Antithrombotic therapy in patients with COVID-19? -Rationale and Evidence

Abstract

In patients with severe or critical Coronavirus disease 2019 (COVID-19) manifestations, a thromboinflammatory syndrome, with diffuse microvascular thrombosis, is increasingly evident as the final step of pro-inflammatory cytokines storm. Actually, no proven effective therapies for novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection exist. Preliminary observations on anticoagulant therapy appear to be associated with better outcomes in moderate and severe COVID-19 patients with signs of coagulopathy and in those requiring mechanical ventilation. The pathophysiology underlying the prothrombotic state elicited by SARS-CoV-2 outlines possible protective mechanisms of antithrombotic therapy (in primis anticoagulants) for this viral illness. The indications for antiplatelet/anticoagulant use (prevention, prophylaxis, therapy) are guided by the clinical context and the COVID-19 severity. We provide a practical approach on antithrombotic therapy management for COVID-19 patients from a multidisciplinary point of view.

Keywords: Anticoagulants; Antiplatelet; Antithrombotic therapy; COVID-19; Coronavirus; Thromboinflammatory syndrome.

Fig. 1

Mechanisms of anti-inflammatory effects of anticoagulant (left) and antiplatelet (right) therapies in patients with COVID-19. COX = cyclooxygenase; HSPG = heparan sulfate proteoglycan; MMPs = matrix metalloproteinases; NF-kb = nuclear factor kappa-light-chain-enhancer of activated B cells; SARS-COV-2 = severe acute respiratory syndrome coronavirus 2; TNF = Tumor necrosis factor.

Fig. 2

Algorithm on antithrombotic therapy in patients with COVID-19. ACS = acute coronary syndrome; APT = antiplatelet therapy; DAPT = dual antiplatelet therapy; DIC = disseminated intravascular coagulation; DOACs = direct oral anticoagulants; INR = international normalized ratio; LMWH = low-molecular-weight heparin; MI = myocardial infarction; SAPT = single antiplatelet therapy; UFH = unfractionated heparin; VTE = venous thromboembolism. ^⁎If pharmacological prophylaxis is contraindicated.