Management of venous thromboembolism during the COVID-19 pandemic

Abstract

Since the coronavirus disease of 2019 (COVID-19) was first identified in December 2019 in Wuhan, China, and declared a pandemic, it has harvested thousands of lives across the globe.1World Health OrganizationDirector-General's remarks at the media briefing on 2019-nCoV on 11 February 2020.https://www.who.int/dg/speeches/detail/who-director-general-s-remarks-at-the-media-briefing-on-2019-ncov-on-11-february-2020Date accessed: February 12, 2020Google Scholar Aside from respiratory disease, COVID-19 has been shown to increase risk of thromboembolism.2Zhou F. Yu T. Du R. Fan G. Liu Y. Liu Z. et al.Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study.Lancet. 2020; 395: 1054-1062Abstract Full Text Full Text PDF PubMed Scopus (15717) Google Scholar Multiple hemostatic abnormalities, including increased D-dimer and fibrin degradation product levels, prolonged thrombin and prothrombin times and international normalized ratio, shortened activated partial thromboplastin time, and thrombocytopenia, indicating possible disseminated intravascular coagulation, have been reported.1World Health OrganizationDirector-General's remarks at the media briefing on 2019-nCoV on 11 February 2020.https://www.who.int/dg/speeches/detail/who-director-general-s-remarks-at-the-media-briefing-on-2019-ncov-on-11-february-2020Date accessed: February 12, 2020Google Scholar, 2Zhou F. Yu T. Du R. Fan G. Liu Y. Liu Z. et al.Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study.Lancet. 2020; 395: 1054-1062Abstract Full Text Full Text PDF PubMed Scopus (15717) Google Scholar, 3Gao Y. Li T. Han M. Li X. Wu D. Xu Y. et al.Diagnostic utility of clinical laboratory data determinations for patients with the severe COVID-19.J Med Virol. 2020; 92: 791-796Crossref PubMed Scopus (572) Google Scholar, 4Zhang Y. Xiao M. Zhang S. Xia P. Cao W. Jiang W. et al.Coagulopathy and antiphospholipid antibodies in patients with Covid-19.N Engl J Med. 2020; 82: e38Crossref Scopus (1403) Google Scholar, 5Bikdeli B. Madhavan M.V. Jimenez D. Chuich T. Dreyfus I. Driggin E. et al.COVID-19 and thrombotic or thromboembolic disease: implications for prevention, antithrombotic therapy, and follow-up: JACC state-of-the-art review.J Am Coll Cardiol. 2020; 75: 2950-2973Crossref PubMed Scopus (1807) Google Scholar In addition, other implicated causes include positive antiphospholipid antibodies and sepsis.4Zhang Y. Xiao M. Zhang S. Xia P. Cao W. Jiang W. et al.Coagulopathy and antiphospholipid antibodies in patients with Covid-19.N Engl J Med. 2020; 82: e38Crossref Scopus (1403) Google Scholar With the current recommendations of social distancing and “stay-at-home” orders, most clinical appointments have been changed into virtual visits. Furthermore, patients with potentially serious conditions, such as venous thromboembolism (VTE), might be avoiding hospital visits, which may lead to increased morbidity and mortality. Sedentary lifestyle is expected to increase risk of VTE, especially in patients with underlying risk factors. Consequently, consistent with current evidence,5Bikdeli B. Madhavan M.V. Jimenez D. Chuich T. Dreyfus I. Driggin E. et al.COVID-19 and thrombotic or thromboembolic disease: implications for prevention, antithrombotic therapy, and follow-up: JACC state-of-the-art review.J Am Coll Cardiol. 2020; 75: 2950-2973Crossref PubMed Scopus (1807) Google Scholar our institution has created management recommendations for VTE (Fig). We recommend daily exercise activities, weight reduction, and smoking cessation. For outpatients with low risk (Wells score of 0 for deep venous thrombosis [DVT] and <2 for pulmonary embolism [PE]) or moderate risk (Wells score of 1-2 for DVT and 2-6 for PE) and D-dimer level of <500 ng/mL, we recommend no further testing. For moderate-risk patients and D-dimer level of ≥500 ng/mL or high-risk patients (Wells score of >2 for DVT and >6 for PE), we recommend venous duplex ultrasound or computed tomography at an outpatient imaging center. For stable patients, we recommend outpatient management with direct oral anticoagulants, and inpatient management with parenteral anticoagulation for unstable cases. In addition to early ambulation, we recommend prophylaxis for all patients, favoring enoxaparin over unfractionated heparin. Based on clinical suspicion, and D-dimer level in patients with low risk, we cautiously suggest imaging studies in order to reduce viral transmission and interruption of intensive care. We recommend prophylaxis, low- or regular-intensity full anticoagulation based on imaging availability and bleeding risk. We favor enoxaparin over unfractionated heparin to reduce the need for monitoring of activated partial thromboplastin time, which can be affected by the viral infection. Direct oral anticoagulants may be considered in patients who do not require a procedure. Extended prophylaxis is considered in patients with moderate clinical suspicion and low bleeding risk. Further research is needed for standardized management recommendations for VTE in the era of COVID-19.