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Sinai Anticoagulation Pathway

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MSHS Treatment Guidelines COVID-19 to look for most updated PDF under “MSHS Treatment Guidelines for COVID-19 Adults - COVID-19 Anticoagulation Algorithm” updated 4/28/20. Refer to this document for specific dosages

General Anticoagulation Pathway

All admitted patients with COVID-19:

  • Assess for VTE risk factors, signs or symptoms of DVT and PE, severity, and bleeding risk.
    • Assessment of severity is based on clinical judgment, and includes:
      • symptoms (worsening dyspnea)
      • signs (e.g., RR >24)
      • oxygen requirement (e.g., ≥6L O2 NC)
      • biomarkers (e.g., D-dimer >1.5 or increasing)
    • Increased risk for bleeding includes:
      • active bleeding
      • PLT <50K
      • INR >1.8.

Who should adhere to the Anticoagulation Pathway?

  • All admitted patients with moderate to severe COVID-19
    • Exclude patients with high risk of bleeding

What labs should be tracked daily?

  • Daily CBC
  • PT/PTT
  • D-Dimer

Rationale for early anticoagulation and type of anticoagulant?

  • Early anticoagulation prevents propagation of microthrombi and is associated with decreased mortality.
  • Choice of anticoagulation: Heparins bind tightly to COVID-19 spike proteins and downregulate IL-6 and directly dampen immune activation. DOACs do NOT have anti-inflammatory effects like Heparins

Appropriate steps based on risk level of coagulopathy

Anticoag Risk Steps

What determines High Risk?

  • Worsening dyspnea
  • RR > 24
  • O2 > 6L O2 NC
  • D-dimers > 1.5
  • High creatinine
  • Increased CRP

When to discontinue anticoagulation

  • Hold anticoagulation if evidence of bleeding, platelet count <50K, INR >1.5
  • Upon discharge, consider 2 weeks of prophylactic anticoagulation if patient on anticoagulant in hospital