The current approaches to the management of coronavirus disease 2019 associated coagulopathy

Abstract

Coronavirus disease 2019 (COVID-19) is a highly infectious disease caused by the severe acute respiratory syndrome-CoV-2 virus that appeared in China and has spread globally. Accumulating evidence suggests that the development of specific prothrombotic changes in patients with COVID-19 reflected a high incidence of thrombotic complications. This paper is a narrative review of the diagnostic and management of COVID-19-associated coagulopathy and related venous thromboembolism (VTE). The consecutive search and review of relevant literature were carried out between March 23 and May 22, 2020. Eleven studies assessing the incidence of VTE and eleven guidelines on the management of coagulopathy were identified. The prevalence of VTE in patients with COVID-19 appeared to be unexpectedly high, reaching 8%–13% in the general ward and 9%–18% in the intensive care unit despite pharmacological prophylaxis. The current guidelines suggest prophylactic anticoagulation with low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH) in all inpatients. Intensified anticoagulation in the absence of VTE is not generally recommended but may be considered for patients with obesity, elevated D-dimer, an individually highest risk of VTE, or critical illness. The value of mechanical prophylaxis is underestimated. Extended prophylaxis after discharge may be indicated for patients with increased risk of VTE and low risk of bleeding. Increased D-dimer may be used as an indication for VTE screening by appropriate imaging tests. If VTE is highly suspected according to the clinical signs or D-dimer, then therapeutic anticoagulation may be initiated before VTE confirmation. For putative or confirmed VTE, therapeutic anticoagulation with LMWH or UFH is preferred during inpatient treatment, followed by switching to direct oral anticoagulants after discharge for 3 months. Primary VTE prophylaxis for outpatients is not generally recommended. Most of the guidelines are interim and ambiguous.