New clinical guideline on antithrombotic therapy in arterial thrombosis and thromboembolism in COVID-19

The American College of Chest Physicians (CHEST) recently released a new clinical guideline on antithrombotic therapy in arterial thrombosis andthromboembolism in COVID-19. Published in the journal CHEST, the guideline contains 11 evidence-based recommendations to improve risk-evaluation and to assist in determining the course of treatment.

While there are guidelines for the management of COVID-19-related coagulopathy for venous thromboembolism (VTE), a recent large cohort study showed that COVID-19 was associated with substantially increased incidence of both VTE and arterial thromboses, including myocardial infarction and stroke.

"The new guideline provides recommendations for managing four arterial (pro)thrombotic medical conditions so that when a patient presents with COVID-19 infection either with an acute thrombotic event or a history of them, the clinician will be able to assess the risks and benefits of administering additional medication that may interact with a current antithrombotic, as well as the need for modification of current antithrombotic therapy," says Tatjana Potpara, MD, Ph.D., FESC, lead author on the guideline. "By addressing these interactions and risks in a guideline, we can better prepare clinicians to make informed decisions on their treatment plan and standardize care."

The guideline includes the conditional recommendations relating to:

1. acute coronary syndrome/percutaneous coronary intervention
2. a history of or acute stroke or transient ischemic attack
3. previously known or newly diagnosed atrial fibrillation
4. peripheral artery disease/acute limb ischemia

The recommendations include:

• In hospitalized patients with COVID-19 and confirmed acute coronary syndrome (ACS), we recommend dual antiplatelet therapy to reduce the risk of recurrent ACS or death.
• In outpatients with COVID-19 receiving antiplatelet therapy for a previous stroke, we suggest against the addition of or change to oral or subcutaneous anticoagulation.
• In hospitalized patients with COVID-19, not in the ICU, receiving oral anticoagulation for atrial fibrillation in whom the discontinuation of oral anticoagulation is needed during hospitalization, we suggest switching over to therapeutic dose LMWH or unfractionated heparin.
• In hospitalized patients with COVID-19 and stable peripheral artery disease (i.e., no acute limb events or revascularization procedures within the past 30 days), we suggest continuation of antiplatelet therapy if concurrent prophylactic-dose anticoagulation for COVID-19 is being given.

The existing evidence and panel consensus do not suggest a major departure from the management of arterial thrombosis as per pre-COVID-19 recommendations. Data on the optimal strategies for prevention and management of arterial thrombosis and thromboembolism in patients with COVID-19 are sparse, and more high-quality evidence is needed to inform management strategies in these patients.