Table 4

Current guidelines and recommendations on use of anticoagulation in COVID-19

GuidelineConsideration of therapeutic anticoagulationDuration of therapeutic anticoagulationConsideration of thrombolysisMonitoring of patients receiving therapeutic anticoagulationTermination of anticoagulationMechanical thromboprophylaxis
CDC50 Clinically suspected thromboembolic events or high suspicion despite of normal imaging findings.No mentionInconclusive data. In pregnancy with acute PE and haemodynamic instability, thrombolysis may be usedAs per standard care in patients without COVID-19.Active bleeding severe thrombocytopaenia.No mention
ISTH-IG51 No recommendationsNo mentionNo mentionNo mentionActive bleeding or platelets <25 × 109/L.No mention
ACF52 Clinically suspected thromboembolic events or high suspicion despite of normal imaging findings.3 Months course for patients initiated on anticoagulation during hospitalisation (except in recent bleeding or high bleeding risk).STEMI, acute ischaemic stroke, or high-risk massive PE with haemodynamic instability.Monitor anti-Xa levels in UFH. Monitor anti-Xa or PTT in patients with normal baseline PTT levels and no heparin resistance (> 35 000 u heparin over 24 hours).Active bleeding or profound thrombocytopaeniaIntermittent pneumatic compression if contraindication to pharmacological thromboprophylaxis. Both mechanical and pharmacological thromboprophylaxis in critically ill patients if no contraindication.
ASH53 Increasing the intensity of anticoagulation regimen or change anticoagulants in patients with recurrent thrombosis of catheters and extracorporeal circuits (ie, ECMO, CRRT) on prophylactic anticoagulation regimens.No mentionNo mentionAnti-Xa monitoring of UFH.Active bleeding and platelet count < 25 × 109/L or fibrinogen <0.5 g/L. Therapeutic anticoagulation may need to be held if platelet count <30–50 × 109/L or fibrinogen <1.0 g/L.Mechanical thromboprophylaxis when pharmacological thromboprophylaxis is contraindicated.
SCC-ISTH54 Therapeutic anticoagulation not to be considered for primary prevention. Increased intensity of anticoagulation regimen can be considered in patients without confirmed VTE or PE but have deteriorating pulmonary status or ARDS.Minimum 3 monthsNo mentionNo specific recommendations.No specific recommendations.Mechanical thromboprophylaxis if pharmacological therapy contraindicated.
ACC55 Therapeutic anticoagulation in VTE. Haemodynamically stable patients with submassive PE.No mentionSystemic fibrinolysis is indicated for haemodynamically high-risk PE.No mentionSuspected or confirmed DIC without overt bleeding.Mechanical thromboprophylaxis considered in immobilised patients if pharmacological prophylaxis is contraindicated.
ACCP5 PE or proximal DVTMinimum 3 monthsNo mentionAnti-Xa levels in all patients receiving UFH given potential of heparin resistance.No mentionMechanical thromboprophylaxis in critically ill patients who have a contraindication to pharmacological thromboprophylaxis.

  • ACC, American College of Cardiology; ACCP, American College of Chest Physicians; ACF, Anticoagulation Forum; ARDS, acute respiratory distress syndrome; ASH, American Society of Hematology; CDC, Centers for Disease Control and Prevention; CRRT, continuous renal replacement therapy; DVT, deep vein thrombosis; ECMO, extracorporeal membrane oxygenation; ISTH-IG, International Society of Thrombosis and Hemostasis Interim Guidance; PE, pulmonary embolism; PTT, partial thromboplastin time; SCC-ISTH, Scientific and Standardization Committee of ISTH; STEMI, ST elevation myocardial infarction; UFH, unfractionated heparin.