Therapeutic anticoagulation (LMWH preferred) may be considered in patients without high-risk features for serious bleeding* and NOT requiring organ support. If used, anticoagulation for COVID-19 should start within 72 hours of admission and continue for 14 days or until hospital discharge. Patients who decompensate and require organ support while on therapeutic anticoagulation should continue on therapeutic anticoagulation.
Therapeutic anticoagulation was superior to standard of care for composite 21-day organ support free survival in the ATTACC/ACTIV-4a/REMAP-CAP trials. Benefits
appear to be driven by reducing progression to high-flow oxygen, non-invasive ventilation, or vasopressors. There was insufficient certainty on whether therapeutic anticoagulation improves mortality or intubation.
Therapeutic anticoagulation reduces thrombotic events
(1.4% vs 2.7%) but may increase major bleeding (1.9% vs 0.9%).
*High risk features for bleeding include: age 75 or greater, eGFR less than 30 mL/min, any coagulopathy, platelet count less than 50, use of dual antiplatelet therapy, recent history of serious GI bleed or recent intracranial condition (stroke, neurosurgery, aneurysm, cancer), epidural or spinal catheter.