CHEST Guidelines for VTE Prevention, Diagnosis, and Treatment in COVID-19

Author: Brit Long, MD (@long_brit) // Reviewed by: Alex Koyfman, MD (@EMHighAK) and Manpreet Singh, MD (@MPrizzleER

Evidence suggests patients with COVID-19 are at risk of thromboses and coagulopathy. Up to now, there has not been an established set of clear guidelines. CHEST released a guideline and expert panel report on venous thromboembolism in COVID-19 patients in early June 2020.

This post will take you through the relevant ED recommendations on prevention, diagnosis, and treatment of VTE in these patients.

Recommendations:

VTE Prevention – 

Of note, acutely ill hospitalized patients equates to general inpatients, while critically ill patients are those admitted to the ICU.

1. For acutely ill hospitalized patients with COVID-19 and no contraindications, they suggest anticoagulant thromboprophylaxis over no prophylaxis.

2. For critically ill patients with COVID-19 and no contraindications, they suggest anticoagulant thromboprophylaxis over no prophylaxis.

3. In acutely ill hospitalized patients with COVID-19 receiving thromboprophylaxis, they recommend using LMWH or fondaparinux over UFH. They recommend using LMWH, fondaparinux, or UFH over a DOAC.

  • LMWH and fondaparinux limit staff exposure.
  • They recommend against DOACs because of the high risk of patients for clinical deterioration, and other treatments may interact with DOAC therapy.

4. For critically ill patients with COVID-19, they suggest thromboprophylaxis with LMWH over UFH, and they recommend using LMWH or UFH over fondaparinux or a DOAC.

5. For acutely ill or critically ill hospitalized patients with COVID-19, they recommend against use of antiplatelet agents for VTE prevention.

 

Dosing Regimen – 

6. For acutely ill hospitalized patients with COVID-19, they recommend current standard dose anticoagulant thromboprophylaxis over intermediate (LMWH BID or increased weight-based dosing) or full treatment dosing.

  • They state there are insufficient data to justify increased intensity anticoagulant thromboprophylaxis.

7. In critically ill patients with COVID-19, they recommend current standard dose anticoagulation over intermediate or full treatment dosing.

  • Authors state the data are unclear whether severely ill patients with COVID-19 have a different risk of VTE compared to other severely ill medical ICU patients, and there are insufficient data concerning bleeding risk.

 

Duration of Thromboprophylaxis – 

8. They recommend inpatient thromboprophylaxis only over inpatient plus extended thromboprophylaxis after hospital discharge.

  • They state extended thromboprophylaxis in those with COVID-19 who are at low risk of bleeding can be considered, if emerging data on post-discharge risk of VTE and bleeding demonstrate a net benefit of prophylaxis.

 

Mechanical Prophylaxis – 

9. In critically ill patients, they recommend against adding mechanical prophylaxis to pharmacologic means.

10. In critically ill patients with a contraindication to pharmacologic thromboprophylaxis, mechanical means can be used.

 

Diagnosis of VTE – 

11. In critically ill patients, they suggest against routine ultrasound screening for detection of asymptomatic DVT.

 

Role of D-dimer and other Biomarkers – 

There are few studies evaluating D-dimer levels, either a single level or using a dynamic change, to predict VTE in patients with COVID-19.

 

VTE Treatment – 

12. For acutely ill admitted patients with proximal DVT or PE, they suggest parenteral anticoagulation with therapeutic weight-adjusted LMWH or IV UFH. LMWH limits staff exposure. In patients without drug interactions, they recommend initial DOAC therapy with apixaban or rivaroxaban. Dabigatran and edoxaban can be used after initial parenteral anticoagulation. Vitamin K antagonist therapy can be used with overlap with initial parenteral anticoagulation.

13. For outpatient COVID-19 patients with proximal DVT or PE and no drug interactions, they recommend using apixaban, dabigatran, rivaroxaban, or edoxaban. Initial parenteral anticoagulation is needed before dabigatran and edoxaban. If patients are not treated with DOAC therapy, they recommend vitamin K antagonists over LMWH.

14. In critically ill patients with proximal DVT or PE, they suggest using parenteral anticoagulation over oral therapies. In those who are critically ill with proximal DVT or PE, they recommend LMWH or fondaparinux over UFH.

15. For those with proximal DVT or PE and COVID-19, they recommend a minimum treatment duration of 3 months.

 

Thrombolytic Therapy – 

16. In most patients with COVID-19 and acute, confirmed PE with no hypotension, they recommend against systemic thrombolytic therapy.

  • Hypotension defined by SBP < 90 mm Hg or BP decreased by at least 40 mm Hg for longer than 15 minutes.

17. In patients with COVID-19 and acute, confirmed PE with hypotension or signs of obstructive shock due to PE, and if not at high bleeding risk, they recommend systemic thrombolytics over no therapy.

18. In patients with COVID-19 and acute PE with cardiopulmonary deterioration due to PE after starting anticoagulation but who have not developed hypotension and have low bleeding risk, they recommend systemic thrombolytics over no therapy.

  • Cardiopulmonary deterioration defined by progressive increase in HR, decrease in BP but remains > 90 mm Hg, increase in JVP, worsening gas exchange, signs of shock (cold sweaty skin, reduced urine output, confusion), progressive right heart dysfunction on echocardiography, or increase in cardiac biomarkers

19. They recommend against advanced therapies (systemic thrombolysis, catheter-directed thrombolysis, or thrombectomy) for most patients without objectively confirmed VTE.

20. In patients with COVID-19 receiving thrombolytic therapy, they recommend using a peripheral vein for systemic thrombolysis, rather than catheter-directed thrombolysis.

21. For patients with COVID-19 and recurrent VTE despite anticoagulation with therapeutic weight-adjusted LMWH and documented compliance, they recommend increasing the dose of LMWH by 25-30%.

22. For those with COVID-19 and VTE despite anticoagulation with a DOAC or vitamin K antagonist therapy and documented compliance, they recommend switching to therapeutic weight-adjusted LMWH.


Reference:

Moores LK, Tritschler T, Brosnahan S, et al. Prevention, Diagnosis, and Treatment of VTE in Patients With COVID-19: CHEST Guideline and Expert Panel Report [published online ahead of print, 2020 Jun 2]. Chest. 2020;S0012-3692(20)31625-1. doi:10.1016/j.chest.2020.05.559

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