COVID-19; Practice guideline; anticoagulants; thrombosis; Anticoagulants; Humans; Anticoagulants/therapeutic use; Belgium/epidemiology; COVID-19/complications; Venous Thromboembolism/drug therapy; Thrombosis/complications; Thrombosis/drug therapy; Thrombosis/prevention & control; Belgium; Venous Thromboembolism; Medicine (all); General Medicine
Abstract :
[en] COVID-19 is associated with an increased risk for thrombotic complications. The trials investigating the optimal thromboprophylactic dose are performed in challenging times and seemingly produce conflicting evidence. The burdensome circumstances, divergent endpoints, and different analytical approaches hamper comparison and extrapolation of available evidence. Most importantly, clinicians should provide thromboprophylaxis in hospitalized COVID-19 patients while (re)assessing bleeding and thrombotic risk frequently. The COVID-19 Thromboprophylaxis Working Group of the BSTH updated its guidance document. It aims to summarize the available evidence critically and to guide clinicians in providing the best possible thromboprophylaxis.
Disciplines :
Cardiovascular & respiratory systems
Author, co-author :
Vanassche, Thomas ; Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
Engelen, Matthias M ; Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
Orlando, Christelle ; Department of Haematology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel, Brussels, Belgium
Vandenbosch, Kristel ; Centre Hospitalier Universitaire de Liège - CHU > > Service d'hématologie biologique et immuno-hématologie
Gadisseur, Alain; Department of Haematology, Antwerp University Hospital, Antwerp, Belgium
Hermans, Cedric; Department of Haematology, Brussels, Belgium
Jochmans, Kristin; Department of Haematology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel, Brussels, Belgium
Minon, Jean-Marc; Department of Laboratory Medicine, Thrombosis-Haemostasis and Transfusion Unit, CHR Citadelle, Liege, Belgium
Motte, Serge; Department of Vascular Diseases, Erasme University Hospital, Brussels, Belgium
Peperstraete, Harlinde; Department of Cardiac Intensive Care, Ghent University Hospital, Ghent, Belgium
Peters, Pierre ; Centre Hospitalier Universitaire de Liège - CHU > > Service d'hématologie biologique et immuno-hématologie
Sprynger, Muriel ; Centre Hospitalier Universitaire de Liège - CHU > > Service de cardiologie
Lancellotti, Patrizio ; Centre Hospitalier Universitaire de Liège - CHU > > Service de cardiologie
Dehaene, Isabelle ; Vlaamse Vereniging Voor Obstetrie En Gynaecologie, Universitair Ziekenhuis Gent, Ghent, Belgium
Emonts, Patrick ; Centre Hospitalier Universitaire de Liège - CHU > > Service de gynécologie-obstétrique (CHR)
Vandenbriele, Christophe ; Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
Verhamme, Peter ; Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
Connors JM, Levy JH. COVID-19 and its implications for thrombosis and anticoagulation. Blood. 2020; 135 (23): 2033–2040. doi: 10.1182/blood.2020006000
Fauvel C, Weizman O, Trimaille A, et al. Pulmonary embolism in COVID-19 patients: a French multicentre cohort study. Eur Heart J. 2020; 41 (32): 3058–3068. doi: 10.1093/eurheartj/ehaa500
Klok FA, Kruip MJHA, van der Meer NJM, et al. Confirmation of the high cumulative incidence of thrombotic complications in critically ill ICU patients with COVID-19: an updated analysis. Thromb Res. 2020; 191: 148–150. doi: 10.1016/j.thromres.2020.04.041
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. doi: 10.1016/j.thromres.2020.04.013
Longchamp A, Longchamp J, Manzocchi-Besson S, et al. Venous thromboembolism in critically Ill patients with COVID-19: results of a screening study for deep vein thrombosis. Res Pract Thromb Haemost. 2020; 4 (5): 842–847. doi: 10.1002/rth2.12376
Middeldorp S, Coppens M, van Haaps TF, et al. Incidence of venous thromboembolism in hospitalized patients with COVID-19. J Thromb Haemost. 2020; 18 (8): 1995–2002. doi: 10.1111/jth.14888
Moll M, Zon RL, Sylvester KW, et al. VTE in ICU patients with COVID-19. Chest. 2020; 158 (5): 2130–2135. doi: 10.1016/j.chest.2020.07.031
Stessel B, Vanvuchelen C, Bruckers L, et al. Impact of implementation of an individualised thromboprophylaxis protocol in critically ill ICU patients with COVID-19: A longitudinal controlled before-after study. Thromb Res. 2020; 194: 209–215. doi: 10.1016/j.thromres.2020.07.038
Bourguignon A, Beaulieu C, Belkaid W, et al. Incidence of thrombotic outcomes for patients hospitalized and discharged after COVID-19 infection. Thromb Res. 2020; 196: 491–493. doi: 10.1016/j.thromres.2020.10.017
Kaptein FHJ, Stals MAM, Grootenboers M, et al. Incidence of thrombotic complications and overall survival in hospitalized patients with COVID-19 in the second and first wave. Thromb Res. 2020; 199: 143–148. doi: 10.1016/j.thromres.2020.12.019
Schulman S, Hu Y, Konstantinides S. Venous Thromboembolism in COVID-19. Thromb Haemost. 2020; 120 (12): 1642–1653. doi: 10.1055/s-0040-1718532
Tang N, Li D, Wang X, et al. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. J Thromb Haemost. 2020; 18 (4): 844–847. doi: 10.1111/jth.14768
Waite AAC, Hamilton DO, Pizzi R, et al. Hypercoagulopathy in severe COVID-19: implications for acute care. Thromb Haemost. 2020 Dec; 120 (12): 1654–1667.
Tang N, Bai H, Chen X, et al. Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy. J Thromb Haemost. 2020; 18 (5): 1094–1099. doi: 10.1111/jth.14817
Bilaloglu S, Aphinyanaphongs Y, Jones S, et al. Thrombosis in hospitalized patients with COVID-19 in a New York City health system in a New York City health system. JAMA. 2020 Aug25; 324 (8): 799–801. doi: 10.1001/jama.2020.13372
Di Castelnuovo AF, Costanzo S, Iacoviello L. Heparin in COVID-19 patients is associated with reduced in-hospital mortality: the multicentre Italian CORIST study. Thromb Haemost. 2021 Jan7; 121 (08): 1054–1065. doi: 10.1055/a-1347-6070
Billett HH, Reyes-Gil M, Szymanski J, et al. Anticoagulation in COVID-19: effect of enoxaparin, heparin, and apixaban on mortality. Thromb Haemost. 2020 Dec; 120 (12): 1691–1699.
Vanassche T, Orlando C, Vandenbosch K, et al. Belgian clinical guidance on anticoagulation management in hospitalised and ambulatory patients with COVID-19. Acta Clin Belg. 2020 Oct; 3: 1–6.
Connors JM, Brooks MM, Sciurba FC, et al. Effect of antithrombotic therapy on clinical outcomes in outpatients with clinically stable symptomatic COVID-19: the ACTIV-4B randomized clinical trial. JAMA. 2021 Nov2; 326 (17): 1703–1712. doi: 10.1001/jama.2021.17272
Barco S, Voci D, Held U, et al. Enoxaparin for primary thromboprophylaxis in symptomatic outpatients with COVID-19 (OVID): a randomised, open-label, parallel-group, multicentre, phase 3 trial. Lancet Haematol. 2022; 9 (8): e585–e593. doi: 10.1016/S2352-3026(22)00175-2
Cools F, Virdone S, Sawhney J, et al. Thromboprophylactic low-molecular-weight heparin versus standard of care in unvaccinated, at-risk outpatients with COVID-19 (ETHIC): an open-label, multicentre, randomised, controlled, phase 3b trial. Lancet Haematol. 2022; 9 (8): e594–e604. doi: 10.1016/S2352-3026(22)00173-9
Battistoni I, Francioni M, Morici N, et al. Pre- and in-hospital anticoagulation therapy in coronavirus disease 2019 patients: a propensity-matched analysis of in-hospital outcomes. J Cardiovasc Med (Hagerstown). 2022 Apr1; 23 (4): 264–271. doi: 10.2459/JCM.0000000000001284
Cohen SL, Gianos E, Barish MA, et al. Prevalence and predictors of venous thromboembolism or mortality in hospitalized COVID-19 patients. Thromb Haemost. 2021 Aug; 121 (8): 1043–1053.
Di Castelnuovo A, Costanzo S, Antinori A, et al. Heparin in COVID-19 patients is associated with reduced in-hospital mortality: the multicenter Italian CORIST study. Thromb Haemost. 2021 Aug; 121 (8): 1054–1065.
Ionescu F, Jaiyesimi I, Petrescu I, et al. Association of anticoagulation dose and survival in hospitalized COVID-19 patients: a retrospective propensity score-weighted analysis. Eur J Haematol. 2021 Feb; 106 (2): 165–174.
Pereyra D, Heber S, Schrottmaier WC, et al. Low-molecular-weight heparin use in coronavirus disease 2019 is associated with curtailed viral persistence: a retrospective multicentre observational study. Cardiovasc Res. 2021 Dec17; 117 (14): 2807–2820. doi: 10.1093/cvr/cvab308
Poli D, Antonucci E, Ageno W, et al. Low in-hospital mortality rate in patients with COVID-19 receiving thromboprophylaxis: data from the multicentre observational START-COVID register. Intern Emerg Med. 2022 Jun; 17 (4): 1013–1021.
Rentsch CT, Beckman JA, Tomlinson L, et al. Early initiation of prophylactic anticoagulation for prevention of coronavirus disease 2019 mortality in patients admitted to hospital in the United States: cohort study. BMJ. 2021 Feb11; 372: n311. doi: 10.1136/bmj.n311
Shen L, Qiu L, Liu D, et al. The association of low molecular weight heparin use and in-hospital mortality among patients hospitalized with COVID-19. Cardiovasc Drugs Ther. 2022 Feb; 36 (1): 113–120.
Gonzalez-Porras JR, Belhassen-Garcia M, Lopez-Bernus A, et al. Low molecular weight heparin is useful in adult COVID-19 inpatients. Experience during the first Spanish wave: observational study. Sao Paulo Med J. 2022 Jan-Feb; 140 (1): 123–133.
Meizlish ML, Goshua G, Liu Y, et al. Intermediate-dose anticoagulation, aspirin, and in-hospital mortality in COVID-19: A propensity score-matched analysis. Am J Hematol. 2021 Apr1; 96 (4): 471–479. doi: 10.1002/ajh.26102
Smadja DM, Bonnet G, Gendron N, et al. Intermediate- vs. standard-dose prophylactic anticoagulation in patients with COVID-19 admitted in medical ward: a propensity score-matched cohort study. Front Med. 2021; 8: 747527. doi: 10.3389/fmed.2021.747527
Engelen MM, Vandenbriele C, Spalart V, et al. Thromboprophylaxis in COVID-19: weight and severity adjusted intensified dosing. Res Pract Thromb Haemost. 2022; 6 (3): e12683. doi: 10.1002/rth2.12683
Sholzberg M, Tang GH, Rahhal H, et al. Effectiveness of therapeutic heparin versus prophylactic heparin on death, mechanical ventilation, or intensive care unit admission in moderately ill patients with COVID-19 admitted to hospital: RAPID randomised clinical trial. BMJ. 2021 Oct14; 375: n2400. doi: 10.1136/bmj.n2400
Spyropoulos AC, Goldin M, Giannis D, et al. 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 Dec1; 181 (12): 1612–1620. doi: 10.1001/jamainternmed.2021.6203
Lawler PR, Goligher EC, Berger JS, et al. Therapeutic anticoagulation with heparin in noncritically Ill patients with covid-19. N Engl J Med. 2021 Aug26; 385 (9): 790–802.
Sholzberg M, da Costa BR, Tang GH, et al. Randomized trials of therapeutic heparin for COVID-19: A meta-analysis. Res Pract Thromb Haemost. 2021; 5 (8): e12638.
Morici N, Podda G, Birocchi S, et al. Enoxaparin for thromboprophylaxis in hospitalized COVID-19 patients: the X-COVID-19 randomized trial. Eur J Clin Invest. 2022 May; 52 (5): e13735.
Samama MM, Cohen AT, Darmon JY, et al. A comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients. Prophylaxis in Medical Patients with Enoxaparin Study Group. N Engl J Med. 1999 Sep9; 341 (11): 793–800. doi: 10.1056/NEJM199909093411103
Leizorovicz A, Cohen AT, Turpie AG, et al. Randomized, placebo-controlled trial of dalteparin for the prevention of venous thromboembolism in acutely ill medical patients. Circulation. 2004 Aug17; 110 (7): 874–879. doi: 10.1161/01.CIR.0000138928.83266.24
Goligher EC, Bradbury CA, McVerry BJ, et al. Therapeutic anticoagulation with heparin in critically Ill patients with covid-19. N Engl J Med. 2021 Aug26; 385 (9): 777–789.
Bohula EA, Berg DD, Lopes MS, et al. Anticoagulation and antiplatelet therapy for prevention of venous and arterial thrombotic events in critically Ill patients with COVID-19: COVID-PACT. Circulation. 2022 Aug29; 146 (18): 1344–1356. doi: 10.1161/CIRCULATIONAHA.122.061533
Bikdeli B, Talasaz AH, Rashidi F, et al. Intermediate-dose versus standard-dose prophylactic anticoagulation in patients with COVID-19 admitted to the intensive care unit: 90-day results from the INSPIRATION randomized trial. Thromb Haemost. 2022 Jan; 122 (1): 131–141.
Sadeghipour P, Talasaz AH, Rashidi F, et al. Effect of intermediate-dose vs standard-dose prophylactic anticoagulation on thrombotic events, extracorporeal membrane oxygenation treatment, or mortality among patients with COVID-19 admitted to the intensive care unit: the INSPIRATION randomized clinical trial. JAMA. 2021 Apr27; 325 (16): 1620–1630. doi: 10.1001/jama.2021.4152
Perepu US, Chambers I, Wahab A, et al. Standard prophylactic versus intermediate dose enoxaparin in adults with severe COVID-19: A multi-center, open-label, randomized controlled trial. J Thromb Haemost. 2021 Sep; 19 (9): 2225–2234.
Spyropoulos AC, Ageno W, Albers GW, et al. Post-discharge prophylaxis with rivaroxaban reduces fatal and major thromboembolic events in medically Ill patients. J Am Coll Cardiol. 2020 Jun30; 75 (25): 3140–3147. doi: 10.1016/j.jacc.2020.04.071
Ramacciotti E, Barile Agati L, Calderaro D, et al. Rivaroxaban versus no anticoagulation for post-discharge thromboprophylaxis after hospitalisation for COVID-19 (MICHELLE): an open-label, multicentre, randomised, controlled trial. Lancet. 2022 Jan1; 399 (10319): 50–59. doi: 10.1016/S0140-6736(21)02392-8
Giannis D, Allen SL, Tsang J, et al. Postdischarge thromboembolic outcomes and mortality of hospitalized patients with COVID-19: the CORE-19 registry. Blood. 2021 May20; 137 (20): 2838–2847. doi: 10.1182/blood.2020010529
Engelen MM, Vandenbriele C, Balthazar T, et al. Venous thromboembolism in patients discharged after COVID-19 hospitalization. Semin Thromb Hemost. 2021 Jun; 47 (4): 362–371.
Cuker A, Tseng EK, Nieuwlaat R, et al. American Society of Hematology living guidelines on the use of anticoagulation for thromboprophylaxis in patients with COVID-19: January 2022 update on the use of therapeutic-intensity anticoagulation in acutely ill patients. Blood Adv. 2022; 6 (17): 4975–4982.
Cuker A, Tseng EK, Schünemann HJ, et al. American Society of Hematology living guidelines on the use of anticoagulation for thromboprophylaxis in patients with COVID-19: March 2022 update on the use of anticoagulation in critically ill patients. Blood Adv. 2022; 6 (17): 4975–4982.
Cuker A, Tseng EK, Nieuwlaat R, et al. American Society of Hematology living guidelines on the use of anticoagulation for thromboprophylaxis in patients with COVID-19: July 2021 update on postdischarge thromboprophylaxis. Blood Adv. 2022; 6 (2): 664–671. doi: 10.1182/bloodadvances.2021005945
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 Jul; 162 (1): 213–225.
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 Sep; 158 (3): 1143–1163.
Schulman S, Sholzberg M, Spyropoulos AC, et al. “ISTH guidelines for antithrombotic treatment in COVID-19”: reply. J Thromb Haemost. 2022; 20 (11): 2710–2711. doi: 10.1111/jth.15854
NICE. COVID-19 rapid guideline: managing COVID-19: National Institutes of Health and Care Excellence (NICE); 2022. Available from: https://www.guidelines.co.uk/infection/nice-managing-covid-19-guideline/455939.article
NIH. Antithrombotic therapy in patients with COVID-19. National Institute of Health (NIH); 2022. Available from: https://www.covid19treatmentguidelines.nih.gov/therapies/antithrombotic-therapy/
WHO. Living guidance for clinical management of COVID-19. World Health Organistation; 2021. Available from: https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-2
Wiegers HMG, Middeldorp S. Contemporary best practice in the management of pulmonary embolism during pregnancy. Ther Adv Respir Dis. 2020; 14: 1753466620914222. doi: 10.1177/1753466620914222
Schutgens RE. DOAC in COVID-19: yes or no? Hemasphere. 2021; 5 (1): e526. doi: 10.1097/HS9.0000000000000526
Testa S, Paoletti O, Giorgi-Pierfranceschi M, et al. Switch from oral anticoagulants to parenteral heparin in SARS-CoV-2 hospitalized patients. Intern Emerg Med. 2020; 15 (5): 751–753.