June 3, 2020

CHEST expert panel issues guidelines for the prevention, diagnosis and treatment of VTE in patients with COVID-19

An American College of Chest Physicians (CHEST) panel of experts has published a set of guidelines, providing 21 optimal strategies when treating patients with venous thromboembolism (VTE) and COVID-19.

“Emerging evidence shows that severe COVID-19 can be complicated by coagulopathy. In the most severe cases, this manifests as disseminated intravascular coagulation (DIC), which is a prothrombotic condition with a high risk of [VTE],” the panel stated. It added that the presence of DIC has been found to be a strong predictor of mortality. 

The panel noted that the evidence on the optimal strategies to prevent, diagnose, and treat venous thromboembolism in patients with COVID-19 “is sparse, but rapidly evolving.”

Key clinical questions were developed by the panel using the PICO (population, intervention, comparator, and outcome) format that addressed urgent clinical questions regarding the prevention, diagnosis and treatment of VTE in patients with COVID-19.

The panel performed systematic review and critical analysis of the literature based on 13 PICO questions. Literature evaluation was done using GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology. The panel noted that “very little evidence exists in the COVID-19 population”. Therefore, the panel used expert consensus and existing evidence-based guidelines to develop the guidance statements.

The guidelines presented in the report include the following recommendations: 

  1. In the absence of contraindication, coagulant thromboprophylaxis is recommended in critically ill patients with COVID-19 and suggested for use in acutely ill hospitalized patients with COVID-19.
  2. In critically ill or acutely ill hospitalized patients with COVID-19, the panel recommends against the use of antiplatelet agents for VTE prevention.
  3. In acutely ill hospitalized patients with COVID-19, anticoagulant thromboprophylaxis with low-molecular-weight heparin (LMWH) or fondaparinux over anticoagulant thromboprophylaxis with unfractionated heparin (UFH) is suggested, and anticoagulant thromboprophylaxis with LMWH, fondaparinux or UFH over anticoagulant thromboprophylaxis with a direct oral anticoagulant (DOAC) is recommended.
  4. In critically ill patients with COVID-19, anticoagulant thromboprophylaxis with LMWH is suggested over anticoagulant thromboprophylaxis with UFH; and anticoagulant thromboprophylaxis with LMWH or UFH is recommended over anticoagulant thromboprophylaxis with fondaparinux or a DOAC. 
  5. In acutely ill hospitalized patients with COVID-19, the panel recommends current standard dose anticoagulant thromboprophylaxis over intermediate (LMWH BID or increased weight-based dosing) or full treatment dosing, per existing guidelines. 
  6. In critically ill patients with COVID-19, the panel suggests current standard dose anticoagulant thromboprophylaxis over intermediate (LMWH BID or increased weight-based dosing) or full treatment dosing, per existing guidelines. 
  7. In patients with COVID-19, the panel recommends inpatient thromboprophylaxis only over inpatient plus extended thromboprophylaxis after hospital discharge. 
  8. In critically ill patients with COVID-19, the panel suggests against the addition of mechanical prophylaxis to pharmacological thromboprophylaxis.
  9. In critically ill patients with COVID-19 who have a contraindication to pharmacological thromboprophylaxis, the panel suggests the use of mechanical thromboprophylaxis 
  10. In critically ill patients with COVID-19, the panel suggests against routine ultrasound screening for the detection of asymptomatic deep vein thrombosis (DVT).
  11. For acutely ill hospitalized COVID-19 patients with proximal DVT or pulmonary embolism (PE), the panel suggests initial parenteral anticoagulation with therapeutic weight adjusted LMWH or intravenous UFH. In patients without any drug-to-drug interactions, the panel suggests 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. 
  12. For outpatient COVID-19 patients with proximal DVT or PE and no drug-to-drug interactions, the panel recommends apixaban, dabigatran, rivaroxaban or edoxaban. Initial parenteral anticoagulation is needed before dabigatran and edoxaban. For patients who are not treated with a DOAC, the panel suggests vitamin K antagonists over LMWH (for patient convenience and comfort). Parenteral anticoagulation needs to be overlapped with vitamin K antagonists. 
  13. In critically ill COVID-19 patients with proximal DVT or PE, the panel suggests parenteral over oral anticoagulant therapy. In critically ill COVID-19 patients with proximal DVT or PE who are treated with parenteral anticoagulation, the panel suggests LMWH or fondaparinux over UFH. 
  14. For COVID-19 patients with proximal DVT or PE, the panel recommends anticoagulation therapy for a minimum duration of three months. 
  15. 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 ≥ 40 mm Hg lasting longer than 15 minutes), the panel recommends against systemic thrombolytic therapy.
  16. 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, the panel suggests systemically administered thrombolytics over no such therapy.
  17. 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, the panel suggests systemic thrombolytic therapy over no such therapy.
  18. The panel recommends against the use of any advanced therapies (systemic thrombolysis, catheter-directed thrombolysis or thrombectomy) for most patients without objectively confirmed VTE. 
  19. In those patients with COVID-19 receiving thrombolytic therapy, the panel suggests systemic thrombolysis using a peripheral vein over catheter directed thrombolysis. 
  20. In patients with COVID-19 and recurrent VTE despite anticoagulation with therapeutic weight adjusted LMWH (and documented compliance), the panel suggests increasing the dose of LMWH by 25 to 30%.
  21. 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) the panel suggests switching treatment to therapeutic weight-adjusted LMWH. 

In noting the limitations of the report, the panel stated that “the current body of evidence does not allow for delineation between macro (DVT/PE) and microthrombosis, and the approach to these may differ, which could drive at least a portion of mortality in these patients."

SOURCE: American College of Chest Physicians