In this single-center study, the rate of thrombotic
diseases did not increase in the general population as
evidenced by ED admissions during the COVID-19
era, compared to the same period in the previous year.
In addition, there was no significant difference in
the number of venous and arterial thrombotic cases
between the two years.
Our hospital serves a city of approximately 350,000
population. Within one week of the first COVID-19
case in Turkey, patients suspected of COVID-19
infections were diagnosed in the study hospital. The
ED was arranged in accordance with the Republic of Turkey, Ministry of Health guidelines, with suspected
COVID-19 patients examined in an area separate
from the other ED admissions. If a patient carried
the COVID-19, but did not show any infectious or
respiratory symptoms, they would be unaware of their
infection and might have presented with other atypical
symptoms, and such cases would not be initially
suspected of COVID-19. There are reported cases of
COVID-19 presenting with venous thrombotic events
or stroke and subsequently being diagnosed with
COVID-19.[10,11] We believe that such cases would result in more ED admissions for thrombotic events
during the pandemic, but failed to show an increase in
thrombotic events in the ED of the study center.
Most reports of venous or arterial thrombosis
in COVID-19 patients are based on patients with a
severe course of infection and in the intensive care
unit (ICU) setting.[12-15] However, not all thrombotic
events related to COVID-19 were associated with
ICU requirement, and severe arterial or venous
thromboembolism (VTE) were detected in patients
with milder symptoms [5,6,16-18] or even as presenting symptoms.[10,19] It is likely that the risk of thrombosis
is high in severe cases and low in mild or asymptomatic
cases. As the patients with CVS-related admissions
did not present with typical symptoms of COVID-19
and they were not tested for the novel coronavirus, the
number of COVID-19 infections among this patient
group may be undetermined.
There was a drop in the absolute number of total
ER admissions during the COVID-19 era. Selfisolation,
stay-at-home orders by the government,
or fear of contracting the virus at the hospital may
have prevented patients from seeking emergency care.
Despite the drop in total ED admissions, there was an
insignificant increase in the number of CVS-related
admissions. The demographic factors were overall
not different between the two years, except for
chronic renal failure which was less frequent in
2020; therefore, the lack of increase in thrombotic
events cannot be attributed to the differences in
comorbidities. It is possible that patients with more
severe symptomatology opted to seek emergency care
during the pandemic and patients with mild symptoms
of any cause did not admit to the ED. Due to similar
reasons, some minor VTE or ATE may not have
reached the hospital due to fears of leaving the house
or waiting in the hospital. Italy is one of the European
countries with the largest impact of COVID-19 and
the association with thrombosis notwithstanding,
admissions for acute coronary syndrome reduced in
all parts of the country.[20] Likewise, recorded cases
of strokes diminished in a neurological center in Italy
during the March.[21] The prominent explanation in
both cases in Italy and our case is the fear of contact
with the virus, while seeking medical attention for
other causes. It is a point of concern that some patients
with minor thrombotic disease, such as a distal deep
vein thrombosis or a mild new-onset claudication
may wait, until the pandemic recedes to seek medical
attention and their disease may complicate the course
of treatment.
The main limitation of this study is its retrospective
design and insufficient data collection. Another
limitation is that our study was conducted in a single
state hospital serving a city of a relatively small
population. Although the study hospital is the largest
in the city, there could be patients admitted to
smaller distant hospitals and, therefore, not included
in the study. Thus, further studies from larger cities or
multi-center studies are needed to confirm our results.
In conclusion, the rate of thromboembolic events
did not increase in the general population admitted
to the ED during the first 11 weeks of the COVID-
19 pandemic in Rize province of Turkey. However,
further studies from other centers are needed to
determine whether thromboembolic events tend
to increase due to mild or asymptomatic cases of
COVID-19.
Declaration of conflicting interests
The authors declared no conflicts of interest with respect
to the authorship and/or publication of this article.
Funding
The authors received no financial support for the research
and/or authorship of this article.
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