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Should Patients With COVID-19 Receive Post-Discharge Thromboprophylaxis? Short Answers to Frequently Asked Questions

Călin Pop
Călin Pop
 e 
Marcel Pop
Marcel Pop
   | 09 nov 2022
Romanian Journal of Cardiology's Cover Image
INFORMAZIONI SU QUESTO ARTICOLO
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Article Category: Review
Pubblicato online: 09 nov 2022
Pagine: 138 - 143
DOI: https://doi.org/10.2478/rjc-2022-0026
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© 2022 Călin Pop et al., published by Sciendo
This work is licensed under the Creative Commons Attribution 4.0 International License.

Existing guidelines and consensus documents addressing post-discharge VTE thromboprophylaxis after COVID-19 infection

Source Setting Recommendation
Ref 22. American Society of Hematology living guidelines on the use of anticoagulation for thromboprophylaxis in patients with COVID-19: July 2021 update on post discharge thromboprophylaxis. Cuker A et al. American Society of Hematology No thromboprophylaxis for patients who do not have suspected or confirmed VTE, or another indication for anticoagulation. Post-discharge thromboprophylaxis may be reasonable in patients judged to be at elevated risk of thrombosis and low risk of bleeding.
Ref 23. Prevention, diagnosis, and treatment of VTE in patients with coronavirus disease 2019: CHEST guideline and expert panel report. Moores LK et al. CHEST Guideline and Expert Panel Report Extended prophylaxis 45 days to consider if post-discharge risk of VTE and bleeding indicate a net benefit of such prophylaxis.
Ref 24. Prevention and treatment of venous thromboembolism associated with coronavirus disease 2019 infection: a consensus statement before guidelines. Zhai Z et al. Statement of Chinese Thoracic Society & Chinese Association of Chest Physicians Assess whether the patient has VTE or whether the patient still has VTE risk factors after discharge. If the patient is still at elevated risk of VTE on discharge, subcutaneous injection of LMWH can be considered with a prolonged thromboprophylaxis over DOACs use.
Ref 25. COVID-19 and thrombotic or thromboembolic disease: implications for prevention, antithrombotic therapy, and follow-up: JACC State-of-the-Art Review. Bikdeli B et al. JACC State-of-the-Art Review Consideration of extended prophylaxis (for up to 45 days) for patients with elevated risk of VTE (e.g., reduced mobility, comorbidities such as active cancer, and elevated D-dimer >2 times the upper limit of normal) who have low risk of bleeding.
Ref 26. Scientific and Standardization Committee Communication: clinical guidance on the diagnosis, prevention, and treatment of venous thromboembolism in hospitalized patients with COVID-19. Spyropoulos AC et al. Standardization Committee of the International Society on Thrombosis and Haemostasis

Extended post discharge thromboprophylaxis should be considered for all hospitalized patients with COVID-19 that meet high VTE risk criteria. The duration of post discharge thromboprophylaxis can be approximately 14 days at least and up to 30 days.

Either LMWH or a DOAC can be for extended duration thromboprophylaxis.
Ref 27. Prevention and management of venous thromboembolism in patients with COVID-19. web site www.sign.ac.uk Guidelines Scottish Intercollegiate Guidelines Network (SIGN) & Thrombosis UK www.thrombosisuk.org Extended thromboprophylaxis considering in patients at elevated risk for VTE and low risk of bleeding. Options for treatment include a LMWH or DOAC for 14 days; however, choice and duration of extended thromboprophylaxis will depend on clinical judgement.

Completed and ongoing trials/studies of post-discharge VTE after COVID-19 infection

Trials/Studies Type/Number of patients Follow-up (days) DVT incidence PE incidence VTE incidence
Ref 12. Incidence of thrombotic outcomes for patients hospitalized and discharged after COVID-19 infection. Bourguignon A et al. Retrospective 175 patients 42 – 0.71% (95% CI 0–2,1%) –
Ref 13. Post-discharge thrombosis and hemorrhage in patients with COVID-19. Zwicker JI et al. Retrospective 163 patients 30 – – 0.6% (95% CI, 0.1–4.6)
Ref 14. Incidence of symptomatic, image-confirmed venous thromboembolism following hospitalization for COVID-19 with 90-day follow-up. Salisbury R et al. Retrospective 145 patients 59 0.7% 0.7% 1.4%
Ref 15. Post-discharge venous thromboembolism following hospital admission with COVID-19. Roberts LN et al Retrospective 1877 68 – – 4.8 per 1000 discharges (0.47%)
Ref 16. Incidence of symptomatic venous thromboembolism following hospitalization for coronavirus disease 2019: prospective results from a multi-center study. Rashidi F et al Prospective, multicenter 1529 patients 45 – – 0.2% (95% CI 0.1%–0.6%)
Ref 17. Pulmonary thrombosis in Covid-19: before, during and after hospital admission. Vlachou M et al. Retrospective 370 patients 30 – – 1.08%
Ref 18. Venous Thromboembolism in patients discharged after COVID-19 hospitalization. Engelen MM et al Prospective 146 patients 42 0.7% 0.7% 1.4%
Ref 19. Post-discharge thromboembolic outcomes and mortality of hospitalized patients with COVID-19: the CORE-19 registry. Giannis D et al. Registry 4906 90 0.90% 0.85% 1.55%
Ref 28. Vascular thromboembolic events following COVID-19 hospital discharge: Incidence and risk factors. Eswaran H et al. Retrospective 447 patients 30 1% 1% 2.0% (1.1% in those discharged on anticoagulation and 2.7% in those discharged without anticoagulation - OR, 0.52; 95% CI, 0.08–2.26)
Ref 29. Incidence of venous thromboembolic events in COVID-19 patients after hospital discharge: A systematic review and meta-analysis. Zuin M et al. Meta-analysis 18,949 patients 61.7 mean length of follow-up (21 to 180) Pooled incidence 0.9% (95% CI:0.3 to 2.1) Pooled incidence 1.5% (95% CI: 0.5–4.0) Pooled incidence 1.8% (95% CI: 0.8–4.1%)
Ref 31. Effect of anticoagulation therapy on clinical outcomes in moderate to severe coronavirus disease 2019 (COVID-19) - COVID-PREVENT. Clinical Trials.gov Identifier: NCT04416048 Ongoing Recruiting – – – –
Ref 32. Rationale and design for the study of rivaroxaban to reduce thrombotic events, hospitalization, and death in outpatients with COVID-19: The PREVENT-HD study. Am Heart J 2021; 235:12–23. Capell WH et al. Ongoing - Recruiting – – – –
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