Thromboprophylaxis in Patients with COVID-19: Systematic Review of National and International Clinical Guidance Reports

Abstract

Background: Venous thromboembolism (VTE) is common among patients with severe coronavirus disease 2019 (COVID-19). Anticoagulation in hospitalized COVID-19 patients has been associated with survival benefit; however, the optimal thromboprophylaxis strategy has not yet been defined. Objective: To identify published guidance reports by national and international societies regarding thromboprophylaxis strategies in COVID-19 patients in different settings (outpatients, hospitalized, post-discharge). Methods: A systematic review of the literature (Pubmed/EMBASE) was conducted independently by two investigators. Results: Among 1942 initially identified articles, 33 guidance documents were included: 20 published by national and 13 by international societies. These documents provide recommendations mainly for hospitalized (97% of reports) and post-discharge (75%) COVID-19 patients, and less so for outpatients (34%). Thrombotic and bleeding risk stratification prior to any treatment decision is the cornerstone of all suggested thromboprophylaxis strategies; 81% of the documents recommend thromboprophylaxis for all hospitalized patients with a prophylactic dosage of low molecular weight heparin irrespective of VTE risk. Intermediate or therapeutic dose intensity is recommended in high VTE risk patients by 56% and 28% of documents, respectively. Mechanical thromboprophylaxis is suggested in case of high bleeding risk or contraindication to pharmacological thromboprophylaxis (59% of documents). Extended pharmacological thromboprophylaxis is recommended for patients with high VTE risk after hospital discharge (63% of documents). For non-hospitalized outpatients, 28% of documents recommend pharmacological thromboprophylaxis for high VTE risk. Conclusion: The current guidance identifies thromboprophylaxis in COVID-19 patients, especially during hospitalization, as of major importance for the prevention of VTE. Recommendations are derived from limited evidence from observational studies.

High versus Standard Intensity of Thromboprophylaxis in Hospitalized Patients with COVID-19: A Systematic Review and Meta-Analysis

“…The majority of the available guidance documents recommend standard prophylactic low dose of thromboprophylaxis in all hospitalized patients; however, higher doses can be selectively recommended on an individualized basis for patients at high or very high thrombotic risk, provided they also have a low risk of bleeding [ 7 ]. The available evidence, mainly derived from observational studies, is heterogeneous regarding the beneficial role of higher doses since the latter are administered in patients with critical disease and unfavorable prognostic factors [ 7 , 42 ]. Recent randomized studies have been published providing a high level of evidence, but their findings seem to be heterogeneous as well [ 9 , 10 , 11 , 12 , 13 , 30 , 33 ].…”

“…Moreover, the administration of thromboprophylaxis in hospitalized patients with COVID-19 has been associated with survival benefit [ 5 , 6 ]. Based on such available evidence, current guidelines recommend thromboprophylaxis in all hospitalized patients with COVID-19, mainly in the form of prophylactic dose of low molecular weight heparin (LMWH) [ 7 ].…”

“…However, some of these guidelines qualify a higher (intermediate) than prophylactic dose of anticoagulation in patients with severe COVID-19 and increased thromboembolic risk [ 7 ], despite the fact that the latter recommendation represents mainly expert opinion rather than evidence [ 6 ]. Indeed, the available evidence is weak since this is derived mainly from observational studies, where the selection of higher versus prophylactic doses of anticoagulation has been decided for patients with critical disease.…”

Incidence, Risk Factors, and Timing of Macrovascular Thrombosis in the Post-COVID-19 Elderly and Assessing the Need and Duration of Extended Thromboprophylaxis: A Prospective Study

“…Anticoagulation with heparin in hospitalized COVID-19 patients has been shown to bring down the in-hospital thrombotic risk and mortality in all patients (5,7,10,11,13,14,(17)(18)(19)(26)(27)(28) as well as the 28-day mortality and thrombotic risk in critically ill patients (7,13,14). Accordingly, current guidelines recommend anticoagulation for all hospitalized patients.…”

Acute Pulmonary Embolism Post COVID-19 Pneumonia – A Case Report

“…However, these laboratory derangements do not provide sufficient incentive to intervene. Although, no high-quality studies exist to dictate streamlined management strategies, there has been practice guidelines issued by many national health bodies to combat this complication [8,9]. Hence,clinicians resort to institutional practices which may vary in aggressiveness in approach.…”