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 Expert consensus recommends taking proactive measures or even discontinuing all antiplatelet therapy in patients with platelet counts < 100,000/μL and < 50,000/μL, respectively. 7 There is, however, a more current recommendation that suggests switching to monotherapy if the count is < 50,000/ μL and suspending therapy if the count is < 25,000/μL, always considering ischemic risk vs. bleeding risk. 5 4.3. Thrombolytics Both the American Heart Association and the European Society of Cardiology indicate the use of thrombolysis as the first option in suspected/confirmed COVID-19 patients with acute myocardial infarction and ST-segment elevation, both in centers without hemodynamic services and in those with hemodynamic services that have not made adequate preparations to avoid contaminating the team. 5,7,44-47 So far, there is no contraindication for using thrombolytics in this context,andtheiruseshouldbebasedontheusualcontraindications and should be individualized in situations of electrical or hemodynamic instability, disseminated intravascular coagulation, thrombocytopenia, bleeding and renal or hepatic failure. 48 It should be pointed out that differential diagnoses of ST-segment elevation should always be considered, such as myopericarditis, for which thrombolysis should be avoided. 5 5. Final Considerations Evidence about the interaction of COVID-19 with coagulation and platelet activation systems is still early. There is strong evidence that this pathway could be an important therapeutic target. However, more robust studies are still needed to determine the real importance of prothrombotic mechanisms and the best therapy for this group of patients. Table 1 – General recommendations about COVID-19/antiplatelet agents and anticoagulants Indication Class of recommendation Level of evidence Drug association between antithrombotic therapies and medications used in the treatment of COVID-19 In patients using lopinavir-ritonavir, prasugrel should be the antiplatelet agent of choice IIB B In patients using lopinavir-ritonavir, if prasugrel is contraindicated, clopidogrel should be used IIB B In patients using lopinavir-ritonavir, if clopidogrel is used, platelet activity should be monitored IIB B Ticagrelor should be discouraged in patients using lopinavir-ritonavir IIB B In patients who are already using anticoagulants and will be using lopinavir-ritonavir, the anticoagulant must be replaced with the parenteral form (heparins) IIA B In patients who are already using anticoagulants, avoid associating rivaroxaban or edoxaban with lopinavir-ritonavir III B In patients who are already using anticoagulants with warfarin (and must continue this medication) and lopinavir-ritonavir, prothrombin time should be evaluated more frequently. IIA B Remdesivir has no significant drug interaction with antiplatelet agents and anticoagulants IIA B Corticosteroids have no significant drug interaction with antiplatelet agents and anticoagulants IIA B Immunoglobulins and anti-interleukin-6 antibodies have no significant drug interaction with antiplatelet agents and anticoagulants IIB B Hydroxychloroquine and chloroquine have no significant drug interaction with antiplatelet agents and anticoagulants IIB B In patients using hydroxychloroquine or chloroquine, the QT interval should be monitored IA B The use of anticoagulants in patients with COVID-19 Chemical prophylaxis for thromboembolic events should be performed for all inpatients IIA B Full anticoagulation should be considered in special cases after assessing the risk/benefits, e.g., using the sepsis-induced coagulopathy score or D-dimer >6 normal IIB B In patients who are already using anticoagulants, the medication should be continued whenever possible IIA B Consider extending chemical prophylaxis for thromboembolic events up to 45 days after discharge for at-risk patients IIB B The use of antiplatelet agents in patients with COVID-19 The medication patients with chronic coronary disease should be continued IIA C In patients using dual antiplatelet therapy post-angioplasty (with a PCI more than 3 months ago) monotherapy may be considered, as long as the risk of bleeding and stent thrombosis is considered. IIA B 299