This article focuses on:
- Definition of high risk for progression to ICU
- Rationale for early anticoagulation
- Rationale for choice of anticoagulant
Definition of high risk for progression to ICU
- Clinicians should consider combination of exam findings ( e.g, labored breathing, RR> 24, decreased O2 requirement (e.g. >4LNC) and lab biomarkers (e.g: elevated CRP, elevated creatinine, rising d-dimer >1.0)
Rationale for early anticoagulation
- Pathophysiology of COVID-19 associated respiratory disease is consistent with pulmonary vascular thromboemboli with increased dead space ventilation
- Autopsy studies have demonstrated venous thromboembolism in deceased coronavirus patients.
- Early anticoagulation is necessary to prevent propagation of microthrombi at disease presentation.
- Anticoagulation may be presented with decreased mortality
Rationale for choice of anticoagulant
- Heparins bind tightly to COVID-19 spike proteins
- Heparins also downregulate IL-6 and directly dampen immune activation
- DOACs do not appear to have these anti-inflammatory properties
- Rivaroxaban can be used in place of Apixaban in this algorithm