Thromboprophylaxis in Patients with COVID-19: Systematic Review of National and International Clinical Guidance Reports

Background: Venous thromboembolism (VTE) is common among patients with severe coronavirus disease 2019 (COVID-19). Anticoagulation in hospitalized COVID-19 patients has been associated with survival benefit; however, the optimal thromboprophylaxis strategy has not yet been defined. Objective: To identify published guidance reports by national and international societies regarding thromboprophylaxis strategies in COVID-19 patients in different settings (outpatients, hospitalized, post-discharge). Methods: A systematic review of the literature (Pubmed/EMBASE) was conducted independently by two investigators. Results: Among 1942 initially identified articles, 33 guidance documents were included: 20 published by national and 13 by international societies. These documents provide recommendations mainly for hospitalized (97% of reports) and post-discharge (75%) COVID-19 patients, and less so for outpatients (34%). Thrombotic and bleeding risk stratification prior to any treatment decision is the cornerstone of all suggested thromboprophylaxis strategies; 81% of the documents recommend thromboprophylaxis for all hospitalized patients with a prophylactic dosage of low molecular weight heparin irrespective of VTE risk. Intermediate or therapeutic dose intensity is recommended in high VTE risk patients by 56% and 28% of documents, respectively. Mechanical thromboprophylaxis is suggested in case of high bleeding risk or contraindication to pharmacological thromboprophylaxis (59% of documents). Extended pharmacological thromboprophylaxis is recommended for patients with high VTE risk after hospital discharge (63% of documents). For non-hospitalized outpatients, 28% of documents recommend pharmacological thromboprophylaxis for high VTE risk. Conclusion: The current guidance identifies thromboprophylaxis in COVID-19 patients, especially during hospitalization, as of major importance for the prevention of VTE. Recommendations are derived from limited evidence from observational studies.

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Sex-based outcomes in contemporary antiplatelet therapy trials

Open Heart ◽

10.1136/openhrt-2021-001761 ◽

2021 ◽

Vol 8 (2) ◽

pp. e001761

Author(s):

Mirvat Alasnag ◽

Tara L Jones ◽

Yasmin Hanfi ◽

Nicola Ryan

Keyword(s):

High Risk ◽

Antiplatelet Therapy ◽

Bleeding Risk ◽

Coronary Intervention ◽

Representation Of Women ◽

Percutaneous Coronary ◽

Risk Patients ◽

High Risk Populations ◽

High Bleeding Risk ◽

Randomised Controlled

Balancing ischaemic and bleeding risks in high-risk populations undergoing percutaneous coronary interventions has become an everyday dilemma for clinicians. It is particularly difficult to make decisions concerning combinations and duration of antiplatelet regimens in women given the poor representation of women in trials that have shaped current practice. Several contemporary landmark trials have recently been presented at the American College of Cardiology. The trials included the Harmonising Optimal Strategy for Treatment of coronary artery diseases-EXtended Antiplatelet Monotherapy, Ticagrelor With Aspirin or Alone in High-Risk Patients After Coronary Intervention and the TicAgrelor versus CLOpidogrel in Stabilised Patients With Acute Myocardial Infarction. In this article, we summarise the main findings of these trials and include the The Polymer-free Drug-Coated Coronary Stents in Patients at High Bleeding Risk (LEADERS FREE) in search for evidence based best practices for women patients. Although some of these trials had prespecified a subanalysis of sex differences, women constituted only 17%–30% of participants making sex-specific analyses challenging. Data suggest that women benefit from de-escalation to both ticagrelor and clopidogrel monotherapy. However, given the increased bleeding risks observed in women further randomised controlled trials are necessary to determine the most appropriate combination and duration of dual antiplatelet therapy as well as maintenance single antiplatelet therapy.

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FINAL TWO-YEAR RESULTS FROM THE RANDOMIZED ONYX ONE TRIAL IN HIGH BLEEDING RISK PATIENTS TREATED WITH 1-MONTH DAPT

Journal of the American College of Cardiology ◽

10.1016/s0735-1097(21)02258-0 ◽

2021 ◽

Vol 77 (18) ◽

pp. 899

Author(s):

Stephan Windecker ◽

Elvin Kedhi ◽

Azeem Latib ◽

David Kandzari ◽

Ajay Kirtane ◽

...

Keyword(s):

Bleeding Risk ◽

Risk Patients ◽

High Bleeding Risk

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Acute coronary syndrome patients with two minor high-bleeding risk criteria have the same bleeding rate that patients with one major criteria

European Heart Journal ◽

10.1093/ehjci/ehaa946.1311 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

A Cordero ◽

J.M Garcia-Acuna ◽

M Rodriguez-Manero ◽

B Cid ◽

B Alvarez Alvarez ◽

...

Keyword(s):

Major Bleeding ◽

Academic Research ◽

Bleeding Risk ◽

Bleeding Events ◽

Post Discharge ◽

Bleeding Rate ◽

Coronary Syndrome ◽

All Cause Mortality ◽

High Bleeding Risk ◽

Minor Criteria

Abstract Background In 2019 the Academic Research Consortium of high-bleeding risk (ARC-HBR) proposed a new and binary definition of high-bleeding risk (HBR) patients based on the presence of 1 major or 2 minor criteria. Methods Prospective study of all consecutive patients admitted for ACS in two different centers. We analyzed bleeding incidence in patients with 1 major criteria (1MC) vs. 2 minor criteria (2mC) using the 2019 ARC-HBR consensus. Bleeding events were collected according those fitting definitions 3 or 5 of the BARC consortium. Results We included 8,724 patients included and 40.9% we classified as HBR; 20.9% for 1MC and 20.0% for 2mC. In-hospital mayor bleeding rate was 8.6%; no-HBR patients had 0.3%, 2mC 15.1% and 1MC 29.7% (p<0.001 for the comparison). In contrast, the statistically highest in-hospital mortality was observed in patients with 2mC (11.4%), followed by patients with 1MC (8.0%) and no-HBR patients (2.0%). During follow-up (median time 57.8 months) all-cause mortality rate was 21.0% and cardiovascular dead 14.2%. The incidence of post-discharge major bleeding was 10.5%. No-HBR patients had the lowest bleeding rate (7.4%) and no difference was observed in patients with 1MC (14.6%) or 2mC (15.8%) (figure). The multivariate analysis, adjusted by age, gender, medical treatment, atrial fibrillation and revascularization and considering all-cause mortality as competing risk, showed independent association of 1MC (sHR: 1.46, 95% 1.22–1.75) and 2mC (sHR: 1.31, 95% CI 1.05–1.63) with post-discharge major bleeding. Conclusions HBR patients according to the 2019 ARC-HBR containing 2mC or 1MC are at similar and higher risk of in-hospital or post-discharge bleeding events Funding Acknowledgement Type of funding source: None

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TCT CONNECT-64 Impact of DAPT Cessation in High Bleeding-Risk Patients Undergoing PCI: Insights From the PARIS Registry

Journal of the American College of Cardiology ◽

10.1016/j.jacc.2020.09.038 ◽

2020 ◽

Vol 76 (17) ◽

pp. B27-B28

Author(s):

Davide Cao ◽

George Dangas ◽

Samantha Sartori ◽

Zhongjie Zhang ◽

Cono Ariti ◽

...

Keyword(s):

Bleeding Risk ◽

Risk Patients ◽

High Bleeding Risk

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Drug-coated balloons for coronary artery disease: current concepts and controversies

Future Cardiology ◽

10.2217/fca-2019-0009 ◽

2019 ◽

Vol 15 (6) ◽

pp. 437-454 ◽

Cited By ~ 3

Author(s):

Dario Buccheri ◽

Renzo M Lombardo ◽

Bernardo Cortese

Keyword(s):

Bleeding Risk ◽

Coronary Intervention ◽

Side Branch ◽

Bioresorbable Vascular Scaffold ◽

Total Occlusion ◽

Small Vessels ◽

Stent Restenosis ◽

Risk Patients ◽

Artery Disease ◽

High Bleeding Risk

Drug-coated balloons (DCBs) are a novel development for percutaneous coronary intervention. The first successful application was in-stent restenosis but in recent years, strong evidence has been released for its use in native small-vessels disease. Additional applications such as acute myocardial infarction, chronic total occlusion and bifurcation lesions are still under investigation. This article reviews the key studies evaluating the role of DCBs in several settings and reports on interesting cases where DCBs showed positive results for high-risk patients with neoplasm, as well as with high bleeding risk, planned surgery or renal injury. We also highlight a new biodegradable therapy for coronary bifurcation treatment, in which a bioresorbable vascular scaffold is implanted in the main branch, completed with a DCB angioplasty in the side branch when a treatment is deemed necessary.

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