Antithrombotic Therapy in Arterial Thrombosis and Thromboembolism in COVID-19
Publication Date: June 29, 2023
Last Updated: June 30, 2023
Summary of Recommendations
In hospitalized patients with Coronavirus disease 2019 (COVID-19) who have a baseline indication to antiplatelet therapy due to a prior acute coronary syndrome (ACS), we suggest continuing antiplatelet therapy unchanged. (C, U)
Remark: Considerations on switching from ticagrelor or clopidogrel to prasugrel apply on a caseby-case basis if there are concerns for drug-drug interaction
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In hospitalized patients with COVID-19 and confirmed ACS, we recommend dual antiplatelet therapy (DAPT) to reduce the risk of recurrent ACS or death. (S, U)
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In hospitalized patients with COVID-19 and myocardial injury without an ACS, we suggest against the initiation of DAPT. (C, U)
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In hospitalized patients with COVID-19 on DAPT for recent ACS who are receiving prophylacticdose anticoagulant therapy for COVID-19, we suggest continuing DAPT. (C, U)
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In hospitalized patients with COVID-19 on DAPT for recent ACS who are on therapeutic-dose parenteral anticoagulant therapy for COVID-19, we suggest individualized decisions that consider the risk of bleeding regarding continuation of DAPT alongside anticoagulation. (C, U)
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In outpatients with COVID-19 on antiplatelet therapy for a previous stroke, we suggest against the addition of or change to oral or subcutaneous anticoagulation. (C, U)
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In hospitalized non-intensive care unit (ICU) patients with COVID-19 on antiplatelet therapy for a previous stroke, we suggest continuation of the antiplatelet and addition of prophylactic-dose low molecular weight heparin (LMWH). (C, U)
Remark: For carefully selected patients who have an indication for therapeutic-dose anticoagulation with LMWH for COVID-19 and have a favourable thrombotic/bleeding risk profile, continuation of the antiplatelet and addition of therapeutic-dose anticoagulation with LMWH may be considered.
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In hospitalized ICU patients with COVID-19 on antiplatelet therapy for a previous stroke, we suggest continuation of the antiplatelet and addition of prophylactic-dose LMWH. (C, U)
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In hospitalized patients with COVID-19 who present with acute ischemic stroke and have indication for recanalization therapy (intravenous administration of recombinant tissue plasminogen activator [rTPA] or endovascular treatment [EVT]), we suggest treatment with the indicated recanalization therapy. (C, U)
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In hospitalized patients with COVID-19 and an acute stroke or transient ischemic attack (TIA) of no established etiology, we suggest treatment with antiplatelet therapy as per current recommendations for non-COVID-19 patients. (C, U)
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In hospitalized non-ICU patients with COVID-19 on oral anticoagulation for atrial fibrillation (AF) in whom the discontinuation of oral anticoagulation is needed during hospitalization, we suggest switching over to therapeutic dose LMWH or unfractionated heparin (UFH). (C, U)
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In hospitalized ICU patients with COVID-19 taking oral anticoagulation for AF, we suggest switching over to therapeutic-dose or prophylactic-dose LMWH or UFH, based on individualized decision making. (C, U)
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In outpatients with COVID-19 and new-onset AF, we suggest starting a direct oral anticoagulant (DOAC) if their CHA2DS2-VASc score is ≥ 1 in males, and ≥ 2 in females; if DOACs cannot be used, we suggest a Vitamin K antagonist (VKA) with high time in therapeutic range (>70%). (C, U)
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In hospitalized (either non-ICU or ICU) patients with COVID-19 and new-onset AF, we suggest starting therapeutic-dose parenteral anticoagulation irrespective of their CHA2DS2-VASc score. Long-term oral anticoagulation is suggested if the score is ≥ 1 in males or ≥ 2 in females. (C, U)
Remark: Antiplatelet therapy alone should not be used for the prevention of thromboembolism in patients with COVID-19 and new-onset AF. In accordance to previously published guidance, we recommend checking platelet count, coagulation parameters, and liver and renal function prior to starting antithrombotic medications.
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In hospitalized patients with COVID-19 and stable peripheral artery disease (PAD; i.e., no acute limb events or revascularization procedures within the past 30 days), we suggest continuation of antiplatelet therapy if concurrent prophylactic-dose anticoagulation for COVID-19 is being given. (C, U)
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In hospitalized patients with COVID-19 and stable PAD (i.e., no acute limb events or revascularization procedures within the past 30 days) who are receiving single antiplatelet Journal Pre-proof 6 therapy and therapeutic-dose anticoagulation for COVID-19 is being given, we suggest individualizing the decision whether to continue or hold the antiplatelet agent. (C, U)
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In hospitalized patients with COVID-19 and acute limb-threatening ischemia, we suggest early revascularization in consultation with vascular specialist, if conforming with clinical presentation, patient values, anatomy and resources. (C, U)
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The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.
Title
Antithrombotic Therapy in Arterial Thrombosis and Thromboembolism in COVID-19
Authoring Organization
American College of Chest Physicians
Publication Month/Year
June 29, 2023
Last Updated Month/Year
September 5, 2023
Country of Publication
US
Document Objectives
Increasing evidence shows that the risk of thrombotic complications in coronavirus disease 2019 (COVID-19) is associated with a hypercoagulable state. Several organizations have released guidelines for the management of COVID-19-related coagulopathy and prevention of venous thromboembolism. However, there is an urgent need for practical guidance on the management of arterial thrombosis and thromboembolism in this setting.The existing evidence and panel consensus do not suggest a major departure from the management of arterial thrombosis as per pre-COVID-19 recommendations. Data on the optimal strategies for prevention and management of arterial thrombosis and thromboembolism in patients with COVID-19 is sparse. More high-quality evidence is needed to inform management strategies in these patients.
Inclusion Criteria
Male, Female, Adult, Older adult
Health Care Settings
Ambulatory, Outpatient, Operating and recovery room
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Diseases/Conditions (MeSH)
D013923 - Thromboembolism, D000086382 - COVID-19
Keywords
thromboembolism, Coronavirus, covid-19, COVID, arterial thrombosis
Source Citation
Potpara, T., et al. (2023) Antithrombotic therapy in arterial thrombosis and thromboembolism in COVID-19: An American College of Chest Physicians Expert Panel Report. CHEST Journal. doi.org/10.1016/j.chest.2023.06.032.