Anticoagulation in Patients With COVID-19: JACC Review Topic of the Week

doi:10.1016/j.jacc.2021.12.023

Journal of the American College of Cardiology

Volume 79, Issue 9, 8 March 2022, Pages 917-928

https://doi.org/10.1016/j.jacc.2021.12.023 Get rights and content

Under a Creative Commons license

open access

Highlights

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Clinical, laboratory, and autopsy findings support an association between COVID-19 and thromboembolic disease.
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Randomized trials have not demonstrated a benefit for full-dose heparin in critically ill patients with COVID-19.
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In noncritically ill patients with COVID-19 evidence supports an increase in organ-free support days with full-dose vs prophylactic-dose heparin, albeit with increased bleeding.

Abstract

Clinical, laboratory, and autopsy findings support an association between coronavirus disease-2019 (COVID-19) and thromboembolic disease. Acute COVID-19 infection is characterized by mononuclear cell reactivity and pan-endothelialitis, contributing to a high incidence of thrombosis in large and small blood vessels, both arterial and venous. Observational studies and randomized trials have investigated whether full-dose anticoagulation may improve outcomes compared with prophylactic dose heparin. Although no benefit for therapeutic heparin has been found in patients who are critically ill hospitalized with COVID-19, some studies support a possible role for therapeutic anticoagulation in patients not yet requiring intensive care unit support. We summarize the pathology, rationale, and current evidence for use of anticoagulation in patients with COVID-19 and describe the main design elements of the ongoing FREEDOM COVID-19 Anticoagulation trial, in which 3,600 hospitalized patients with COVID-19 not requiring intensive care unit level of care are being randomized to prophylactic-dose enoxaparin vs therapeutic-dose enoxaparin vs therapeutic-dose apixaban. (FREEDOM COVID-19 Anticoagulation Strategy [FREEDOM COVID]; NCT04512079)

Central Illustration

Key Words

anticoagulation

clinical trial

coagulopathy

COVID-19

Abbreviations and Acronyms

DIC

disseminated intravascular coagulation

ICU

intensive care unit

LMWH

low–molecular weight heparin

SARS-CoV2

severe acute respiratory syndrome-coronavirus-2

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: Listen to this manuscript's audio summary by Editor-in-Chief Dr Valentin Fuster on JACC.org.

: Donald Clark, III, MD, MPH, served as Guest Associate Editor for this paper. Javed Butler, MD, MPH, MBA, served as Guest Editor-in-Chief for this paper.

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