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Key Clinical Updates in Primary VTE Prevention & Treatment in Severe COVID-19

Therapeutic dosing of anticoagulation may benefit some patients who are hospitalized in the acute care setting with COVID-19, who have very elevated D-dimer values and require supplemental oxygen, and who have low bleeding risk.

Patients who are critically ill in ICUs have not been shown to benefit from therapeutic dosing.

There is no clear benefit from VTE prophylaxis for patients with COVID-19 who do not require hospitalization.

ATTACC Investigators; ACTIV-4a Investigators; REMAP-CAP Investigators; Lawler PR et al. N Engl J Med. [PMID: 34351721]

REMAP-CAP Investigators; ACTIV-4a Investigators; ATTACC Investigators; Goligher EC et al. N Engl J Med. [PMID: 34351722]

Spyropoulos AC. JAMA Intern Med. [PMID: 34617959]

Patients hospitalized with severe COVID-19 have an increased incidence of thrombotic complications, including venous (DVT, PE) and arterial (stroke, limb occlusion) events. Although the reasons for this hypercoagulability are not yet well understood, the profound systemic inflammatory response associated with severe COVID-19 is thought to play a role.

CLINICAL FINDINGS

While the hypercoagulability in COVID-19 resembles DIC, laboratory and clinical findings are somewhat different. Laboratory findings in patients with severe COVID-19 may include markedly elevated D-dimer and modestly prolonged prothrombin time. However, patients with COVID-19 tend to have elevated fibrinogen levels; thrombocytopenia is rare and nonsevere; and bleeding complications are unusual. Thrombosis in patients with COVID-19 is associated with a poor prognosis and often occurs despite standard pharmacologic prophylaxis.

RISK STRATIFICATION & INITIAL PROGNOSTICATION IN SEVERE COVID-19

Given the prevalence and prognostic value of abnormal laboratory findings at presentation, patients hospitalized with COVID-19 should have PT/INR, PTT, D-dimers, and fibrinogen measured at presentation. Serial monitoring should be considered even in patients who are otherwise clinically stable. Worsening laboratory parameters during hospitalization should prompt consideration of transfer to a higher level of care and heightened clinical suspicion for thrombosis.

VTE PROPHYLAXIS FOR SEVERE COVID-19

In the absence of strong contraindications, all patients hospitalized with COVID-19 should receive pharmacologic VTE prophylaxis. LMWH is preferred over unfractionated heparin to minimize staff exposure and the chance of HIT.

For patients with a prior history of VTE who take an oral anticoagulant for secondary prevention at the time of admission, transition to LMWH should be considered due to its shorter half-life and potential anti-inflammatory properties.

Some patients who are hospitalized in the acute care setting with COVID-19, who have very elevated D-dimer values (over 4 times the upper limit of normal) and require supplemental oxygen, and who have low bleeding risk, may benefit from therapeutic dosing of anticoagulation. Patients who are critically ill in ICUs have not been shown to benefit from therapeutic dosing. At this time, there is also no clear benefit from VTE prophylaxis for patients with COVID-19 who do not require hospitalization. ...

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