Management of venous thromboembolism in COVID-19 patients: CHEST guidelines

American College of Chest Physicians® (CHEST) panel of experts have developed new CHEST guidelines for prevention, diagnosis and treatment of venous thromboembolism in patients with COVID-19.

There is sufficient evidence that severe COVID-19 can be complicated by a significant coagulopathy, that likely manifests in the form of both microthrombosis and venous thromboembolism (VTE). This recognition has led to the urgent need for practical guidance regarding prevention, diagnosis, and treatment of VTE.

Summary of Recommendations

1. In the absence of a contraindication, in acutely ill hospitalized patients with COVID-19, we suggest anticoagulant thromboprophylaxis over no anticoagulant thromboprophylaxis.

2. In the absence of a contraindication, in critically ill patients with COVID-19, we recommend anticoagulant thromboprophylaxis over no anticoagulant thromboprophylaxis.

3. In acutely ill hospitalized patients with COVID-19, we suggest anticoagulant thromboprophylaxis with low-molecular-weight heparin (LMWH) or fondaparinux over anticoagulant thromboprophylaxis with unfractionated heparin (UFH); and we recommend anticoagulant thromboprophylaxis with LMWH, fondaparinux or UFH over anticoagulant thromboprophylaxis with a direct oral anticoagulant (DOAC).

4. In critically ill patients with COVID-19, we suggest anticoagulant thromboprophylaxis with LMWH over anticoagulant thromboprophylaxis with UFH; and we recommend anticoagulant thromboprophylaxis with LMWH or UFH over anticoagulant thromboprophylaxis with fondaparinux or a DOAC.

5. In critically ill or acutely ill hospitalized patients with COVID-19, we recommend against the use of antiplatelet agents for venous thromboembolism (VTE) prevention.

6. In acutely ill hospitalized patients with COVID-19, we recommend current standard dose anticoagulant thromboprophylaxis over intermediate (LMWH BID or increased weight-based dosing) or full treatment dosing, per existing guidelines.

7. In critically ill patients with COVID-19, we suggest current standard dose anticoagulant thromboprophylaxis over intermediate (LMWH BID or increased weight-based dosing) or full treatment dosing, per existing guidelines.

8. In patients with COVID-19, we recommend inpatient thromboprophylaxis only over inpatient plus extended thromboprophylaxis after hospital discharge.

9. In critically ill patients with COVID-19, we suggest against the addition of mechanical prophylaxis to pharmacological thromboprophylaxis.

10. In critically ill patients with COVID-19 who have a contraindication to pharmacological thromboprophylaxis, we suggest the use of mechanical thromboprophylaxis.

11. In critically ill COVID-19 patients, we suggest against routine ultrasound screening for the detection of asymptomatic deep vein thrombosis (DVT).

12. For acutely ill hospitalized COVID-19 patients with proximal DVT or pulmonary embolism (PE), we suggest initial parenteral anticoagulation with therapeutic weight adjusted LMWH or intravenous UFH. The use of LWMH will limit staff exposure and avoid the potential for heparin pseudo-resistance. In patients without any drug-to-drug interactions, we suggest initial oral anticoagulation with apixaban or rivaroxaban. Dabigatran and edoxaban can be used after initial parenteral anticoagulation. Vitamin K antagonist therapy can be used after overlap with initial parenteral anticoagulation.

13. For outpatient COVID 19 patients with proximal DVT or PE and no drug-to-drug interactions, we recommend apixaban, dabigatran, rivaroxaban or edoxaban. Initial parenteral anticoagulation is needed before dabigatran and edoxaban. For patients who are not treated with a DOAC, we suggest vitamin K antagonists over LMWH (for patient convenience and comfort). Parenteral anticoagulation needs to be overlapped with vitamin K antagonists.

14. In critically ill COVID-19 patients with proximal DVT or PE, we suggest parenteral over oral anticoagulant therapy. In critically ill COVID-19 patients with proximal DVT or PE who are treated with parenteral anticoagulation, we suggest LMWH or fondaparinux over UFH.

Remarks: UFH might be preferred over LMWH or fondaparinux in patients at high

bleeding risk (including those with severe renal failure), or in those with overt or

imminent hemodynamic decompensation due to PE, in whom primary reperfusion

treatment may be necessary. The decision to use UFH should be balanced with the risks

associated with extra staff exposure and issues with heparin resistance as above.

15. For COVID 19 patients with proximal DVT or PE, we recommend anticoagulation

therapy for a minimum duration of three months.

16. In most patients with COVID-19 and acute, objectively confirmed PE not associated

with hypotension (systolic blood pressure < 90 mm Hg or blood pressure drop of >=k 40 mm Hg lasting longer than 15 minutes), we recommend against systemic thrombolytic therapy.

17. In patients with COVID-19 and both acute, objectively confirmed PE and hypotension (systolic blood pressure < 90 mm Hg) or signs of obstructive shock due to PE, and who are not at high risk of bleeding, we suggest systemically administered thrombolytics over no such therapy.

18. In patients with COVID-19 and acute PE with cardiopulmonary deterioration due to PE (progressive increase in heart rate, a decrease in systolic BP which remains >90 mm Hg, an increase in jugular venous pressure, worsening gas exchange, signs of shock (eg, cold sweaty skin, reduced urine output, confusion), progressive right heart dysfunction on echocardiography, or an increase in cardiac biomarkers) after initiation of anticoagulant therapy who have not yet developed hypotension and who have a low risk of bleeding, we suggest systemic thrombolytic therapy over no such therapy.

19. We recommend against the use of any advanced therapies (systemic thrombolysis,catheter-directed thrombolysis or thrombectomy) for most patients without objectively confirmed VTE.providers consider the differential of RV strain (preexisting pulmonary hypertension,high PEEP, severe ARDS) before entertaining the use of empiric thrombolysis.

20. In those patients with COVID-19 receiving thrombolytic therapy, we suggest systemic thrombolysis using a peripheral vein over catheter directed thrombolysis.

21. In patients with COVID-19 and recurrent VTE despite anticoagulation with therapeutic weight adjusted LMWH (and documented compliance), we suggest increasing the dose of LMWH by 25 to 30%.

22. In patients with COVID-19 and recurrent VTE despite anticoagulation with apixaban,dabigatran, rivaroxaban or edoxaban (and documented compliance), or vitamin K antagonist therapy (in the therapeutic range) we suggest switching treatment to therapeutic weight-adjusted LMWH.