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PULMONARY VASCULAR: GUIDELINES AND CONSENSUS STATEMENTS| VOLUME 162, ISSUE 1, P213-225, JULY 01, 2022

Thromboprophylaxis in Patients With COVID-19: A Brief Update to the CHEST Guideline and Expert Panel Report

Lisa K. Moores, Tobias Tritschler, Shari Brosnahan, et al

Chest 2022; 162: 213-225 Published:February 12, 2022

DOI:https://doi.org/10.1016/j.chest.2022.02.006

Background

Patients hospitalized with COVID-19 often exhibit markers of a hypercoagulable state and have an increased incidence of VTE. In response, CHEST issued rapid clinical guidance regarding prevention of VTE. Over the past 18 months the quality of the evidence has improved. We thus sought to incorporate this evidence and update our recommendations as necessary.

Study Design and Methods

This update focuses on the optimal approach to thromboprophylaxis in hospitalized patients. The original questions were used to guide the search, using MEDLINE via PubMed. Eight randomized controlled trials and one observational study were included. Meta-analysis, using a random effects model, was performed. The panel created summaries using the GRADE Evidence-to-Decision framework. Updated guidance statements were drafted, and a modified Delphi approach was used to obtain consensus.

Results

We provide separate guidance statements for VTE prevention for hospitalized patients with acute (moderate) illness and critically ill patients in the ICU. However, we divided each original question and resulting recommendation into two questions: standard prophylaxis vs therapeutic (or escalated dose) prophylaxis and standard prophylaxis vs intermediate dose prophylaxis. This led to a change in one recommendation, and an upgrading of three additional recommendations based upon higher quality evidence.

Conclusions

Advances in care for patients with COVID-19 have improved overall outcomes. Despite this, rates of VTE in these patients remain elevated. Critically ill patients should receive standard thromboprophylaxis for VTE, and moderately ill patients with a low bleeding risk might benefit from therapeutic heparin. We see no role for intermediate dose thromboprophylaxis in either setting.

Summary of Recommendations

1. In hospitalized patients with acute illness with COVID-19 who have low risk of bleeding, with consideration for the remarks below, we suggest therapeutic dose heparin (UFH or LMWH) over current standard dose anticoagulant thromboprophylaxis (Conditional Recommendation, Ungraded Consensus-Based Statement).

Remarks: Providers should carefully weigh the risks of thrombosis and bleeding in making this decision. Patients with a significantly elevated D-dimer level (studies have previously defined this as 2-4× the upper limit of normal), those with prior VTE, or those with other comorbidities known to be associated with VTE may be at increased risk of thrombosis. Patients with high risk of bleeding include, but are not limited to, those with known bleeding within the last 30 days requiring ED presentation or hospitalization, known history of an inherited or acquired bleeding disorder, active dual antiplatelet therapy, recent ischemic stroke, intracranial malignancy, history of bleeding diatheses (eg, hemophilia), history of GI bleeding within previous 3 months, thrombolysis within the previous 7 days, presence of an epidural or spinal catheter, recent major surgery < 14 days, or uncontrolled hypertension (systolic BP > 200 mm Hg, diastolic BP > 120 mm Hg).

2. In hospitalized patients with acute illness with COVID-19 who are not receiving therapeutic dose heparin (UFH or LMWH), we recommend current standard dose anticoagulant thromboprophylaxis over intermediate dose anticoagulation (defined as LMWH bid or increased weight-based dosing that is less than recommended therapeutic doses) (Strong Recommendation, Ungraded Consensus-Based Statement).

3. In critically ill patients with COVID-19, we suggest current standard dose anticoagulant thromboprophylaxis (with UFH or LMWH) over therapeutic dose anticoagulation(Conditional Recommendation, Ungraded Consensus-Based Statement).

4. In critically ill patients with COVID-19, we suggest current standard dose anticoagulant thromboprophylaxis over intermediate dose anticoagulation (defined as LMWH bid or increased weight-based dosing that is less than recommended therapeutic doses) (Conditional Recommendation, Ungraded Consensus-Based Statement).

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