Table 6.
Summary of Consensus Recommendation on Antithrombotic Therapy During the COVID-19 Pandemic
| Patients with mild COVID-19 (outpatient) |
| For outpatients with mild COVID-19, increased mobility should be encouraged. Although indiscriminate use of pharmacological VTE prophylaxis should not be pursued, assessment for the risk of VTE and of bleeding is reasonable. Pharmacologic prophylaxis could be considered after risk assessment on an individual case basis for patients who have elevated risk VTE, without high bleeding risk.∗ |
| There is no known risk of developing severe COVD-19 due to taking antithrombotic agents (i.e., antiplatelet agents or anticoagulants). If patients have been taking antithrombotic agents for prior known thrombotic disease, they should continue their antithrombotic agents as recommended. |
| For outpatients on vitamin K antagonists who do not have recent stable INRs, and are unable to undergo home or drive-through INR testing, it is reasonable to transition the treatment DOACs if there are no contraindications and no problems with drug availability and affordability. If DOACs are not approved or available, LMWH can be considered as alternative.∗ |
| Patients with moderate or severe COVID-19 without DIC (hospitalized) |
| Hospitalized patients with COVID-19 should undergo risk stratification for VTE prophylaxis. |
| For hospitalized patients with COVID-19 and not in DIC, prophylactic doses of anticoagulation should be administered to prevent VTE.∗†‡ If pharmacological prophylaxis is contraindicated, it is reasonable to consider intermittent pneumatic compression. |
| For hospitalized patients with COVID-19 and not in DIC, there are insufficient data to consider routine therapeutic or intermediate-dose parenteral anticoagulation with UFH or LMWH.∗§ |
| Routine screening for VTE (e.g., bilateral lower extremity ultrasound) for hospitalized patients with COVID-19 with elevated D-dimer (>1,500 ng/ml) cannot be recommended at this point.|| |
| Patients with moderate or severe COVID-19 and suspected or confirmed DIC (hospitalized) |
| For patients with moderate or severe COVID-19 and in DIC but without overt bleeding, prophylactic anticoagulation should be administered.∗†¶ |
| For hospitalized patients with COVID-19 with suspected or confirmed DIC, but no overt bleeding, there are insufficient data to consider routine therapeutic or intermediate-dose parenteral anticoagulation with UFH or LMWH.∗ |
| For patients with moderate or severe COVID-19 on chronic therapeutic anticoagulation, who develop suspected or confirmed DIC without overt bleeding, it is reasonable to consider the indication for anticoagulation and weigh with risk of bleeding when making clinical decisions regarding dose adjustments or discontinuation. The majority of authors of this paper recommended reducing the intensity of anticoagulation in this clinical circumstance, unless the risk of thrombosis is considered to be exceedingly high.# |
| For patients with moderate or severe COVID-19 and an indication for dual antiplatelet therapy (e.g., percutaneous coronary intervention within the past 3 months or recent myocardial infarction) and with suspected or confirmed DIC without overt bleeding, in the absence of evidence, decisions for antiplatelet therapy need to be individualized. In general, it is reasonable to continue dual antiplatelet therapy if platelet count is >50,000, reduce to single antiplatelet therapy if platelet count is >25,000 and <50,000, and discontinue if platelet count is <25,000. However, these guidelines may be revised upward or downward depending on the individualized relative risk of thrombotic complications vs. bleeding. |
| For patients who were admitted and are now being discharged for COVID-19, routine screening for VTE risk is reasonable for consideration of pharmacological prophylaxis for up to 45 days post-discharge. Pharmacological prophylaxis should be considered if there is elevated risk for thrombotic events, without high bleeding risk.∗∗ Ambulation and physical activity should be encouraged. |
| Patients with COVID-19 presenting with ACS |
| For presentations concerning for STEMI and COVID-19, clinicians should weigh the risks and severity of STEMI presentation with that of potential COVID-19 severity in the patient, as well as risk of COVID-19 to the individual clinicians and to the health care system at large. Decisions for primary percutaneous coronary intervention or fibrinolytic therapy should be informed by this assessment.∗ |
| Patients without COVID-19 who have previously known thrombotic disease |
| There is no known risk of developing severe COVD-19 due to taking antithrombotic agents. Patients should continue their antithrombotic agents as recommended. |
| To minimize risks associated with health care worker and patient in-person interactions, follow-up with e-visits and telemedicine is preferable in most cases. |
| Patients without COVID-19 who develop new thrombotic disease |
| To minimize risks associated with health care worker and patient in-person interactions, in-home treatment or early discharge should be prioritized. |
| To minimize risks associated with health care worker and patient in-person interactions, follow-up with e-visits and telemedicine is preferable in most cases. |
| Patients without COVID-19 but with comorbid conditions (e.g., prior VTE, active cancer, major cardiopulmonary disease), who are homebound during the pandemic |
| Recommendations include increased mobility, and risk assessment for the risk of VTE and risk of bleeding is reasonable. Administration of pharmacologic prophylaxis could be considered after risk assessment on an individual case basis for patients who have elevated risk for thrombotic events, without high bleeding risk. |
DOAC = direct oral anticoagulant; INR = international normalized ratio; other abbreviations as in Tables 1 and 5.
Indicates recommendations as reached by consensus of at least 66% of authors determined via the Delphi method.
Although high-quality data are lacking, some panel members (55%) considered it reasonable to use intermittent pneumatic compression in patients with severe COVID-19, in addition to pharmacological prophylaxis. Specific areas of concern included limited data on use in the prone position as well as potential high incidence of pre-existing asymptomatic DVT.
If VTE prophylaxis is considered, enoxaparin 40 mg daily or similar LMWH regimen (e.g., dalteparin 5,000 U daily) can be administered. Subcutaneous heparin (5,000 U twice to 3 times daily) can be considered for patients with renal dysfunction (i.e., creatinine clearance <30 ml/min).
Although the majority of the writing group did make this recommendation, 31.6% of the group were in favor of intermediate-dose anticoagulation (e.g., enoxaparin 1 mg/kg/day, or enoxaparin 40 mg twice daily, or UFH with target aPTT of 50–70 s) and 5.2% considered therapeutic anticoagulation.
The majority of the investigators recommended against routine VTE screening (68%); however, the remaining members of the group (32%) recommended to consider such testing.
The majority of the investigators recommended prophylactic anticoagulation (54%). A minority of investigators (29.7%) voted for intermediate-dose parenteral anticoagulation in this setting, and 16.2% considered therapeutic anticoagulation.
Although the majority of investigators voted to reduce the intensity of anticoagulation if the indication were not acute (62%), this survey question did not meet the prespecified cutoff of 66%.
The majority of the writing group recommended prophylaxis with DOACs (51%) and a minority (24%) recommended LMWH, if available and appropriate.