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Semin Thromb Hemost 2023; 49(01): 062-072
DOI: 10.1055/s-0042-1744302
Review Article

To Anticoagulate or Not to Anticoagulate in COVID-19: Lessons after 2 Years

John G. Rizk‡   *
1   Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, Maryland
,
Aashish Gupta‡   *
2   John Ochsner Heart and Vascular Institute, Ochsner Clinical School-The University of Queensland School of Medicine, New Orleans, Louisiana
,
Jose G. Lazo Jr.   *
3   UCSF Medical Center, University of California, San Francisco, San Francisco, California
,
Partha Sardar
2   John Ochsner Heart and Vascular Institute, Ochsner Clinical School-The University of Queensland School of Medicine, New Orleans, Louisiana
,
Brandon Michael Henry
4   Cardiac Intensive Care Unit, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
5   Disease Prevention and Intervention & Population Health Programs, Texas Biomedical Research Institute, San Antonio, Texas
,
Carl J. Lavie
2   John Ochsner Heart and Vascular Institute, Ochsner Clinical School-The University of Queensland School of Medicine, New Orleans, Louisiana
,
Mark B. Effron
2   John Ochsner Heart and Vascular Institute, Ochsner Clinical School-The University of Queensland School of Medicine, New Orleans, Louisiana
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Abstract

A hypercoagulable state associated with coronavirus disease 2019 (COVID-19) has been well documented and is believed to be strongly supported by a proinflammatory state. The hypercoagulable state in turn results in increased incidence of arterial and venous thromboembolism (VTE) seen in hospitalized COVID-19 when compared with hospitalized non-COVID-19 patient cohorts. Moreover, patients with arterial or VTE and COVID-19 have higher mortality compared with COVID-19 patients without arterial or VTE. Prevention of arterial or VTE thus remains an essential question in the management of COVID-19 patients, especially because of high rates of reported microvascular and macrovascular thrombosis. This has prompted multiple randomized control trials (RCTs) evaluating different anticoagulation strategies in COVID-19 patients at various stages of the disease. Herein, we review findings from RCTs in the past 2 years of antithrombotic therapy in critically ill hospitalized patients, noncritically ill hospitalized patients, patients postdischarge from the hospital, and outpatients. RCTs in critically ill patients demonstrated therapeutic dose anticoagulation does not improve outcomes and has more bleeding than prophylaxis dose anticoagulant in these patients. Trials in noncritically ill hospitalized patients showed a therapeutic dose anticoagulation with a heparin formulation might improve clinical outcomes. Anticoagulation with a direct oral anticoagulant posthospital discharge may improve outcomes, although there is a large RCT in progress. Nonhospitalized COVID-19 patients have an insufficient burden of events to be candidates for antithrombotic therapy. Anticoagulation in pregnant and lactating patients with COVID-19, as well as antiplatelet therapy for COVID-19, is also reviewed.

Keywords

COVID-19 - anticoagulation - thrombosis - bleeding

* These authors contributed equally (co-first authors).




Publication History

Article published online:
25 April 2022

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