Thrombotic and hemorrhagic complications of COVID-19 for adults hospitalized in high-income countries compared to low- and middle-income countries in an international registry

Background: COVID-19 has been associated with a broad range of thromboembolic, ischemic, and hemorrhagic complications (coagulopathy complications). Most studies have focused on patients with severe disease from high-income countries (HIC). Objectives: The main aims were to compare the frequency of coagulopathy complications in developing countries (low- and middle-income countries (LMIC)) with those in HICs, to delineate the frequency across a range of treatment levels, and to determine associations with in-hospital mortality. Patients/Methods: Adult patients enrolled in an observational, multinational registry, the International Severe Acute Respiratory and Emerging Infections COVID-19 study, between January 1, 2020 and September 15, 2021 met inclusion criteria, including admission to the hospital for lab-confirmed, acute COVID-19 and data on complications and survival. The advanced treatment cohort received care such as admission to intensive care, mechanical ventilation, or inotropes or vasopressors- the basic treatment cohort did not receive any of these interventions. Results: The study population was 495,682 patients from 55 countries- 63% from LMIC; 85% were in the basic treatment cohort. The frequency of coagulopathy complications was higher in HICs (0.76-3.4%) than in LMICs (0.09-1.22%). Complications were more frequent in the advanced treatment cohort compared to the basic treatment cohort. Coagulopathy complications were associated with increased inhospital mortality (OR 1.58, 95% CI 1.52-1.64). The increased mortality associated with these complications was higher in LMICs (58.5%) than in HICs (35.4%). After controlling for coagulopathy complications, treatment intensity, and multiple other factors, mortality was higher for patients in LMICs than for patients in HICs (OR 1.45, 95% CI 1.39-1.51). Conclusions: In a large, international registry of patients hospitalized with COVID-19, coagulopathy complications were more frequent in HICs than in LMICs (developing countries). Increased mortality associated with coagulopathy complications was of greater magnitude for patients in LMICs. Additional research is needed regarding timely diagnosis and intervention for coagulation derangements associated with COVID-19, particularly for limited resource settings.