It has become clear in recent months that the severe acute respiratory syndrome 2 (SARS-CoV-2) virus, which causes coronavirus disease 2019 (COVID-19) affects the cardiovascular system, in addition to the lungs, prompting clinicians to reevaluate common standard care procedures for patients infected with the coronavirus. An expert panel released a set of 22 guidelines for the prevention, detection, and treatment of venous thromboembolism (VTE) and hypercoagulability in patients infected with COVID-19, which were published in Chest. 1
Patients with severe coronavirus infections can have a dramatic rise in cytokine levels causing a cytokine storm, which activates the bodys coagulation system, leading to a hypercoagulable state. Laboratory results from patients infected with the virus show highly abnormal D-dimer levels, indicating that fibrin degradation products are circulating in the blood stream.2
Anticoagulant therapy appears to be essential for patients admitted to the intensive care unit (ICU) with COVID-19. According to observational studies, even when treated with at least a standard dose of an anticoagulant, up to 54% of patients were diagnosed with VTE.3 A 24% reduction in absolute mortality was reported by clinicians in a hospital in Wuhan, China, for patients with severe COVID-19 and sepsis-induced coagulopathy who were treated with vs without heparin.4 These patients may have an elevated risk for VTE. It is recommended that patients hospitalized for COVID-19 be administered anticoagulant thromboprophylaxis, in the absence of contraindications for these drugs. The use of antiplatelet medications is not recommended. In patients without COVID-19, anticoagulants are favored over antiplatelets, as heparin has been shown to reduce the incidence of pulmonary embolisms (PEs) and proximal and distal VTEs.
Direct oral anticoagulants (DOACs) may not be recommended for patients with severe COVID-19 and acute VTE for 4 reasons: SARS-CoV-2 can cause gastrointestinal symptoms (ie, vomiting and diarrhea) which may reduce the effectiveness of oral medications; some patients with COVID-19 require inhibitors or inducers of P-glycoprotein or cytochrome P450, which may reduce the safety and/or efficacy of DOACs; viral infection increases the incidence of acute kidney injury, which is a contraindication for DOACs. In 12 patients with a severe SARS-CoV-2 infection that were being treated with DOACs, C-trough DOAC levels were 6 times higher than before hospitalization.5
Due to SARS-CoV-2-related gastrointestinal symptoms, subcutaneous therapies (heparin or fondaparinux) are the preferred delivery method. Low molecular weight heparin (LMWH) or fondaparinux are both administered once daily without the need, in most cases, for monitoring. Unfractionated heparin (UFH), requires 2 doses per day, increasing the staffs risk for exposure. In addition, treatment with high doses of UFH which may be required to increase the activated partial thromboplastin time, may lead to heparin resistance. It is therefore recommended that patients with severe COVID-19 and acute VTE be treated with LMWH or fondaparinux, and that patients in the ICU be given LMWH, as no study has examined the safety and efficacy of fondaparinux in this patient population.
Patients with COVID-19 should be treated with standard anticoagulant dosage (LMWH BID or weight-based dosing). In most cases, thromboprophylaxis therapy should be discontinued after hospital discharge.
For inpatients with COVID-19 and proximal deep vein thrombosis (DVT) or PE, an initial parenteral anticoagulant of weight-adjusted LMWH followed by dabigatran or edoxaban with a vitamin K antagonist overlap is recommended. For patients with COVID-10 and proximal DVT or PE who are being cared for at home, LMWH is not recommended; apixaban, dabigatran, rivaroxaban, or edoxaban are preferred with a vitamin K antagonist overlap. For patients with COVID-19 in the ICU with proximal DVT or PE, oral therapies should be avoided. In all patients with a proximal DVT or PE, it is recommended that thromboprophylaxis be continued for 3 months.
Diffuse alveolar damage6 and frank alveolar hemorrhage7 were observed in autopsies of patients who died from COVID-19, indicating an increased risk for bleeding, and suggesting that advanced therapies (ie, systemic thrombolysis, thrombectomy, or catheter-directed thrombolysis) should not be used for the treatment of most patients with COVID-19.
Three categories of patients with COVID-19 are candidates for thrombolytic therapy: Patients with acute PE, no hypotension, and a low risk for bleeding who exhibit cardiopulmonary deterioration (progressing increase in heart rate, blood pressure maintained at >90 mm Hg, increase in jugular venous pressure, worsening gas exchange, shock, progressing right heart dysfunction, or an increase in cardiac biomarkers) after anticoagulant therapy; Patients with objectively confirmed VTE or in whom cardiac arrest is anticipated; and Patients with acute, objectively confirmed PE, hypotension, and a low risk for bleeding. In these patients, systemic thrombolysis using a peripheral vein should be used over catheter-directed thrombolysis.
In patients with acute, objectively confirmed PE without hypotension (systolic blood pressure <90 mm Hg or at least a 15-minute drop in blood pressure below 40 mm Hg), systemic thrombolytic therapy should not be used.
Despite a lack of evidence regarding the use of mechanical prophylaxis in addition to pharmacologic thromboprophylaxis in patients with COVID-19, the guidance authors recommend the sole use of mechanical prophylaxis in patient with a contraindication for LMWH.
In cases of recurrent VTE despite anticoagulation treatment with weight-adjusted LMWH, the dosage should be increased by 25% to 30%. Patient treated with oral anticoagulants should be switched to LMWH.
Routine ultrasound screenings for the detection of asymptomatic DVT in severely ill patients should be avoided unless the patient exhibits unexplained right ventricular dysfunction or refractory hypoxemia.
Limitations of these guidelines include the fact that they were formulated based on studies examining these treatment in patients with and without COVID-19. In the latter case, recommendations were issued based on general standards of care, which may not be optimal for patients with COVID-19. In addition, well-designed, randomized trials will be needed to determine optimal anticoagulant dosing, and specific treatments for macro vs microthrombosis.
As we consider this a living document that will be updated, we will incorporate additional questions to these updates as needed, noted the guidelines authors.
Disclosures: Some authors declared receiving consulting or funding from the pharmaceutical industry. A complete list of disclosures can be found in the original study.
References
Go here to read the rest:
Diagnosing, Treating, and Preventing Venous Thromboembolism in COVID-19: Expert Panel Guidelines - The Cardiology Advisor
- Molecular Cardiology Research Lab - Texas Heart Institute - April 15th, 2018 [April 15th, 2018]
- Cardiology - Cardiologists - New York - Montefiore Medical ... - May 7th, 2018 [May 7th, 2018]
- PET/CT - Molecular Imaging - Nuclear MedicinePET-CTPET ... - May 26th, 2018 [May 26th, 2018]
- Molecular Cardiology Centenary Institute - July 16th, 2018 [July 16th, 2018]
- Pediatric Cardiology Fellowship | Pediatrics | University ... - September 25th, 2018 [September 25th, 2018]
- Molecular Multi - 3formulas.com - November 4th, 2018 [November 4th, 2018]
- Society of Nuclear Medicine and Molecular Imaging (SNMMI) - December 20th, 2018 [December 20th, 2018]
- Cardiology 2019 | Cardiology Conferences | Cardiology ... - February 5th, 2019 [February 5th, 2019]
- Cardiology | medicine | Britannica.com - March 18th, 2019 [March 18th, 2019]
- Cardiology | Baylor College of Medicine | Houston, Texas - April 12th, 2019 [April 12th, 2019]
- Cardiology Conferences | Cardiology Meetings | cardiology ... - September 11th, 2019 [September 11th, 2019]
- Nuclear Medicine/Radiopharmaceuticals Market Research Report by Key Players Analysis - Rapid News Network - September 21st, 2019 [September 21st, 2019]
- Macroscopic Imaging Market Growth with Worldwide Industry Analysis to 2019-2027 - Rapid News Network - September 21st, 2019 [September 21st, 2019]
- PET MRI Market to Record an Exponential CAGR by 2025 - Analytics News - September 21st, 2019 [September 21st, 2019]
- In Vitro Diagnostics/IVD Market Rapid Growth with Rising Application Scope by 2026 | Top Players- Danaher, Abbott, Thermo Fisher Scientific Inc,... - September 21st, 2019 [September 21st, 2019]
- Nuclear Imaging Devices Market Industry Outlook, Size, Share, Growth Prospects, Key Opportunities, Trends and Forecast - Wolf Mirror - September 21st, 2019 [September 21st, 2019]
- Heparin-induced Thrombocypenia Treatment Market Size & Share Expanding Across The Globe By 2018 2028 - NewsVarsity - September 21st, 2019 [September 21st, 2019]
- Medical Animation Market is Booming at a CAGR of 8.5% Due To Growing Demand By 2019 - 2026 - US Trade Media - September 21st, 2019 [September 21st, 2019]
- Molecular Imaging Market Will Make a Huge Impact in Near Future - Wolf Mirror - September 21st, 2019 [September 21st, 2019]
- FDA Clears ARTIS icono Family of Angiography Systems From Siemens Healthineers - BioSpace - September 21st, 2019 [September 21st, 2019]
- MR Solutions' liquid helium free PET-MR system firmly on the agenda at WMIC - DOTmed HealthCare Business News - September 21st, 2019 [September 21st, 2019]
- Molecular Imaging Devices Market Forecast to 2024 Explored in Latest Research - OnYourDesks - September 21st, 2019 [September 21st, 2019]
- Antibody Production Market Overview on Key Innovations 2023 - TodayTimes - September 24th, 2019 [September 24th, 2019]
- BRIC IVD Market Overview and Scope 2019 to 2024 | Key Players: Roche Diagnostics, Abbott Laboratories, Inc., & more Analytics News - Analytics... - September 24th, 2019 [September 24th, 2019]
- Best Report on Diagnostic Catheter Market 2026 with Major Eminent Key Players Biosense Webster, Inc, Medtronic plc, St. Jude Medical, Boston... - September 24th, 2019 [September 24th, 2019]
- Molecular Imaging Devices Market Industry Shares Report Analysis 2019-2027 - QbnNews - September 24th, 2019 [September 24th, 2019]
- Molecular Imaging Market value projected to expand by 2017 2027 - Analytics News - September 24th, 2019 [September 24th, 2019]
- ESMO Annual Meeting 2019: Menarini Ricerche Presents the Preclinical Characterization of MEN1611, a Novel PI3K Inhibitor in Development for the... - September 24th, 2019 [September 24th, 2019]
- Not for the faint-hearted: why some kids blackout playing video games - The Age - September 24th, 2019 [September 24th, 2019]
- Role of Machine Learning and AI in Precision Medicine - Healthcare Tech Outlook - October 11th, 2019 [October 11th, 2019]
- Here's Why Qiagen Plummeted Today - The Motley Fool - October 11th, 2019 [October 11th, 2019]
- Research Fellow in Muscle Biology job with UNIVERSITY OF LEEDS | 182894 - Times Higher Education (THE) - October 12th, 2019 [October 12th, 2019]
- Upregulation Of Renal GLUT2 And SGLT2 Is Involved In High-Fat Diet-Ind | DMSO - Dove Medical Press - October 17th, 2019 [October 17th, 2019]
- Contrasting of Merit Medical Systems Inc. (MMSI) and BioLife Solutions Inc. (NASDAQ:BLFS) - MS Wkly - October 18th, 2019 [October 18th, 2019]
- Unexpected Growth Seen in Radiopharmaceutical Market Global Forecast to 2025 with Key Players Bayer, Cardinal Health, GE Healthcare, ABT Molecular... - October 18th, 2019 [October 18th, 2019]
- No. 447: Thunderbolts and lasers, with Adelphi's all-world dean and the Father of Rock 'n Roll - Innovate Long Island - October 18th, 2019 [October 18th, 2019]
- Global Molecular Imaging Agents Market Report: Regional Data Analysis by Production, Revenue, Price and Gross Margin - Market Research Writeup - October 22nd, 2019 [October 22nd, 2019]
- Gene Therapy/Editing Series 1: A Brief Introduction To Gene Therapy - Seeking Alpha - October 29th, 2019 [October 29th, 2019]
- What are the Major Reasons for Rise in Molecular Imaging Market in Recent Period? - The Chicago Sentinel - October 29th, 2019 [October 29th, 2019]
- IVD Market insights size status gross margin and outlook 2019-2025 investigated in the latest research -... - WhaTech - October 30th, 2019 [October 30th, 2019]
- Radiopharmaceutical Market Size, Share 2019 - Growth Insight, Comprehensive Analysis, Top Leading Players, Future Demand and Forecast to 2023 -... - October 30th, 2019 [October 30th, 2019]
- This is the world's smallest commercially available sensor, and it really is tiny! - RedShark News - October 30th, 2019 [October 30th, 2019]
- New model of irregular heartbeat could boost drug efficacy | The Source - Washington University in St. Louis Newsroom - October 30th, 2019 [October 30th, 2019]
- Global In Vitro Diagnostics (IVD) Market Industry Analysis and Forecast (2018-2026) - Maxi Wire - November 7th, 2019 [November 7th, 2019]
- New Studies Demonstrate the Predictive Value of the Vectra Test in People Diagnosed with Rheumatoid Arthritis - GlobeNewswire - November 10th, 2019 [November 10th, 2019]
- BRIC IVD Market with Future Prospects, Key Player SWOT Analysis and Forecast To 2024 - Columnist 360 - December 2nd, 2019 [December 2nd, 2019]
- Global Molecular Imaging Agents Market: What it got next? Find out with the latest research available at 'The Market Reports' - Inquiry 24 - December 2nd, 2019 [December 2nd, 2019]
- Molecular Imaging Market to Witness CAGR of 7.5% Rise in Value Share During the Period 2017 2027 - chronicles24 - December 2nd, 2019 [December 2nd, 2019]
- Medical Imaging Equipment Market Global Industry Size, Revenue Growth Development, Business Opportunities, Future Trends, Top Key Players, Market... - December 12th, 2019 [December 12th, 2019]
- PhD Position in Molecular Medicine job with NORWEGIAN UNIVERSITY OF SCIENCE & TECHNOLOGY -NTNU | 188846 - Times Higher Education (THE) - December 12th, 2019 [December 12th, 2019]
- Miss America 2020: Here's a look at the 51 beautiful women who will be competing to take home the crown - MEAWW - December 18th, 2019 [December 18th, 2019]
- Vitro Diagnostics Market: Key Players and Production Information analysis with Forecast 2022 - Downey Magazine - December 18th, 2019 [December 18th, 2019]
- Famed Medical Researcher Partners with Center for Vein Restoration Dr. Armin Foghi - PR Web - December 18th, 2019 [December 18th, 2019]
- Human fat cells tweaked to function like a pacemaker - Times of India - December 18th, 2019 [December 18th, 2019]
- Human fat cells tweaked to work like hearts pacemaker: Study - BusinessLine - December 18th, 2019 [December 18th, 2019]
- Year in Review: Payment Fights, Wearables, Burnout Defined Cardiology Practice in 2019 - TCTMD - December 18th, 2019 [December 18th, 2019]
- Global Nuclear Imaging Equipment Market 2019-2023 | Evolving Opportunities With Canon Inc. and Mediso Ltd. | Technavio - Business Wire - January 12th, 2020 [January 12th, 2020]
- Isothermal Nucleic Acid Amplification Technology Market Worth $3.3 Billion in 2024 - Exclusive Report by MarketsandMarkets - PRNewswire - January 16th, 2020 [January 16th, 2020]
- No one knew why some Amish children were dying suddenly. Now researchers have some answers - The Albany Herald - January 16th, 2020 [January 16th, 2020]
- Quantum Genomics to Present at the Gordon Research Conference 2020 Dedicated to the Renin Angiotensin Aldosterone System - Yahoo Finance - January 16th, 2020 [January 16th, 2020]
- Mount Sinai Research Finds that Heterogeneity of Liver Cancer Cells Help Explain Tumor Progression in Patients - PR Web - January 20th, 2020 [January 20th, 2020]
- Medical Imaging Equipment Market Size 2020, Trends, Industry Share, Business Opportunities and Demand Forecast to 2025 - Medical Market News - January 31st, 2020 [January 31st, 2020]
- Invicro Scientists Work on Imaging Synaptic Density in Schizophrenia Published in Nature Communications - Yahoo Finance - January 31st, 2020 [January 31st, 2020]
- 2020 In Vitro Diagnostics (IVD) Market Report- Growth, Challenges, Attractive Valuation and Top Key Players - Science of Change - February 1st, 2020 [February 1st, 2020]
- IVD Market To Inspect Growth Trends during Forecast Period 2019 to 2026 |Siemens, Danaher Corporation, Becton - Expedition 99 - February 1st, 2020 [February 1st, 2020]
- Invicro Scientists Work on Imaging Synaptic Density in Schizophrenia Published in Nature Communications - Business Wire - February 1st, 2020 [February 1st, 2020]
- PET Radiopharmaceuticals Market Report (2019-2025) | The demand for the Market will drastically increase in the Future - Chronicle 99 - February 17th, 2020 [February 17th, 2020]
- In Vitro Diagnostics (IVD) and Laboratory Developed Tests for Autoimmune Diseases Market With Top Countries Data Analysis and Forecast 2025 by Recent... - February 17th, 2020 [February 17th, 2020]
- North American Nuclear Medicine Market Expected to Reach USD 2.7 Billion by 2024 with a CAGR of 4.1% - ResearchAndMarkets.com - Business Wire - February 17th, 2020 [February 17th, 2020]
- Biologic And Medical Imaging Reagents Market to Make Great Impact in near Future by -2022 - Kentucky Journal 24 - February 17th, 2020 [February 17th, 2020]
- Global In Vitro Diagnostics (IVD) Industry, Forecast to 2027 - Molecular Diagnostics to Exhibit the Fastest Growth - Yahoo Finance - March 8th, 2020 [March 8th, 2020]
- GeneDx Celebrates 20 Year History as Pioneer In Genetic Sequencing and Testing - BioBuzz - March 22nd, 2020 [March 22nd, 2020]
- Contract Development and Manufacturing Organization Market worth USD 278.98 Billion by 2026; Increasing Demand for Pharmaceutical Products Will Aid... - March 24th, 2020 [March 24th, 2020]
- Outlook into the Global Hybrid Imaging Market to 2025 - by Application, Type, End Use and Region - Yahoo Finance - March 24th, 2020 [March 24th, 2020]
- Smoking cessation counseling and e-cigs may be effective for breaking the habit - Mental Daily - April 1st, 2020 [April 1st, 2020]
- How daylight saving time affects health, and why Turkey was right to abandon it - Daily Sabah - April 1st, 2020 [April 1st, 2020]
- Single-Photon Emission Computed Tomography Market by Key Players, Regions, Type and Application, Forecast to 2027 - Jewish Life News - April 1st, 2020 [April 1st, 2020]
- Caravaggio Backs Apixaban for Prevention of VTE Recurrence in Cancer Patients - TCTMD - April 1st, 2020 [April 1st, 2020]
- In-Vitro Diagnostics Market 2020 | Top Business Growing Strategies, Technological Innovation and Emerging Trends of Outlook To 2028 - Publicist360 - April 10th, 2020 [April 10th, 2020]
- Abbott's Point-of-Care COVID-19 Test Delivers Results Within Minutes - The Cardiology Advisor - April 10th, 2020 [April 10th, 2020]