a recently published retrospective series of cases, a frequent elevation of <span class="elsevierStyleSmallCaps">d</span>-dimer has been observed, which has been related to acute pulmonary thrombosis, which has dramatically worsened the prognosis in this subgroup of patients.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> It is striking that those patients with a higher <span class="elsevierStyleSmallCaps">d</span>-dimer also show more marked desaturations even without observing pneumonia on CTPA (Computarized Tomography Pulmonary Angiography).</p><p id="par0010" class="elsevierStylePara elsevierViewall">Unlike hemorrhagic viruses (Ebola, Marburg...), SARS-Cov-2 could be a highly prothrombotic virus that causes alterations in the coagulation cascade not well characterized at present that would lead to a progressive elevation of <span class="elsevierStyleSmallCaps">d</span>-dimer in function of the severity and extent of microthrombosis. In turn, this hypothesis could explain that these patients have a clearly worse prognosis since in them, orotracheal intubation would provide oxygen to a lung with no microvascular perfusion due to disseminated microthrombotic disease, which would also only be seen in CTPA in very advanced stages and in which little can be done to reverse this situation.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Gradually a therapeutic scheme is being established that would include hydroxychloroquine and azithromycin<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> (or in other cases lopinavir/ritonavir) in the early stages of moderate disease that does not require treatment in ICU (Intensive Care Unit) but given the analytical indication (elevation of <span class="elsevierStyleSmallCaps">d</span>-dimer) and imaging (thrombosis in CTPA) in many cases, should be evaluated the early inclusion of low molecular weight heparin (LMWH) at doses of at least high-risk prophylaxis in all these patients without thrombopenia <20,000 platelets or acute bleeding and manifesting high <span class="elsevierStyleSmallCaps">d</span>-dimer. Given the paucity of prospective studies, the need for urgent effective management, and the relative safety of these LMWH doses, the HAH (hydroxychloroquine–azithromycin–heparin) regimen could be tested in randomized clinical trials to improve the evolution of the disease in cases of torpid evolution.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical features of patients infected with 2019 novel coronavirus in Wuhan China" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C.Y. Huang" 1 => "X.L. 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Chen" 1 => "Xiang" 2 => "Zhang" 3 => "Shutong" 4 => "Liu" 5 => "Bin" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "Findings of acute pulmonary embolism in COVID-19 patients" "fecha" => "2020" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Gautret" 1 => "J.C. Lagier" 2 => "P. Parola" 3 => "V.T. Hoang" 4 => "L. Meddeb" 5 => "M. 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