Prevention and Treatment of Venous Thromboembolism Key Clinical Questions
04. How should patients with or without CAC already on therapeutic anticoagulation be managed?
a. HOMERuN institutions
Seven (33%) of institutions comment on how to manage the anticoagulants of patients who are on chronic therapeutic anticoagulation. All 7 recommend continuation of therapeutic anticoagulation, but there was some variability in what agents should be used/continued when the guidance commented on this. Two (9.5%) recommended continuation of home DOAC therapy, with conversion to either unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) if the patient deteriorates. Two (9.5%) recommend converting DOAC therapy to LMWH upon admission to the hospital.
b. What is Known
The literature to date indicates that inpatients with COVID-19 infection appear to have a heightened risk of VTE as mentioned above. Further, some data indicate an increased risk of VTE associated with elevated D-dimer levels in COVID-19 patients. Since patients on therapeutic anticoagulation for a pre-existing thromboembolic event or risk are likely at heightened risk for nosocomial VTE, the additional risk of VTE from COVID-19, especially in the presence of elevated D-dimer levels, only increases the necessity to continue anticoagulation in this population.
c. What is Not Known
It is uncertain what level of D-dimer elevation should warrant heightened concern for development of VTE. The effect of therapeutic anticoagulation on patients with COVID-19 is still ill-defined, nor is there certainty as to whether DOAC, UFH, and LMWH all have similar effects on the course of COVID-19.