Coagulation Abnormalities Associated with COVID-19: A Narrative Review

Abstract

Coronavirus disease 2019 (COVID-19), a viral respiratory illness caused by severe acute respiratory disease coronavirus 2 (SARS-COV-2), has caused in the last 5 years a global pandemic of unprecedented scale in the modern era. Other than the typical respiratory symptoms, patients suffering from moderate to severe COVID-19 are at risk of developing a peculiar systemic coagulopathy, known as COVID-19-associated coagulopathy. In addition to a predominantly hypercoagulable state, COVID-19 patients may experience hemorrhagic complications triggered by the viral infection. The current knowledge on the underlying molecular mechanisms, the laboratory and clinical characteristics of coagulation abnormalities associated with COVID-19, along with their management, will be summarized in this narrative review.

Keywords

COVID-19 - SARS-CoV-2 - coagulopathy - thrombosis - bleeding

Authors' Contributions

M.F. and D.F. wrote the article. P.M.M. revised the article.

Publikationsverlauf

Eingereicht: 12. März 2025

Angenommen: 19. Mai 2025

Accepted Manuscript online:
23. Mai 2025

Artikel online veröffentlicht:
17. Juni 2025

• References

• 1 Zhai P, Ding Y, Wu X, Long J, Zhong Y, Li Y. The epidemiology, diagnosis and treatment of COVID-19. Int J Antimicrob Agents 2020; 55 (05) 105955
• 2 WHO. Coronavirus disease (COVID-19) pandemic. Accessed on February 14, 2025 at: https://www.who.int/emergencies/diseases/novel-coronavirus-2019
• 3 Zhou F, Yu T, Du R. et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020; 395 (10229): 1054-1062
• 4 Franchini M, Cruciani M, Mengoli C. et al. Convalescent plasma and predictors of mortality among hospitalized patients with COVID-19: a systematic review and meta-analysis. Clin Microbiol Infect 2024; 30 (12) 1514-1522
• 5 Focosi D, Franchini M, Maggi F, Shoham S. COVID-19 therapeutics. Clin Microbiol Rev 2024; 37 (02) e0011923
• 6 Yuan Y, Jiao B, Qu L, Yang D, Liu R. The development of COVID-19 treatment. Front Immunol 2023; 14: 1125246
• 7 Franchini M, Marano G, Cruciani M. et al. COVID-19-associated coagulopathy. Diagnosis (Berl) 2020; 7 (04) 357-363
• 8 Conway EM, Mackman N, Warren RQ. et al. Understanding COVID-19-associated coagulopathy. Nat Rev Immunol 2022; 22 (10) 639-649
• 9 Iba T, Levy JH, Levi M, Thachil J. Coagulopathy in COVID-19. J Thromb Haemost 2020; 18 (09) 2103-2109
• 10 Ono R, Kitagawa I. SARS-CoV-2 infection-induced immune thrombocytopenia: a systematic review of current reports. Ann Hematol 2024; 103 (10) 3921-3939
• 11 Castelli R, Gidaro A, Manetti R. et al. Acquired hemophilia A after SARS-CoV-2 immunization: A narrative review of a rare side effect. Vaccines (Basel) 2024; 12 (07) 709
• 12 González-López TJ, Bárez A, Bernardo-Gutiérrez A. et al. Recommendations on the management of patients with immune thrombocytopenia (ITP) in the context of SARS-CoV-2 infection and vaccination: consensus guidelines from a Spanish ITP Expert Group. Infect Dis Ther 2023; 12 (02) 303-315
• 13 Franchini M, Cappello E, Valdiserra G. et al. Investigating a signal of acquired hemophilia associated with COVID-19 vaccination: A systematic case review. Semin Thromb Hemost 2023; 49 (01) 15-26
• 14 Franchini M, Liumbruno GM, Pezzo M. COVID-19 vaccine-associated immune thrombosis and thrombocytopenia (VITT): Diagnostic and therapeutic recommendations for a new syndrome. Eur J Haematol 2021; 107 (02) 173-180
• 15 Sarkar M, Madabhavi IV, Quy PN, Govindagoudar MB. COVID-19 and coagulopathy. Clin Respir J 2021; 15 (12) 1259-1274
• 16 Alnima T, Mulder MMG, van Bussel BCT, Ten Cate H. COVID-19 coagulopathy: From pathogenesis to treatment. Acta Haematol 2022; 145 (03) 282-296
• 17 Peyvandi F, Artoni A, Novembrino C. et al. Hemostatic alterations in COVID-19. Haematologica 2021; 106 (05) 1472-1475
• 18 Bonaventura A, Vecchié A, Dagna L. et al. Endothelial dysfunction and immunothrombosis as key pathogenic mechanisms in COVID-19. Nat Rev Immunol 2021; 21 (05) 319-329
• 19 Yousefi P, Soltani S, Siri G. et al. Coagulopathy and thromboembolic events a pathogenic mechanism of COVID-19 associated with mortality: An updated review. J Clin Lab Anal 2023; 37 (11-12): e24941
• 20 Gheblawi M, Wang K, Viveiros A. et al. Angiotensin converting enzyme 2: SARS-CoV-2 receptor and regulator of the renin-angiotensin system: Celebrating the 20th anniversary of the discovery of ACE2. Circ Res 2020; 126 (10) 1456-1474
• 21 He S, Blombäck M, Wallén H. COVID-19: Not a thrombotic disease but a thromboinflammatory disease. Ups J Med Sci 2024; 129: 129
• 22 Rettew A, Garrahy I, Rahimian S, Brown R, Sangha N. COVID-19 Coagulopathy. Life (Basel) 2024; 14 (08) 953
• 23 Favaloro EJ, Henry BM, Lippi G. Increased VWF and decreased ADAMTS-13 in COVID-19: Creating a milieu for (micro)thrombosis. Semin Thromb Hemost 2021; 47 (04) 400-418
• 24 Sharma S, Mishra A, Ashraf Z. COVID-19 induced coagulopathy (CIC): Thrombotic manifestations of viral infection. TH Open 2022; 6 (01) e70-e79
• 25 Szturmowicz M, Demkow U. Neutrophil extracellular traps (NETs) in severe SARS-CoV-2 lung disease. Int J Mol Sci 2021; 22 (16) 8854
• 26 Li S, Wang H, Shao Q. The central role of neutrophil extracellular traps (NETs) and by-products in COVID-19 related pulmonary thrombosis. Immun Inflamm Dis 2023; 11 (08) e949
• 27 Al-Kuraishy HM, Al-Gareeb AI, Al-Hussaniy HA, Al-Harcan NAH, Alexiou A, Batiha GE. Neutrophil extracellular traps (NETs) and Covid-19: A new frontier for therapeutic modality. Int Immunopharmacol 2022; 104: 108516
• 28 Middleton EA, He XY, Denorme F. et al. Neutrophil extracellular traps contribute to immunothrombosis in COVID-19 acute respiratory distress syndrome. Blood 2020; 136 (10) 1169-1179
• 29 Gralinski LE, Sheahan TP, Morrison TE. et al. Complement activation contributes to severe acute respiratory syndrome coronavirus pathogenesis. MBio 2018; 9 (05) e01753-e18
• 30 Cheng J, Zeng H, Chen H. et al. Current knowledge of thrombocytopenia in sepsis and COVID-19. Front Immunol 2023; 14: 1213510
• 31 Lippi G, Plebani M, Henry BM. Thrombocytopenia is associated with severe coronavirus disease 2019 (COVID-19) infections: A meta-analysis. Clin Chim Acta 2020; 506: 145-148
• 32 Cunningham RM, Johnson Moore KL, Moore JS. Coagulopathy during COVID-19 infection: A brief review. Clin Exp Med 2023; 23 (03) 655-666
• 33 Dubey L, Dorosh O, Dubey N. et al. COVID-19-induced coagulopathy: Experience, achievements, prospects. Cardiol J 2023; 30 (03) 453-461
• 34 Wada H, Thachil J, Di Nisio M. et al.; The Scientific Standardization Committee on DIC of the International Society on Thrombosis Haemostasis. Guidance for diagnosis and treatment of DIC from harmonization of the recommendations from three guidelines. J Thromb Haemost 2013; 11 (04) 761-767
• 35 Tang N, Li D, Wang X, Sun Z. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. J Thromb Haemost 2020; 18 (04) 844-847
• 36 Butt A, Erkan D, Lee AI. COVID-19 and antiphospholipid antibodies. Best Pract Res Clin Haematol 2022; 35 (03) 101402
• 37 Favaloro EJ, Henry BM, Lippi G. Is lupus anticoagulant a significant feature of COVID-19? A critical appraisal of the literature. Semin Thromb Hemost 2022; 48 (01) 55-71
• 38 Favaloro EJ, Henry BM, Lippi G. COVID-19 and antiphospholipid antibodies: Time for a reality check?. Semin Thromb Hemost 2022; 48 (01) 72-92
• 39 Maiese A, Manetti AC, La Russa R. et al. Autopsy findings in COVID-19-related deaths: A literature review. Forensic Sci Med Pathol 2021; 17 (02) 279-296
• 40 Fahmy OH, Daas FM, Salunkhe V. et al. Is microthrombosis the main pathology in coronavirus disease 2019 severity?-A systematic review of the postmortem pathologic findings. Crit Care Explor 2021; 3 (05) e0427
• 41 Dolhnikoff M, Duarte-Neto AN, de Almeida Monteiro RA. et al. Pathological evidence of pulmonary thrombotic phenomena in severe COVID-19. J Thromb Haemost 2020; 18 (06) 1517-1519
• 42 Lodigiani C, Iapichino G, Carenzo L. et al.; Humanitas COVID-19 Task Force. Venous and arterial thromboembolic complications in COVID-19 patients admitted to an academic hospital in Milan, Italy. Thromb Res 2020; 191: 9-14
• 43 Poli D, Antonucci E, Ageno W. et al. Thromboembolic complications in COVID-19 patients hospitalized in Italian ordinary wards: Data from the multicenter observational START-COVID register. TH Open 2022; 6 (03) e251-e256
• 44 Klok FA, Kruip MJHA, van der Meer NJM. et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res 2020; 191: 145-147
• 45 Boonyawat K, Chantrathammachart P, Numthavaj P. et al. Incidence of thromboembolism in patients with COVID-19: A systematic review and meta-analysis. Thromb J 2020; 18 (01) 34
• 46 Sakr Y, Giovini M, Leone M. et al. Pulmonary embolism in patients with coronavirus disease-2019 (COVID-19) pneumonia: A narrative review. Ann Intensive Care 2020; 10: 124
• 47 Demelo-Rodriguez P, Alonso-Beato R, Jara-Palomares L. et al.; RIETE Investigators. COVID-19-associated venous thromboembolism: risk of recurrence and major bleeding. Res Pract Thromb Haemost 2023; 7 (07) 102206
• 48 Spyropoulos AC, Goldin M, Giannis D. et al.; HEP-COVID Investigators. HEP-COVID Investigators. Efficacy and safety of therapeutic-dose heparin vs standard prophylactic or intermediate-dose heparins for thromboprophylaxis in high-risk hospitalized patients with COVID-19: The HEP-COVID randomized clinical trial. JAMA Intern Med 2021; 181 (12) 1612-1620
• 49 Lawler PR, Goligher EC, Berger JS. et al.; ATTACC Investigators, ACTIV-4a Investigators, REMAP-CAP Investigators. Therapeutic anticoagulation with heparin in noncritically ill patients with Covid-19. N Engl J Med 2021; 385 (09) 790-802
• 50 Goligher EC, Lawler PR, Jensen TP. et al.; REMAP-CAP, ATTACC, and ACTIV-4a Investigators. Heterogeneous treatment effects of therapeutic-dose heparin in patients hospitalized for COVID-19. JAMA 2023; 329 (13) 1066-1077
• 51 Goligher EC, Bradbury CA, McVerry BJ. et al.; REMAP-CAP Investigators, ACTIV-4a Investigators, ATTACC Investigators. Therapeutic anticoagulation with heparin in critically ill patients with Covid-19. N Engl J Med 2021; 385 (09) 777-789
• 52 McQuilten ZK, Venkatesh B, Jha V. et al. Anticoagulation strategies in non-critically ill patients with Covid-19. NEJM Evid 2023; 2 (02) a2200293
• 53 Godoy LC, Neal MD, Goligher EC. et al. Heparin dose intensity and organ support-free days in patients hospitalized for COVID-19. JACC Adv 2024; 3 (03) 100780
• 54 Pilia E, Belletti A, Fresilli S, Finco G, Landoni G. Efficacy and safety of heparin full-dose anticoagulation in hospitalized non-critically ill COVID-19 patients: A meta-analysis of multicenter randomized controlled trials. J Thromb Thrombolysis 2022; 54 (03) 420-430
• 55 Bonfim LCMG, Guerini IS, Zambon MG. et al. Optimal dosing of heparin for prophylactic anticoagulation in critically ill COVID-19 patients: A systematic review and meta-analysis of randomized controlled trials. J Crit Care 2023; 77: 154344
• 56 Ena J, Valls V. Therapeutic-dose anticoagulation or thromboprophylaxis with low-molecular-weight heparin for moderate Covid-19: Meta-analysis of randomized controlled trials. Clin Exp Med 2023; 23 (04) 1189-1196
• 57 Ortega-Paz L, Galli M, Capodanno D. et al. Safety and efficacy of different prophylactic anticoagulation dosing regimens in critically and non-critically ill patients with COVID-19: a systematic review and meta-analysis of randomized controlled trials. Eur Heart J Cardiovasc Pharmacother 2022; 8 (07) 677-686
• 58 Meng J, Tang H, Xiao Y. et al. Appropriate thromboprophylaxis strategy for COVID-19 patients on dosage, antiplatelet therapy, outpatient, and postdischarge prophylaxis: A meta-analysis of randomized controlled trials. Int J Surg 2024; 110 (06) 3910-3922
• 59 World Health Organization. COVID-19 clinical management: living guidance. August 18, 2023. Accessed February 20, 2025 at: https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2023.2
• 60 Coronavirus Disease 2019 (COVID-19) Treatment Guidelines Panel. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. National Institutes of Health; 2021. Accessed February 20, 2025 at: https://www.covid19treatmentguidelines.nih.gov/
• 61 Moores LK, Tritschler T, Brosnahan S. et al. Prevention, diagnosis, and treatment of VTE in patients with coronavirus disease 2019: CHEST guideline and expert panel report. Chest 2020; 158 (03) 1143-1163
• 62 Moores LK, Tritschler T, Brosnahan S. et al. Thromboprophylaxis in patients with COVID-19: A brief update to the CHEST Guideline and Expert Panel Report. Chest 2022; 162 (01) 213-225
• 63 Barnes GD, Burnett A, Allen A. et al. Thromboembolic prevention and anticoagulant therapy during the COVID-19 pandemic: Updated clinical guidance from the anticoagulation forum. J Thromb Thrombolysis 2022; 54 (02) 197-210
• 64 Schulman S, Arnold DM, Bradbury CA. et al.; International Society on Thrombosis and Haemostasis. 2023 ISTH update of the 2022 ISTH guidelines for antithrombotic treatment in COVID-19. J Thromb Haemost 2024; 22 (06) 1779-1797
• 65 Siegal DM, Tseng EK, Schünemann HJ. et al. ASH living guidelines on use of anticoagulation for thromboprophylaxis in patients with COVID-19: executive summary. Blood Adv 2025; 9 (06) 1247-1260
• 66 Wahid L, Ortel TL. Anticoagulant therapy in patients hospitalized with COVID-19. JAMA Intern Med 2021; 181 (12) 1621-1622
• 67 Berg DD. Therapeutic-dose anticoagulation in hospitalized patients with COVID-19: Are we getting closer to the truth?. JACC Adv 2024; 3 (03) 100779
• 68 Chen X, Zhang S, Liu H. et al. Effect of anticoagulation on the incidence of venous thromboembolism, major bleeding, and mortality among hospitalized COVID-19 patients: an updated meta-analysis. Front Cardiovasc Med 2024; 11: 1381408
• 69 Reis S, Faske A, Monsef I. et al. Anticoagulation in COVID-19 patients - An updated systematic review and meta-analysis. Thromb Res 2024; 238: 141-150
• 70 Obeagu EI, Tukur M, Akaba K. Impacts of COVID-19 on hemostasis: coagulation abnormalities and management perspectives. Ann Med Surg (Lond) 2024; 86 (10) 5844-5850
• 71 Vaughn VM, Yost M, Abshire C. et al. Trends in venous thromboembolism anticoagulation in patients hospitalized with COVID-19. JAMA Netw Open 2021; 4 (06) e2111788
• 72 Kovács EH, Tánczos K, Szabó L. et al. Higher dose anticoagulation cannot prevent disease progression in COVID-19 patients: a systematic review and meta-analysis. Biomedicines 2022; 10 (09) 2194
• 73 Flumignan RL, Civile VT, Tinôco JDS. et al. Anticoagulants for people hospitalised with COVID-19. Cochrane Database Syst Rev 2022; 3 (03) CD013739
• 74 Santos BC, Flumignan RL, Civile VT, Atallah ÁN, Nakano LC. Prophylactic anticoagulants for non-hospitalised people with COVID-19. Cochrane Database Syst Rev 2023; 8 (08) CD015102
• 75 Tian Y, Pan T, Wen X. et al. Efficacy and safety of direct oral anticoagulants compared with heparin for preventing thromboembolism in hospitalized patients with COVID-19: a systematic review and meta-analysis. Clin Appl Thromb Hemost 2023; 29: 10 760296231164355
• 76 Potpara T, Angiolillo DJ, Bikdeli B. et al. Antithrombotic therapy in arterial thrombosis and thromboembolism in COVID-19: An American College of Chest Physicians Expert Panel Report. Chest 2023; 164 (06) 1531-1550
• 77 Sahu KK, Borogovac A, Cerny J. COVID-19 related immune hemolysis and thrombocytopenia. J Med Virol 2021; 93 (02) 1164-1170
• 78 Alonso-Beato R, Morales-Ortega A, Fernández FJH. et al. Immune thrombocytopenia and COVID-19: Case report and review of literature. Lupus 2021; 30 (09) 1515-1521
• 79 Kewan T, Gunaratne TN, Mushtaq K, Alayan D, Daw H, Haddad A. Outcomes and management of immune thrombocytopenia secondary to COVID-19: Cleveland clinic experience. Transfusion 2021; 61 (07) 2014-2018
• 80 Bahadoram M, Saeedi-Boroujeni A, Mahmoudian-Sani MR, Hussaini H, Hassanzadeh S. COVID-19-induced immune thrombocytopenic purpura; Immunopathogenesis and clinical implications. Infez Med 2022; 30 (01) 41-50
• 81 Alharbi MG, Alanazi N, Yousef A. et al. COVID-19 associated with immune thrombocytopenia: a systematic review and meta-analysis. Expert Rev Hematol 2022; 15 (02) 157-166
• 82 Yazdani AN, Abdi A, Velpuri P. et al. A review of hematological complications and treatment in COVID-19. Hematol Rep 2023; 15 (04) 562-577
• 83 Zhang Y, Zeng X, Jiao Y. et al. Mechanisms involved in the development of thrombocytopenia in patients with COVID-19. Thromb Res 2020; 193: 110-115
• 84 Yazdanpanah N, Rezaei N. Autoimmune complications of COVID-19. J Med Virol 2022; 94 (01) 54-62
• 85 Franchini M, Marano G, Cruciani M. et al. Advances in managing rare acquired bleeding disorders. Expert Rev Hematol 2020; 13 (06) 599-606
• 86 Coppola A, Franchini M, Tripodi A. et al.; ad hoc Working Group (Appendix 1). Acquired haemophilia A: Italian Consensus Recommendations on diagnosis, general management and treatment of bleeding. Blood Transfus 2022; 20 (03) 245-262
• 87 Franchini M, Glingani C, De Donno G. et al. The first case of acquired hemophilia A associated with SARS-CoV-2 infection. Am J Hematol 2020; 95 (08) E197-E198
• 88 Franchini M, Focosi D. Association between SARS-CoV-2 infection or vaccination and acquired hemophilia A: A case report and literature update. Thromb Res 2023; 222: 7-11
• 89 Németh M, Mühl D, Csontos C, Nagy Á, Alizadeh H, Szakács Z. Acquired hemophilia A after SARS-CoV-2 infection: A case report and an updated systematic review. Biomedicines 2023; 11 (09) 2400
• 90 Gelbenegger G, Traby L, Rahimi N, Knöbl P. Management of acquired haemophilia A in severe Covid-19: Haemostatic bridging with emicizumab to keep the balance between bleeding and thrombosis. Br J Clin Pharmacol 2023; 89 (02) 908-913
• 91 Ianuà E, Caldarelli M, De Matteis G, Cianci R, Gambassi G. Hematological complications in a COVID-19 patient: A case report. Diseases 2023; 12 (01) 5
• 92 Hafzah H, McGuire C, Hamad A. A case of acquired hemophilia A following SARS-CoV-2 infection. Cureus 2021; 13 (07) e16579
• 93 Jamal M, Bangash HI, Habiba M. et al. Immune dysregulation and system pathology in COVID-19. Virulence 2021; 12 (01) 918-936
• 94 Franchini M, Focosi D. Innovative therapies for acquired hemophilia A. Semin Thromb Hemost 2025; 51 (01) 68-72