ABC | Volume 115, Nº2, August 2020

Statement Arq Bras Cardiol. 2020; 115(2):292-301 Position Statement on the Use of Antiplatelet Agents and Anticoagulants in Patients Infected with the New Coronavirus (COVID-19) – 2020 Figure 1 – Management suggestion and flowchart for assessing anticoagulant therapy in critically ill patients with COVID-19. RR: respiratory rate; SIC: sepsis-induced coagulopathy; INR: international normalized ratio; SOFA: sequential organ failure assessment; DIC: disseminated intravascular coagulation; ULN: upper limit of normal. protein, high or rising D-dimer levels, and high fibrinogen levels. With respect to D-dimer levels, the recommendation is full anticoagulationwhen>3,000 ng/mL, chemical prophylaxis alone when<500 ng/mL, and 40mg enoxaparin every 12 hours when between 500 and 3,000 ng/mL. 42 Prophylaxis for thromboembolism, which should be continued after hospital discharge, must also be individualized with either low molecular weight heparin or new anticoagulants, assessing the risk/ benefit of thrombotic events vs. bleeding (Figure 2). Although there is no specific evidence regarding COVID-19, it is reasonable to consider individualizing the risk stratification of thromboembolic and hemorrhagic events and extending drug prophylaxis for up to 45 days in patients with reduced mobility, cancer, previous VTE, high D-dimer levels (i.e., > 2 times the upper limit of normal). 5 Regarding patients who have been using anticoagulants for any reason, themedication should be continued whenever possible. However, if the patient is hospitalized for COVID-19-associated pneumonia, continuation must be determined on a case-by- case basis. Since there may be changes in the pharmacokinetics of medications, renal failure, liver failure, thrombocytopenia, and disseminated intravascular coagulation in critically ill patients, parenteral anticoagulation with low molecular weight heparin or unfractionated heparin is preferable if there are no contraindications. 5,7,26,27,31,39,40 There is an interaction between lopinavir-ritonavir and oral anticoagulants. It is not advisable to administer rivaroxaban and edoxaban concomitantly. Inpatients usingwarfarin, apixabandoses should be reduced and there should more frequent monitoring of prothrombin time. Thus, in patients who have been using oral anticoagulants and must continue using them after admission, it is advisable to administer low molecular weight heparin in the parenteral form. It should be remembered that if patients evolve to blooddyscrasiaor disseminated intravascular coagulation, the riskof bleeding must be considered when continuing these medications, since they are suspended in almost all cases. 32 4.2. Antiplatelet Agents Patients who use antiplatelet agents for chronic coronary disease should continue taking them. In hospitalized patients on dual antiplatelet therapy, the prescription should be individualized (Figure 3). 5,7,40 Given the high risk of bleeding in patients after percutaneous coronary intervention (PCI) complicated by COVID-19, a shorter duration of dual antiplatelet therapy (DAPT) may be beneficial in this population in addition to the preferential use of clopidogrel in those at high risk of bleeding, although the risk of stent thrombosis vs. bleeding should always be considered. To counterbalance the increased risk of bleeding associated with DAPT, more recent studies have provided evidence in favor of early withdrawal of acetylsalicylic acid after PCI, which mainly reduces bleeding rates. Among patients on DAPT, continuing the P2Y 12 inhibitor in monotherapy (preferably ticagrelor) may be a reasonable strategy when a PCI was performed more than 3 months ago. Due to a lack of evidence, DAPT should not be discontinued for those who received a PCI less than 3 months ago. 5,7 If the patient requires antivirals, there is an interaction between lopinavir-ritonavir and clopidogrel and ticagrelor, and these medications should be avoided or platelet activity evaluated. Prasugrel can be administered with caution, unless there are contraindications. Interactions with intravenous antiplatelet agents such as cangrelor have not been reported. 11,30,32 297