Anticoagulation in COVID-19: A Systematic Review, Meta-analysis, and Rapid Guidance From Mayo Clinic

Abstract

A higher risk of thrombosis has been described as a prominent feature of COVID-19. This systematic review synthesizes current data on thrombosis risk, prognostic implications, and anticoagulation effects in COVID-19. We included 37 studies from 4,070 unique citations. Meta-analysis was performed when feasible. Coagulopathy and thrombotic events were frequent among patients with COVID-19, and further increased in those with more severe forms of the disease. We also present guidance on the prevention and management of thrombosis from a multidisciplinary panel of specialists from the Mayo Clinic. The current certainty of evidence is generally very low, and continues to evolve.

Factors associated with survival in older patients affected by COVID-19: A retrospective cohort study

“…The positive effect of anticoagulant therapy on in-hospital survival was also observed in another study with a larger population ( Paranjpe, Fuster, & Lala, 2020 ). Anti-thrombotic dosage modifications have been proposed in COVID-19 patients with several risk factors for thrombosis such as obesity, previous deep vein thrombosis and active cancer, but more studies addressing this approach with high quality evidence in the light of bleeding risk are still lacking ( Marietta, Ageno, & Artoni, 2020 ; McBane, Torres Roldan, & Niven, 2020 ; Testa, Paoletti, Giorgi-Pierfranceschi, & Pan, 2020 ).…”

Clinical Presentation, Course, and Risk Factors Associated with Mortality in a Severe Outbreak of COVID-19 in Rhode Island, USA, April–June 2020

“…Due to the small numbers taking anticoagulation other than enoxaparin, conclusions regarding differences in the impact of specific anticoagulants could not be made. Current evidence for use of prophylactic anticoagulation in COVID-19 patients is predominantly based on observational studies of inpatient populations [ 29 ], though incidence of pulmonary embolism even in non-hospitalized asymptomatic COVID-19 patients without other predisposing factors for thrombosis suggests that even outpatients could potentially benefit from anticoagulation [ 30 , 31 ]. We found only one anticoagulation study in the LTCF population, a retrospective multi-center case series of 101 Dutch nursing home residents, that reported no significant evidence of mortality benefit with use of oral antithrombotic therapy [ 32 ].…”

Outcomes of COVID-19 With the Mayo Clinic Model of Care and Research

“…29 Among those intubated, adherence to best supportive care was encouraged early. 30 Special emphasis was made on lung protective strategy, early prone positioning, conservative fluid strategy, judicious use of sedative and neuromuscular blocking agents, and management of the hypercoagulable state, 3 as well as adherence to the modified ABC-DEF bundle (assess and manage pain, both spontaneous awakening and breathing trial, choice of sedation, delirium assessment, early mobility and exercise, and family communication and involvement). 31 Although ECMO use was infrequent, going to ECMO early when it was determined to be indicated may have contributed as well.…”

“…Interprofessional work groups were developed across multiple impacted specialties to appraise the emerging literature on topics such as testing strategies 2 and thromboprophylaxis. 3 As necessary, providers with specific expertise in organ-specific complications such as nephrology, hematology, and neurology, among others, were invited to be part of the team and provide input as treatment algorithms were developed and matured. These best practices were compiled and shared with the Mayo Clinic staff in real time through the AskMayoExpert platform, a clinical knowledge resource that serves the Mayo Clinic practice.…”