Anti-coagulant and anti-platelet therapy in the COVID-19 patient: a best practices quality initiative across a large health system

ABSTRACTThe coronavirus disease 2019 (COVID-19) pandemic due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has challenged health-care systems and physicians worldwide to attempt to provide the best care to their patients with an evolving understanding of this unique pathogen. This disease and its worldwide impact have sparked tremendous interest in the epidemiology, pathogenesis, and clinical consequences of COVID-19. This accumulating body of evidence has centered around case series and often empiric therapies as controlled trials are just getting underway. What is clear is that patients appear to be at higher risk for thrombotic disease states including acute coronary syndrome (ACS), venous thromboembolism (VTE) such as deep vein thrombosis (DVT) or pulmonary embolism (PE), or stroke. Patients with underlying cardiovascular disease are also at higher risk for morbidity and mortality if infected. These patients are commonly treated with anticoagulation and/or antiplatelet medications and less commonly thrombolysis during hospitalization, potentially with great benefit but the management of these medications can be difficult in potentially critically ill patients.In an effort to align practice patterns across a large health system (Jefferson Health 2,622 staffed inpatient beds and 319 intensive care unit (ICU) beds across 14 facilities), a task force was assembled to address the utilization of anti-thrombotic and anti-platelet therapy in COVID-19 positive or suspected patients. The task force incorporated experts in Cardiology, Vascular Medicine, Hematology, Vascular Surgery, Pharmacy, and Vascular Neurology. Current guidelines, consensus documents, and policy documents from specialty organizations were used to formulate health system recommendations.Objective Our goal is to provide guidance to the utilization of antithrombotic and antiplatelet therapies in patients with known or suspected COVID-19.KEYWORDS: COVID-19anti-coagulationanti-plateletthrombosisacute coronary syndromevenous thromboembolismstrokeperipheral arterial diseaseleft ventricular assist deviceextracorporeal membrane oxygenation AcknowledgmentsWe want to acknowledge the following people who helped with formulation of our best practice initiative for our institution: David Fischman MD, Michael Savage MD, Alec Vishnevsky MD, Nicholas Ruggiero MD, Robert Watson MD, Mohammad Murtaza MD, Kartic Giri MD, Matthew Decaro MD, Gregary Marhefka MD, Rene Alvarez MD, Eduardo Rame MD, Howard Weitz MD, Yair Lev MD, Nawar Al Rawas MD, Hitoshi Hirose MD,PhD, Paul Dimuzio MD, Babak Abai MD, Dawn Salvatore MD, Christian Fidler MD, Lynda Thomson Pharm D, Steven McKenzie MD, Moshe Chasky MD, Michael Rotkowitz MD, Walter Kraft MD, Robert Perry MD, Laurence Needleman MD, Photi Galanis MD, Luis Eraso MD, Dina Orapallo CRNP, Heather Yenser CRNP.Declaration of interestThe contents of the paper and the opinions expressed within are those of the authors, and it was the decision of the authors to submit the manuscript for publication.The authors report no conflicts of interest for their manuscript.Reviewer’s disclosuresA reviewer on this manuscript has disclosed that their institution has received research grants, and they have received honoraria for CME programs and consulting for companies developing novel antithrombotic therapies. The other peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.