Guidance for the Management of Patients with Vascular Disease or Cardiovascular Risk Factors and COVID-19: Position Paper from VAS-European Independent Foundation in Angiology/Vascular Medicine

Abstract

COVID-19 is also manifested with hypercoagulability, pulmonary intravascular coagulation, microangiopathy, and venous thromboembolism (VTE) or arterial thrombosis. Predisposing risk factors to severe COVID-19 are male sex, underlying cardiovascular disease, or cardiovascular risk factors including noncontrolled diabetes mellitus or arterial hypertension, obesity, and advanced age. The VAS-European Independent Foundation in Angiology/Vascular Medicine draws attention to patients with vascular disease (VD) and presents an integral strategy for the management of patients with VD or cardiovascular risk factors (VD-CVR) and COVID-19. VAS recommends (1) a COVID-19-oriented primary health care network for patients with VD-CVR for identification of patients with VD-CVR in the community and patients' education for disease symptoms, use of eHealth technology, adherence to the antithrombotic and vascular regulating treatments, and (2) close medical follow-up for efficacious control of VD progression and prompt application of physical and social distancing measures in case of new epidemic waves. For patients with VD-CVR who receive home treatment for COVID-19, VAS recommends assessment for (1) disease worsening risk and prioritized hospitalization of those at high risk and (2) VTE risk assessment and thromboprophylaxis with rivaroxaban, betrixaban, or low-molecular-weight heparin (LMWH) for those at high risk. For hospitalized patients with VD-CVR and COVID-19, VAS recommends (1) routine thromboprophylaxis with weight-adjusted intermediate doses of LMWH (unless contraindication); (2) LMWH as the drug of choice over unfractionated heparin or direct oral anticoagulants for the treatment of VTE or hypercoagulability; (3) careful evaluation of the risk for disease worsening and prompt application of targeted antiviral or convalescence treatments; (4) monitoring of D-dimer for optimization of the antithrombotic treatment; and (5) evaluation of the risk of VTE before hospital discharge using the IMPROVE-D-dimer score and prolonged post-discharge thromboprophylaxis with rivaroxaban, betrixaban, or LMWH.

A Matter of Caution: Coagulation Parameters in COVID-19 Do Not Differ from Patients with Ruled-Out SARS-CoV-2 Infection in the Emergency Department

“…To our knowledge, this is the first thorough description of combined routine and nonroutine coagulation analyses comparing patients suspected for COVID-19 and proven SARS-CoV-2 infected patients at admission to the ED. In light of the recent attempts to outline optimal anticoagulation regimes in COVID-19, 20,36,37 our findings underline the difficulty to identify patients who will benefit from anticoagulation at an early stage. Our data might indicate that continuous monitoring of coagulation seems mandatory in patients with proven COVID-19 infection or in those patients where infection cannot yet be reliably ruled out.…”

Angiotensin II, III, and IV may be important in the progression of COVID-19

“…Thrombotic events are common during COVID-19 and antithrombotic therapy has been shown to reduce mortality. 21 ACEIs and ARBs have antithrombotic effects mediated by Ang 1-7. 22 These effects may be lost when the virus disrupts ACE2 function and inhibits Ang 1-7 formation.…”

Rationale and design for the study of rivaroxaban to reduce thrombotic events, hospitalization and death in outpatients with COVID-19: The PREVENT-HD study

“…While acknowledging the potential benefit of post-hospitalization thromboprophylaxis, expert opinion and guidance statements have disagreed on the need for primary thromboprophylaxis in outpatients with COVID-19 with thrombotic risk factors ( 16 , 17 , 18 ). The underlying mechanisms of the hypercoagulable state in patients with COVID-19 are not clear ( 17 ).…”