Skip to main content

Table 5 CDC and societal recommendations regarding therapeutic anticoagulation and thrombolytic therapy in COVID-19

From: Comparison of published guidelines for management of coagulopathy and thrombosis in critically ill patients with COVID 19: implications for clinical practice and future investigations

 

When to consider therapeutic anticoagulation

When to consider thrombolytics

Duration of therapeutic anticoagulation

CDC

Consider when a clinically suspected thromboembolic event is present or highly suspected despite imaging confirmation. Insufficient data to recommend for or against the increase of anticoagulation intensity outside the context of a clinical trial. Mentions patients who have thrombosis of catheters or extracorporeal filters should be treated accordingly to standard institutional protocols for patients without COVID-19.

Insufficient data to recommend for or against thrombolytic therapy outside the context of a clinical trial. In pregnant patients, thrombolytic therapy should only be used for acute PE with life-threatening hemodynamic instability due to risk for maternal hemorrhage.

Not mentioned

ISTH-IG

No specific recommendations

Not mentioned

Not mentioned

ACF

Consider when a clinically suspected thromboembolic event is present or highly suspected despite imaging confirmation.

Consider if clinical indication such as STEMI, acute ischemic stroke, or high risk massive PE with hemodynamic instability. Otherwise, it is not recommended outside context of a clinical trial.

A minimum of 3-month course for anyone who was initiated on anticoagulation during hospitalization (exception is recent bleeding or high bleeding risk). Delayed imaging should not be used to determine anticoagulation duration. Existing guidelines for presumed hospital-associated thromboembolic event should be used to determine anticoagulation beyond the initial 3-month period.

ASH

Consider increasing the intensity of anticoagulation regimen (i.e., from standard to intermediate intensity, from intermediate to therapeutic intensity) or change anticoagulants in patients who have recurrent thrombosis of catheters and extracorporeal circuits (i.e., ECMO, CRRT) on prophylactic anticoagulation regimens.

Not mentioned

Not mentioned

ACCP

Patients with PE or proximal DVT.

Thrombolytics over no such therapy in patients with objectively confirmed PE with hemodynamic instability or signs of obstructive shock who are not at high risk of bleeding. Peripheral thrombolysis recommended over catheter-directed thrombolysis.

Minimum of 3 months

SCC-ISTH

Therapeutic anticoagulation should not be considered for primary prevention until randomized controlled trials are available. Increased intensity of anticoagulation regimen (i.e., from standard or intermediate intensity to therapeutic intensity) can be considered in patients without confirmed VTE or PE but have deteriorating pulmonary status or ARDS.

Not mentioned

Minimum of 3 `months

ACC

Mentions that therapeutic anticoagulation is the key to VTE treatment. Does not make distinction between confirmed or suspected VTE. Hemodynamically stable patients with submassive PE should receive anticoagulation rather than fibrinolytics.

A multidisciplinary PERT may be helpful for intermediate and high risk patient with VTE. For hemodynamically high risk PE, systemic fibrinolysis is indicated with catheter-based therapies reserved for situations that are not amenable to systemic fibrinolysis. Patients with hemodynamically stable intermediate-low or intermediate-high risk PE should receive anticoagulation, and rescue systemic fibrinolysis should be considered in cases of further deterioration with catheter-directed therapies as an alternative. Catheter-directed therapies should be limited to most critical situations given minimal data showing mortality benefit. When considering fibrinolysis vs percutaneous coronary intervention for STEMI, clinicians should weigh risks and severity of STEMI presentation, severity of COVID-19 in patient, risk of COVID-19 to individual clinicians and healthcare system.

Not mentioned

  1. Abbreviations: ARDS acute respiratory distress syndrome, COVID-19 coronavirus disease 2019, CRRT continuous renal replacement therapy, DVT deep vein thrombosis, ECMO extracorporeal membrane oxygenation, i.e. for example, PE pulmonary embolism, PERT pulmonary embolism response team, STEMI ST elevation myocardial infarction, VTE venous thromboembolism