Guidance for the Management of Patients with Vascular Disease or Cardiovascular Risk Factors and COVID-19: Position Paper from VAS-European Independent Foundation in Angiology/Vascular Medicine

Abstract

COVID-19 is also manifested with hypercoagulability, pulmonary intravascular coagulation, microangiopathy, and venous thromboembolism (VTE) or arterial thrombosis. Predisposing risk factors to severe COVID-19 are male sex, underlying cardiovascular disease, or cardiovascular risk factors including noncontrolled diabetes mellitus or arterial hypertension, obesity, and advanced age. The VAS-European Independent Foundation in Angiology/Vascular Medicine draws attention to patients with vascular disease (VD) and presents an integral strategy for the management of patients with VD or cardiovascular risk factors (VD-CVR) and COVID-19. VAS recommends (1) a COVID-19-oriented primary health care network for patients with VD-CVR for identification of patients with VD-CVR in the community and patients' education for disease symptoms, use of eHealth technology, adherence to the antithrombotic and vascular regulating treatments, and (2) close medical follow-up for efficacious control of VD progression and prompt application of physical and social distancing measures in case of new epidemic waves. For patients with VD-CVR who receive home treatment for COVID-19, VAS recommends assessment for (1) disease worsening risk and prioritized hospitalization of those at high risk and (2) VTE risk assessment and thromboprophylaxis with rivaroxaban, betrixaban, or low-molecular-weight heparin (LMWH) for those at high risk. For hospitalized patients with VD-CVR and COVID-19, VAS recommends (1) routine thromboprophylaxis with weight-adjusted intermediate doses of LMWH (unless contraindication); (2) LMWH as the drug of choice over unfractionated heparin or direct oral anticoagulants for the treatment of VTE or hypercoagulability; (3) careful evaluation of the risk for disease worsening and prompt application of targeted antiviral or convalescence treatments; (4) monitoring of D-dimer for optimization of the antithrombotic treatment; and (5) evaluation of the risk of VTE before hospital discharge using the IMPROVE-D-dimer score and prolonged post-discharge thromboprophylaxis with rivaroxaban, betrixaban, or LMWH.

Fig. 1

The principal mechanisms triggered by SARS-CoV-2 infection leading to enhanced thrombin generation and pulmonary intravascular coagulation. GAG, glycosaminoglycans; HMWK, high-molecular-weight kininogen; IL, interleukin; INF, interferon; NET, neutrophil extracellular trap; PK, plasma kallikrein; PPK, plasma prekallikrein; TNFα, tissue necrosis factor α.

Fig. 2

Interactions of antithrombotic and lipid lowering agents with antiviral and convalescence treatment in patients with COVID-19. Drug combinations may have been assessed either by study or within the product label, or an interaction may have been predicted based on the metabolic profiles of the drugs. (data available in : https://www.covid19-druginteractions.org). Interpretation of colors : : These drugs should not be co-administered; : Potential clinically significant interaction that is likely to require additional monitoring, alteration of drug dosage or timing of administration. : Potential interaction likely to be of weak intensity. Additonal action/monitoring or dosage adjustment is unlikely to be required. : No clinically significant interaction expected. VKA, Vitamin K antagonists; DOAC, direct orally active anticoagulants.

Fig. 3

Integral strategy recommended by VAS for the management of patients with vascular disease or cardiovascular risk factors (VD-CVR) to prevent SARS-CoV-2 infection and to decrease the risk of COVID-19 worsening and manifestation of vascular complications during patients' trajectory.