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Use of Anticoagulants in COVID-19: A Review
Sam Ngu1, John Kolton Smith2, Mark Goldin3,4,5
1Department of Hematology and Oncology, Lenox Hill Hospital, Northwell Health, New York, NY.
Insights
Coronavirus disease 2019 (COVID-19) increases thrombotic risk, necessitating enhanced prophylaxis. Risk stratification using D-dimer and disease severity guides anticoagulant choice, dose, and duration for better patient outcomes.
Area of Science:
- Thrombosis and Hemostasis
- Infectious Diseases
- Pharmacology
Background:
- Coronavirus disease 2019 (COVID-19) is linked to increased thrombotic events due to hypercoagulability.
- Elevated D-dimer levels and disease severity predict thrombosis risk in hospitalized COVID-19 patients.
- Breakthrough thrombosis despite prophylaxis highlights the need for improved strategies.
Purpose of the Study:
- To review evidence guiding COVID-19 thromboprophylaxis and treatment.
- To inform updated professional society guidance on anticoagulation for COVID-19 patients.
- To examine emerging data on postdischarge and outpatient COVID-19 thromboprophylaxis.
Main Methods:
- Systematic review of published peer-reviewed observational studies and randomized controlled trials.
- Inclusion of major professional society guidance on thrombosis prevention and treatment.
- Analysis of key trials including INSPIRATION, ACTION, RAPID, HEP-COVID, and MICHELLE.
Main Results:
- High-quality data support changes in COVID-19 thromboprophylaxis practices.
- Risk stratification is crucial for determining anticoagulant selection, dosage, and duration.
- Variability in anticoagulation approaches for COVID-19 persists.
Conclusions:
- Substantial evidence supports enhanced thromboprophylaxis for COVID-19.
- Risk stratification using setting, severity, and biomarkers like D-dimer is critical.
- Further research is needed for optimal anticoagulation in postdischarge and ambulatory settings.
Background:
Coronavirus disease 2019 (COVID-19) is associated with elevated rates of major and fatal thrombotic events, postulated to be the result of a hypercoagulable state mediated through inflammatory and immunomodulatory mechanisms. Early observational studies showed that disease severity and elevated serum D-dimer levels can predict thrombotic risk in patients hospitalized with COVID-19 and reported an alarming phenomenon of breakthrough thrombosis despite standard-of-care prophylaxis, suggesting the need for enhanced thromboprophylactic strategies.
Areas Of Uncertainty:
Data on anticoagulant agent selection, dosing, and duration for COVID-19 inpatients are now poised to inform updated professional society guidance. However, there remains limited high-quality data regarding postdischarge and especially ambulatory patients with COVID-19.
Data Sources:
This review includes published, peer-reviewed, observational, and randomized controlled trial data and major professional society guidance informing thrombosis prevention and treatment in patients with COVID-19.
Therapeutic Advances:
There remains great variability in the approach to anticoagulation in COVID-19. This article will review pathogenesis of COVID-related thrombosis and the evidence guiding thromboprophylaxis particularly in inpatients, with attention to the INSPIRATION, ACTION, RAPID, HEP-COVID, and multiplatform trials. Emerging thromboprophylaxis data from the postdischarge setting (particularly the recently published MICHELLE trial), and the outpatient setting, will be examined. Finally, thrombosis treatment considerations will briefly be reviewed.
Conclusions:
Substantial high-quality data support practice changes to COVID-19 thromboprophylaxis. Risk stratification by setting, disease severity, and biomarkers such as D-dimer is critical in considering choice, dose, and duration of anticoagulants.
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