Chest physicians make 11 recommendations on antithrombotic therapy in COVID-19

Recommendations to guide prevention and management of arterial thrombosis and thromboembolism in patients with COVID-19 were developed by an expert panel assembled by the American College of Chest Physicians.

The experts noted that the recommendations, published June 29 by CHEST, are not a major departure from arterial thrombosis recommendations from before the pandemic. They include the following:

1. 1. In hospitalized COVID-19 patients who have a baseline indication for antiplatelet therapy due to prior acute coronary syndrome (ACS), continuing antiplatelet therapy is suggested.
2. 2. In hospitalized patients with COVID-19 and confirmed ACS, dual antiplatelet therapy (DAPT) is recommended to reduce the risk of recurrent ACS or death.
3. 3. In hospitalized patients with COVID-19 and myocardial injury without ACS, the experts suggest against DAPT.
4. 4. In hospitalized patients with COVID-19 who are on DAPT for recent ACS and receiving prophylactic-dose anticoagulant therapy for COVID-19, continuing DAPT is suggested. For those on therapeutic-dose anticoagulation, individualized decisions that consider bleeding risk are suggested.
5. 5. For hospitalized patients on antiplatelet therapy for a previous stroke, continuing antiplatelet therapy and adding prophylactic-dose low-molecular-weight heparin (LMWH) is suggested.
6. 6. In hospitalized patients with COVID-19 who present with acute ischemic stroke and have an indication for recanalization therapy, recanalization therapy is suggested.
7. 7. For hospitalized patients with COVID-19 who have an acute stroke or transient ischemic attack of no established etiology, antiplatelet therapy as would be used for non-COVID-19 patients is suggested.
8. 8. In hospitalized non-ICU patients with COVID-19 on oral anticoagulation for atrial fibrillation (AF) who need to stop it, switching to therapeutic-dose LMWH or unfractionated heparin (UFH) is suggested. If the patient is in the ICU, switching to therapeutic-dose or prophylactic-dose LMWH or UFH based on individualized decision making is suggested.
9. 9. In hospitalized patients with COVID-19 and new-onset AF, starting therapeutic-dose parenteral anticoagulation is suggested.
10. 10. In hospitalized patients with COVID-19 and stable peripheral artery disease with no acute limb events or revascularization procedures within the past 30 days, continuing antiplatelet therapy is suggested if concurrent prophylactic-dose anticoagulation for COVID-19 is being given. If therapeutic-dose anticoagulation is used for COVID-19, individualized decision making on whether to continue the antiplatelet is suggested.
11. 11. For hospitalized patients with COVID-19 and acute limb-threatening ischemia, early revascularization in consultation with a vascular specialist is suggested.

All were conditional recommendations and ungraded consensus-based statements except for 2, which was a strong recommendation (but also an ungraded consensus-based statement).

The experts noted that there was overall a low quality of evidence specific to antithrombosis for COVID-19 and that many of the recommendations were based on indirect evidence and prior guidelines in similar populations without COVID-19. “Data on the optimal strategies for prevention and management of arterial thrombosis and thromboembolism in patients with COVID-19 is sparse,” they wrote. “More high-quality evidence is needed to inform management strategies in these patients.”