Antithrombotic Therapy Forpatients With COVID-19

JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. -, NO.
-, 2021
ª 2021 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
PUBLISHED BY ELSEVIER
JACC STATE-OF-THE-ART REVIEW
Recent Randomized Trials of

Antithrombotic Therapy for
Patients With COVID-19
JACC State-of-the-Art Review
Azita H. Talasaz, PHARMD,a,b Parham Sadeghipour, MD,c Hessam Kakavand, PHARMD,a,b

Maryam Aghakouchakzadeh, PHARMD,a Elaheh Kordzadeh-Kermani, PHARMD,a Benjamin W. Van Tassell, PHARMD,d,e
Azin Gheymati, PHARMD,a Hamid Ariannejad, MD,b Seyed Hossein Hosseini, PHARMD,a Sepehr Jamalkhani,c
Michelle Sholzberg, MDCM, MSC,f,g Manuel Monreal, MD, PHD,h David Jimenez, MD, PHD,i Gregory Piazza, MD, MS,j
Sahil A. Parikh, MD,k,l Ajay J. Kirtane, MD, SM,k,l John W. Eikelboom, MBBS,m Jean M. Connors, MD,n
Beverley J. Hunt, MD,o Stavros V. Konstantinides, MD, PHD,p,q Mary Cushman, MD, MSC,r,s Jeffrey I. Weitz, MD,t,u
Gregg W. Stone, MD,k,v Harlan M. Krumholz, MD, SM,w,x,y Gregory Y.H. Lip, MD,z,aa Samuel Z. Goldhaber, MD,j
Behnood Bikdeli, MD, MSj,k,w
ABSTRACT
Endothelial injury and microvascular/macrovascular thrombosis are common pathophysiological features of coronavirus
disease-2019 (COVID-19). However, the optimal thromboprophylactic regimens remain unknown across the spectrum of
illness severity of COVID-19. A variety of antithrombotic agents, doses, and durations of therapy are being assessed in
ongoing randomized controlled trials (RCTs) that focus on outpatients, hospitalized patients in medical wards, and pa-
tients critically ill with COVID-19. This paper provides a perspective of the ongoing or completed RCTs related to
antithrombotic strategies used in COVID-19, the opportunities and challenges for the clinical trial enterprise, and areas of
existing knowledge, as well as data gaps that may motivate the design of future RCTs. (J Am Coll Cardiol 2021;-:-–-)
© 2021 by the American College of Cardiology Foundation.
THROMBOEMBOLISM IN PATIENTS WITH patients (1–4). Pooled analyses have helped in

CORONAVIRUS DISEASE-2019 providing aggregate estimates of thrombotic events
(4,5). In a recent systematic review and meta-
Microvascular and macrovascular thrombotic com- analysis, the overall incidence of VTE among in-
plications, including arterial and especially venous patients with COVID-19 was estimated at 17% (95%
thromboembolism (VTE), seem to be common clinical confidence interval [CI]: 13.4 to 20.9), with variation
manifestations of coronavirus disease-2019 (COVID- based on study design and method of ascertainment;
19), particularly among hospitalized and critically ill there was a four-fold higher incidence rate in patients
From the aDepartment of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran; bTehran
Heart Center, Tehran University of Medical Sciences, Tehran, Iran; cCardiovascular Intervention Research Center, Rajaie Car-
diovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran; dDepartment of Pharmacotherapy and
Outcome Science, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia, USA; ePauley Heart Center, Di-
vision of Cardiology, Department of Internal Medicine, School of Pharmacy, Virginia Commonwealth University, Richmond,
Virginia, USA; fDepartments of Medicine and Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario,
Canada; gDepartment of Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada; hDepartment of Internal Medicine, Hospital
Universitari Germans Trials i Pujol, Universidad Católica San Antonio de Murcia, Barcelona, Spain; iRespiratory Department,
Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (Instituto de Ramón y Cajal de Investigación Sanitaria),
Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Madrid, Spain; jCardiovascular Medicine Division,
ISSN 0735-1097/$36.00 https://doi.org/10.1016/j.jacc.2021.02.035

2 Talasaz et al. JACC VOL. -, NO. -, 2021
Antithrombotic Therapy RCTs in COVID-19 -, 2021:-–-
ABBREVIATIONS in the intensive care units (ICUs) compared

AND ACRONYMS HIGHLIGHTS
with non-ICU settings (28% vs. 7%) (6). In
addition, postmortem studies show frequent Venous and arterial thrombosis are
BID = twice daily
evidence of microvascular thrombosis in pa- prevalent in patients with COVID-19.
CI = confidence interval
tients with COVID-19 (7,8). The influence of
COVID-19 = coronavirus Optimal thromboprophylaxis has not
these events on mortality rates remains un-
disease-2019 been established for patients with this
known (9).
CrCl = creatinine clearance disease.
DOAC = direct oral PATHOPHYSIOLOGY OF
Numerous randomized trials are evalu-
anticoagulant
THROMBOEMBOLISM IN COVID-19:
ating antithrombotic regimens for out-
HMGB1 = high-mobility group VIRCHOW’S TRIAD IN ACTION
box protein 1 patients and inpatients with COVID-19.
ICU = intensive care unit
COVID-19 can potentiate all 3 components of Ongoing experience has influenced the
LMWH = low-molecular-
Virchow’s triad and increases the risk of design, conduct, analysis, and reporting
weight heparin
thrombosis (Figure 1). First, severe acute the results of these trials.
NET = neutrophil extracellular
respiratory syndrome-coronavirus-2 (SARS-
trap
CoV-2) infection may trigger endothelial inhibitor; fibrinogen; factors V, VII, VIII, and X; and
PaO2/FiO2 = partial arterial
pressure of oxygen/fraction of dysfunction. Using the angiotensin- von Willebrand factor (16). Increased platelet reac-
inspired oxygen converting enzyme 2, which is expressed on tivity, NETosis, and alterations in the aforementioned
QD = once daily the surface of many cells, SARS-CoV-2 enters hemostatic factors result in a hypercoagulable state
RCT = randomized controlled endothelial cells and may impair their (17–22).
trial intrinsic antithrombotic properties. It is Particularly in COVID-19, it is believed that the
SARS-CoV-2 = severe acute proposed that viremia, hypoxia, the inflam- excessive inflammatory response plays an important
respiratory syndrome-
matory response, increased expression of role in the pathogenesis of thrombosis (thromboin-
coronavirus-2
tissue factor, and elevated levels of neutro- flammation), including pulmonary microthrombosis
UFH = unfractionated heparin
phil extracellular traps (NETs) can together and pulmonary intravascular coagulopathy (7,8).
VTE = venous
disrupt the hemostasis equilibrium and pro- Antiphospholipid antibodies have been identified in
thromboembolism
mote endothelial activation (10–12). This in- some patients (23), but their clinical significance is
WHO = World Health
Organization duction of a procoagulant state along with uncertain (24). Finally, COVID-19 may predispose
the reduction in plasminogen activators patients to venous stasis and increase the risk of
further results in increased platelet reactivity (13–15). (venous) thrombosis. Fatigue, hypoxemia, being
Inflammatory cytokines and endothelial activation connected to medical devices (for hospitalized pa-
can lead to downregulation of antithrombin and tients), or acute illness (including pulmonary
protein C expression. They can also lead to an in- involvement, myocarditis with associated heart fail-
crease in the levels of plasminogen activator ure, or other forms of severe disease) can all lead to
Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA; kClinical Trials Center, Cardiovascular
Research Foundation, New York, New York, USA; lNewYork-Presbyterian Hospital/Columbia University Irving Medical Center,
m
New York, New York, USA; Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton,
Ontario, Canada; nHematology Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School,
Boston, Massachusetts, USA; oHaemostasis and Thrombosis Centre, St. Thomas’ Hospital, London, United Kingdom; pCenter for
Thrombosis and Hemostasis, Johannes Gutenberg University of Mainz, Mainz, Germany; qDepartment of Cardiology, Democritus
University of Thrace, Komotini, Greece; rDepartment of Medicine, University of Vermont Larner College of Medicine and Uni-
versity of Vermont Medical Center, Burlington, Vermont, USA; sDepartment of Pathology and Laboratory Medicine, University of
Vermont Larner College of Medicine and University of Vermont Medical Center, Burlington, Vermont, USA; tDepartment of
Medicine, McMaster University, Hamilton, Ontario, Canada; uThrombosis and Atherosclerosis Research Institute, Hamilton,
Ontario, Canada; vZena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New
w
York, USA; Center for Outcomes Research and Evaluation (CORE), Yale School of Medicine, New Haven, Connecticut, USA;
x
Department of Health Policy and Administration, Yale School of Public Health, New Haven, Connecticut, USA; ySection of Car-
diovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA; zLiverpool
Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool, United Kingdom; and
the aaDepartment of Clinical Medicine, Aalborg University, Aalborg, Denmark. Paul F. Bray, MD, served as Guest Associate Editor
for this paper. Christie Ballantyne, MD, served as Guest Editor-in-Chief for this paper.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’
institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information,
visit the Author Center.
Manuscript received January 29, 2021; accepted February 5, 2021.

JACC VOL. -, NO. -, 2021 Talasaz et al. 3
-, 2021:-–- Antithrombotic Therapy RCTs in COVID-19
limited mobility and venous stasis (25,26). All the METHODS

aforementioned mechanisms may increase the risk of
arterial and venous thrombosis, thereby affecting the We conducted a systematic literature search of trials
severity of illness. in ClinicalTrials.gov and the World Health Organiza-
tion (WHO) International Clinical Trials Registry
ANTITHROMBOTIC PROPHYLAXIS IN
Platform, with the pre-defined key words of COVID-19
COVID-19: PROS AND CONS
and search terms for antiplatelet agents, anticoagu-
lants, anticoagulation, fibrinolytic agents, and
Bedside observations, pathophysiological in-
antithrombotic agents. The identified studies were
vestigations, and initial epidemiological data led to
screened, and those that were designed as RCTs with
enthusiasm for antithrombotic prophylaxis in COVID-
at least 1 active arm of antithrombotic therapy (date
19 (27–31). The concern for thrombotic risk was
of last search December 16, 2020) were included.
heightened by reports of VTE in 13% to 56% of pa-
Supplemental Table 1 summarizes study-level inclu-
tients despite the use of standard prophylaxis
sion and exclusion criteria for this review.
(32–35). This led some experts to recommend empir-
For the included studies, PubMed and MedRxiv
ical use of escalated doses of anticoagulant agents
were searched for design papers, study protocols, or
(36). However, the risks associated with intensified
published results of those studies. The list was com-
use of antithrombotic agents, such as bleeding,
plemented by hand-searching and discussion within
should be weighed against the presumptive benefits
the author group.
(22,27,31).
In addition, there have been variations in meth- REVIEW OF ONGOING OR COMPLETED RCTs
odology and outcomes assessment for thrombotic
events, including the concern about counting in situ After identification of 918 records and manual
thrombosis in small vessels (a recognized feature of screening of 180 records, 75 RCTs were included in
acute lung injury also known as immunothrombosis) this study (Supplemental Figure 1). In 13 cases, a
as pulmonary emboli. Due to these issues, as well as design paper and/or study protocol was available. Of
the concerns regarding excess bleeding, a number of all ongoing studies, 1 RCT reported the results in
guidance statements have not recommended empir- peer-reviewed literature (38) and 1 shared the find-
ical escalated-dose anticoagulation (27,37). ings on a pre-print server (39). For 3 RCTs, final re-
Multiple ongoing randomized controlled trials sults are unknown, but patient enrollment was
(RCTs) are evaluating a variety of antithrombotic paused in critically ill patients due to concern for
regimens in patients with COVID-19 (Figure 2). These futility and potential excess of safety events (40).
include trials of antiplatelet agents, anticoagulants, As of December 16, 2020, a total of 75 RCTs of
fibrinolytic agents, or combinations of these agents. antithrombotic agents for patients with COVID-19
In most trials, the intensity of antithrombotic therapy were registered at the ClinicalTrials.gov or WHO In-
is proportional to the expected thrombotic event ternational Clinical Trials Registry Platform data-
rates in the population under study. Less intensive bases. Figure 2 provides a graphical summary of all
therapies, including antiplatelet agents, oral antico- RCTs of antithrombotic agents in COVID-19 in a
agulants, and standard prophylactic dose of low- pharmacological-based approach. Agents used in
molecular-weight heparin (LMWH), are typically these trials include antiplatelet agents, unfractio-
studied in the outpatient or lower acuity hospital nated heparin (UFH) and heparin derivatives, paren-
settings. In turn, more intensive therapies, including teral direct thrombin inhibitors (DTIs), direct oral
intermediate-dose or fully therapeutic doses of anti- anticoagulants (DOACs), fibrinolytic agents, sulodex-
coagulants, or even fibrinolytic therapy, are under ide (a mixture of heparin sulfate and dermatan
investigation in RCTs of hospitalized critically ill sulfate) (39), dociparstat (a heparin derivative with
patients. anti-inflammatory properties), and nafamostat (a
The aims of the current paper were to systemati- synthetic serine protease inhibitor with anticoagulant
cally summarize the ongoing and completed RCTs of activity). A succinct discussion of the design features
antithrombotic therapy in patients with COVID-19 of these trials is provided in the following sections
and to evaluate the strengths and limitations of the according to the clinical setting. Additional details are
study designs, as well as the challenges and oppor- provided in Supplemental Tables 2 and 3.
tunities related to conducting and interpreting RCTs In each section, the discussion begins with paren-
during a global pandemic. teral anticoagulants, followed by fibrinolytic therapy,
F I G U R E 1 Virchow’s Triad and COVID-19 Associated Coagulopathy
Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) can potentiate all 3 sides of Virchow’s triad, including endothelial
dysfunction, blood flow stasis, and hypercoagulability. Angiotensin-converting enzyme-2 (ACE-2)–dependent viral entry and the virus-
induced inflammatory response can lead to endothelial dysfunction. Bedridden status may lead to stasis; inflammation, viremia, and cytokine
storm can produce a hypercoagulable state. Factor Xa may play a role in spike protein cleavage and endocytosis of the virus.
COVID-19 ¼ coronavirus disease-2019; DIC ¼ disseminated intravascular coagulopathy; FDP ¼ fibrin degradation products; GM-
CSF ¼ granulocyte-macrophage colony-stimulating factor; IL ¼ interleukin; LV ¼ left ventricular; PAI ¼ plasminogen activator inhibitor;
RNA ¼ ribonucleic acid; SIC ¼ sepsis-induced coagulopathy; TF ¼ tissue factor; TNF ¼ tumor necrosis factor; tPA ¼ tissue type plasminogen
activators; uPA ¼ urokinase plasminogen activators; vWF ¼ von Willebrand factor.
oral anticoagulants, antiplatelet agents, and investi- ONGOING CLINICAL TRIALS OF ANTITHROMBOTIC
gational agents with antithrombotic properties. This AGENTS IN THE OUTPATIENT SETTING. Eleven RCTs
sequence is arbitrary and does not indicate treatment of antithrombotic therapy in outpatients with COVID-
preference. Figure 3 illustrates how RCTs of various 19 have been registered in clinical trials databases and
agents can fill the knowledge gaps about antith- are studying enoxaparin, DOACs, aspirin, and sulo-
rombotic therapy in COVID-19 in various settings of dexide compared with no treatment (6 of 11) or
illness severity. with placebo (5 of 11). These trials are mostly (8 of 11)
F I G U R E 2 Summary of RCTs of Antithrombotic Agents in COVID-19 Categorized Based on Pharmacological Class
Unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), direct thrombin inhibitors (DTIs), direct oral anticoagulants (DOACs), antiplatelets, fibrinolytic
agents, and investigational agents are being evaluated in different settings, including outpatients, inpatients (intensive care unit [ICU] and non-ICU), and post-
discharge. *Multifactorial designs or multiple interventions. COVID ¼ coronavirus disease-2019; RCTs ¼ randomized controlled trials.
open-label, with the number of participants ranging LMWHs (at standard prophylactic dose), DOACs (at
from 172 to 7,000 patients, and they include patients both low intensity and high intensity), aspirin, and
with a hyperinflammatory or procoagulant profile sulodexide are the agents under investigation in the
(including elevated levels of C-reactive protein [1 of outpatient setting. ETHIC and OVID RCTs are
11] or D-dimer [2 of 11]) and exclude patients at comparing the effect of a standard prophylactic dose
high risk of bleeding (e.g., those with a history of of enoxaparin versus no intervention on the primary
recent gastrointestinal bleeding or intracranial outcome of hospitalization or mortality in 2,370 in-
hemorrhage). Pregnant women and patients with se- dividuals (41). Low-intensity rivaroxaban (10 mg once
vere kidney dysfunction (creatinine clearance [CrCl] daily [QD]) is being evaluated in a total of 4,600 pa-
levels <30 ml/min) are excluded from 8 of 11 and 6 tients in 2 ongoing RCTs (PREVENT-HD [A Study of
of 11 of these trials, respectively. The most common Rivaroxaban to Reduce the Risk of Major Venous and
primary efficacy outcomes in the outpatient trials Arterial Thrombotic Events, Hospitalization and
include the need for hospitalization, incidence of Death in Medically Ill Outpatients With Acute,
thromboembolic events, mortality, or composite Symptomatic Coronavirus Disease 2019 (COVID-19)
outcomes inclusive of these factors. Bleeding events Infection; NCT04508023] and Study to Evaluate
(5 of 11) constitute the most commonly assessed Safety and Efficacy of Rivaroxaban for High Risk
safety endpoints in the trials with an outpa- People With Mild COVID-19 [NCT04504032]). Low-
tient setting. intensity apixaban (2.5 mg twice daily [BID]) is also
F I G U R E 3 Graphical Summary of Ongoing RCTs of Antithrombotic Therapy in COVID-19 Based on Patient Settings
Categorizing the RCTs evaluating different agents in various settings, including those treated entirely as outpatients, patients in the non-ICU hospital wards, critically ill
patients in the ICU, and post-hospital discharge. Others: dociparstat, nafamostat, and sulodexide. Abbreviations as in Figure 2.
under investigation in the ACTIV-4b (Anti-throm- HERO-19 [Health Care Worker Prophylaxis Against
botics for Adults Hospitalized With COVID-19) trial in COVID-19], and CONVINCE [Corona Virus Edoxaban
up to 7,000 patients. High-intensity DOACs, including Colchicine]). The primary outcome for the COVID-
rivaroxaban (20 mg QD), apixaban (5 mg BID), and PREVENT, HERO-19, and CONVINCE trials is the
edoxaban (60 mg QD), are being investigated among composite of mortality and arterial and venous
7,992 patients in 4 RCTs (COVID-PREVENT, ACTIV-4b, thromboembolism; the primary outcome for the
randomized, double-blind, placebo-controlled ACTIV- Most trials exclude pregnant women (41 of 50) and
4b trial is a composite of venous and arterial throm- patients with active bleeding or history of intracranial
boembolism, hospitalization for cardiovascular/pul- or gastrointestinal bleeding (39 of 50). Many trials
monary events, and all-cause mortality. The impact of also exclude patients with CrCl levels <30 ml/min
low-dose aspirin on the composite rate of hospitali- (20 of 50). In most trials, the time frame for the primary
zations and mortality is being evaluated in 3 RCTs outcome assessment is 28 to 30 days, although a
with a total of 12,080 patients with COVID-19 (ACT- few studies are designed to assess the primary out-
COVID19 [Anti-Coronavirus Therapies to Prevent comes at earlier or longer durations. These RCTs are
Progression of Coronavirus Disease 2019 (COVID-19) focused on primary efficacy outcomes, including
Trial], LEAD COVID-19 [Low-risk, Early Aspirin and all-cause mortality, VTE, arterial thrombosis, require-
Vitamin D to Reduce COVID-19 Hospitalizations], and ment for respiratory support, or a composite of
ACTIV-4b). these outcomes.
SulES-COVID (Sulodexide in the Treatment of Early Twenty-eight ongoing studies are being conducted
Stages of COVID-19) is the only completed trial of to examine the efficacy of heparin-based regimens
antithrombotic therapy in outpatients with COVID-19 on primary outcomes such as all-cause mortality,
(39). This single-center study of 243 participants venous and arterial thrombosis, re-hospitalization,
assessed the efficacy of sulodexide compared with the need for invasive mechanical ventilation, or
placebo on 21-day rates of hospitalization and need composite outcomes inclusive of these factors in
for use of supplemental oxygen. Use of sulodexide hospitalized patients with COVID-19. Bleeding events
was associated with reduced hospital admissions is the most common (17 of 28) primary safety endpoint
(relative risk: 0.6; 95% CI: 0.37 to 0.96; p ¼ 0.03) and used in these trials. The majority of these RCTs have
need for oxygen support (relative risk: 0.71; 95% CI: chosen a standard-dose prophylactic anticoagulation
0.5 to 1; p ¼ 0.05), with no significant effect on mor- regimen as the comparator. Intermediate-dose anti-
tality. The study has limitations, including frequent coagulation will be tested in DAWn-Antico (Direct
(22.1%) post-enrollment exclusions due to negative Antivirals Working Anticoagulation) (45), X-COVID-
SARS-CoV-2 test results or loss to follow-up. 19, COVID-19 HD (Randomised controlled trial
Many of the outpatient antithrombotic therapy comparing efficacy and safety of high versus low Low-
trials for COVID-19 are large, and the follow-up win- Molecular Weight Heparin dosages in hospitalized
dows are sufficient to capture the intended primary patients with severe COVID-19 pneumonia and coa-
outcomes. An issue with some of these trials is an gulopathy not requiring invasive mechanical ventila-
open-label design, which is a pragmatic feature tion), COVI-DOSE (Weight-Adjusted vs Fixed Low
facilitating the design and enrollment but potentially Doses of Low Molecular Weight Heparin for Venous
limits the internal validity, especially for outcomes Thromboembolism Prevention in COVID-19), EMOS-
that may be less bias resistant. In addition, the COVID (Enoxaparin at Prophylactic or Therapeutic
available data do not clarify whether dose adjust- Doses in COVID-19), COVID-19-associated Coagulop-
ments are made for renal or liver dysfunction. athy: Safety and Efficacy of Prophylactic Anti-
coagulation Therapy in Hospitalized Adults With
ONGOING CLINICAL TRIALS OF ANTITHROMBOTIC COVID-19 (NCT04360824), and Impact of the use of
AGENTS IN HOSPITALIZED NON-ICU PATIENTS. low molecular weight heparins (LMWH), at prophy-
We identified 50 ongoing RCTs related to antith- lactic versus intermediate doses, on SARS-CoV2
rombotic therapy in hospitalized non-ICU patients infection (COVID-19) [EUCTR2020-001891-14-ES] with
with COVID-19. Most trials (44 of 50) are open-label. 4,434 patients in total. Conversely, a total of 18 RCTs
The antithrombotic agents under investigation with 19,776 patients will evaluate the efficacy of
include heparin (both systemic and inhaled), DOACs, therapeutic anticoagulation in non-ICU hospitalized
aspirin, P2Y12 inhibitors, dipyridamole, dociparstat, patients (46). Only 2 trials totaling 494 patients
nafamostat, and a combination of these drugs. The (IMPACT [InterMediate ProphylACtic Versus Thera-
planned sample sizes range between 34 and 20,000 peutic Dose Anticoagulation in Critically Ill Patients
patients. Considering the potential link between With COVID-19: A Prospective Randomized Study;
elevated D-dimer levels, microthrombosis, macro- NCT04406389] and HEP-COVID [Systemic Anti-
thrombosis, and worse outcomes in COVID-19 coagulation With Full Dose Low Molecular Weight
(42–44), many RCTs (16 of 50) include patients with Heparin (LMWH) Vs. Prophylactic or Intermediate
elevated D-dimer levels with cutoffs ranging from Dose LMWH in High Risk COVID-19 Patients;
>500 ng/ml to >1,500 ng/ml (or defined as >2 to 4 times NCT04401293]) will directly compare therapeutic
the upper limit of normal per the local laboratory). and intermediate doses of heparin. The different
intensities of heparin derivatives are summarized in rate of invasive mechanical ventilation or death is
Supplemental Table 3. assessed at 45 days’ post-randomization.
Recognizing that heparin has an anticoagulant ef- The potential protective effect of antiplatelet
fect but also an antiviral and anti-inflammatory effect agents in hospitalized patients with COVID-19 is being
(47,48), INHALE-HEP (Inhaled Nebulised Unfractio- evaluated in 11 RCTs. REMAP-CAP (A Randomised,
nated Heparin for the Treatment of Hospitalised Embedded, Multi-factorial, Adaptive Platform Trial
Patients With COVID-19) and NEBUHEPA (Nebulized for Community-Acquired Pneumonia) is a large global
Heparin in Severe Acute Respiratory Syndrome RCT with a multifactorial adaptive design that is
COVID-19) are evaluating the impact of nebulized UFH planning to randomize 7,100 patients to receive
on the rate of intubation in 856 hospitalized patients multiple therapeutic interventions, including an
with COVID-19. PACTR202007606032743 evaluates anticoagulant arm and an antiplatelet agent arm
the impact of nebulized UFH on the partial arterial evaluating aspirin and the P2Y12 inhibitors clopidog-
pressure of oxygen/fraction of inspired oxygen (PaO2/ rel, ticagrelor, or prasugrel (49). PEAC (Protective Ef-
FiO 2) ratio in 100 hospitalized patients. Standard of fect of Aspirin on COVID-19 Patients; NCT04365309)
care (for INHALE-HEP and PACTR202007606032743) aims to test the efficacy of aspirin in shortening clin-
and standard-dose prophylaxis with LMWH (NEBU- ical recovery time. The impact of aspirin on all-cause
HEPA) are the comparators. mortality among hospitalized patients is also under
The use of DOACs in hospitalized ward patients evaluation in the largest adaptive platform RCT for
with COVID-19 is under investigation in 5 RCTs. Low- COVID-19 (RECOVERY [Randomised Evaluation of
intensity rivaroxaban is being investigated in 650 COVID-19 Therapy]) with 20,000 participants (50).
planned participants in the ACOVACT (Austrian RESIST (CTRI/2020/07/026791) aims to evaluate the
Coronavirus Adaptive Clinical Trial) and XACT role of aspirin plus atorvastatin in clinical deteriora-
(Factor Xa Inhibitor Versus Standard of Care Heparin tion characterized by progression according to the
in Hospitalized Patients With COVID-19) trials of WHO clinical improvement ordinal score in 800 hos-
hospitalized patients to assess outcomes such as pitalized patients with COVID-19 (51). CAM-Covid-19
all-cause mortality, ICU admission, and intubation. evaluates the impact of a higher dose of aspirin
High-intensity (but not loading-intensity) DOACs, (325 mg 4 times a day) along with colchicine and
including rivaroxaban and apixaban, are being eval- montelukast on inflammatory markers such as high-
uated in large RCTs that will enroll a total of 4,750 sensitivity C-reactive protein in 34 patients.
participants (ACTION [Randomized Clinical Trial to PARTISAN (Prasugrel in Severe COVID-19 Pneumonia;
Evaluate a Routine Full Anticoagulation Strategy in NCT04445623) will be comparing the effect of prasu-
Patients With Coronavirus (COVID-19); NCT04394377], grel versus placebo among 128 patients with COVID-19
COVID-PREVENT [Effect of Anticoagulation Therapy on the primary outcome of improved oxygenation
on Clinical Outcomes in COVID-19], FREEDOM expressed as the PaO 2/FiO 2 ratio at 7-day follow-up.
[FREEDOM COVID Anticoagulation Strategy Random- Some RCTs are evaluating the impact of dipyr-
ized Trial; NCT04512079] COVID, and XACT [Factor Xa idamole in hospitalized patients with COVID-19.
Inhibitor Versus Standard of Care Heparin in Hospital- Dipyridamole 100 mg 4 times a day and the combi-
ized Patients With COVID-19; NCT04640181]). nation of dipyridamole extended-release 200 mg
Major bleeding is the primary safety endpoint in 3 of 6 twice daily and aspirin 25 mg twice daily are being
trials addressing DOACs in hospitalized non-ICU evaluated in 3 small RCTs (TOLD, DICER [Dipyr-
patients. idamole to Prevent Coronavirus Exacerbation of Res-
C-19-ACS (Preventing Cardiac Complications of piratory Status], and ATTAC-19 [Aggrenox To Treat
COVID-19 Disease with Early Acute Coronary Syn- Acute Covid-19]) for primary outcomes such as
drome Therapy) is an adaptive RCT conducted to D-dimer level changes (for the first 2 trials) and
evaluate the impact of the combination of low-dose improvement in the COVID-19 WHO ordinal scale (a
rivaroxaban (2.5 mg BID) plus aspirin 75 mg/day scale indicting severity of illness, from 0 [not infec-
plus clopidogrel 75 mg/day along with atorvastatin ted] to 8 [death]) (ATTAC-19).
and omeprazole on 30-day all-cause mortality in 3,170 High-mobility group box protein 1 (HMGB1) is a
hospitalized patients with COVID-19. Patients with protein involved in the pathogenesis of inflammation.
definite acute coronary syndromes are excluded from Elevated levels of HMGB1 are associated with worse
this RCT. The effect of dual pathway inhibition using outcomes in COVID-19 (52). Dociparstat, a heparin
the combination of low-dose rivaroxaban and aspirin derivative with presumed anticoagulant and anti-
is being evaluated in the adaptive ACTCOVID19 inflammatory properties, inhibits HMGB1 and may
inpatient study. In this RCT of 4,000 patients, the reduce the formation of NETs and the risk of
thrombosis. The drug is being studied in the Doc- PaO 2/FiO 2) status are the most common components
iparstat for the Treatment of Severe COVID-19 in of the primary efficacy outcomes. Bleeding complica-
Adults at High Risk of Respiratory Failure study tions are the most widely used primary safety
[NCT04389840] to assess its impacts on all-cause outcome among these studies.
mortality and need for mechanical ventilation in UFH and/or LMWH (19 studies) are the most com-
600 patients with severe COVID-19 (53). mon antithrombotic regimens under investigation in
Nafamostat is a synthetic serine protease inhibitor the ongoing trials in critically ill patients. INSPIRA-
with antiviral, anti-inflammatory, and anticoagulant TION (The Intermediate versus Standard-dose Pro-
activity previously used for anticoagulation during phylactic anticoagulation In cRitically-ill pATIents
hemodialysis (54). Nafamostat is under evaluation in with COVID-19: An opeN label randomized controlled
hospitalized patients with COVID-19 in 7 RCTs with trial) (55), IMPROVE (Intermediate or Prophylactic-
826 individuals in total. The primary efficacy Dose Anticoagulation for Venous or Arterial Throm-
outcome in 5 of these 7 trials is time to recovery. boembolism in Severe COVID-19: A Cluster Based
The strengths of many of the antithrombotic trials Randomized Selection Trial; NCT04367831), DAWn-
among inpatients with COVID-19 include relatively Antico, and COVI-DOSE are testing intermediate-
large sample sizes and ample follow-up for detection dose versus standard prophylactic dose anti-
of events. With multiple large clinical trials under- coagulation in more than 1,500 participants in total.
way, robust evidence should soon be available INSPIRATION has recently completed enrollment of
comparing the intermediate/therapeutic doses of 600 patients (55). Preliminary analyses indicate that
heparinoids versus usual care. However, studies such intermediate-dose compared with standard-dose
as PARTISAN and Clinical Trial on the Efficacy and anticoagulation did not reduce a composite of
Safety of Bemiparin in Patients Hospitalized Because venous or arterial thrombosis or death. The full re-
of COVID-19 (NCT04420299) have relatively small sults are imminent. IMPACT and HEP-COVID are
sample sizes and short periods of follow-up (7 and comparing therapeutic anticoagulation with
10 days, respectively), rendering them susceptible to intermediate-dose anticoagulation in a total of 494
a type II error. There is also variability across the individuals. Finally, 11 RCTs are evaluating the po-
trials in methods for identification and ascertainment tential role of therapeutic-dose versus standard pro-
of thrombotic outcomes. Lack of blinding and blinded phylactic dose anticoagulation in 5,142 patients. In
outcome adjudication are practical limitations for December 2020, preliminary results of an interim
some of these trials. analysis of pooled critically ill patients enrolled in 3
trials (ACTIV-4a, REMAP-CAP, and ATTACC [Antith-
ONGOING CLINICAL TRIALS OF ANTITHROMBOTIC rombotic Therapy to Ameliorate Complications of
AGENTS IN CRITICALLY ILL PATIENTS. The risk of COVID-19]) prompted the Data Safety and Monitoring
thrombotic events seems to be highest among criti- Boards to pause enrollment due to futility for the
cally ill patients with COVID-19. A systematic review endpoint of freedom from organ support at 21 days
estimated that VTE event rates in critically ill patients and a potential for harm due to possibly higher rates
with COVID-19 would be estimated at 27.9% (95% CI: of bleeding. More details are forthcoming (40).
22.1 to 34.1) (6). Currently, there are 33 ongoing RCTs Conversely, in January 2021, the same study groups
evaluating the role of antithrombotic agents in criti- paused enrollment into the strata of moderately ill
cally ill patients with COVID-19, of which 18 RCTs hospitalized patients with COVID-19 not requiring
enrolled mixed non-ICU and ICU populations and ICU level of care, in whom a preliminary analysis
15 RCTs solely enrolled ICU patients. The sample size showed a reduction in the need for ventilatory sup-
of these studies range from 15 to 20,000 patients. port or other organ-supportive interventions with
These trials are studying the role of systemic antico- therapeutic-dose enoxaparin (56). Data supporting
agulants (intermediate- to full-therapeutic-dose of these decisions have not yet been finalized or peer
heparin and direct thrombin inhibitors), inhaled reviewed, and they are anxiously awaited.
UFH, fibrinolytic agents (tenecteplase and alteplase), The only published RCT in critically ill patients with
antiplatelet agents (aspirin, clopidogrel, and dipyr- COVID-19 is HESACOVID (Therapeutic versus pro-
idamole), and nafamostat. Inclusion criteria in 11 of phylactic anticoagulation for severe COVID-19: A ran-
33 RCTs require D-dimer cutoffs ranging from domized phase II clinical trial), a single-center study
>500 ng/ml to >3,000 ng/ml (or defined as >2 to 6 of 20 patients requiring invasive mechanical ventila-
times the upper limit of normal limit). All-cause tion randomized to receive therapeutic-dose versus
mortality, venous and arterial thrombotic complica- standard-dose anticoagulation. Therapeutic-dose
tions, and oxygenation (expressed mostly as anticoagulation significantly increased PaO 2/FiO 2
and ventilator-free days (15 days [interquartile 48929], Tenecteplase in Patients With COVID-19
range: 6 to 16 days] vs. 0 days [interquartile range: [NCT04505592], and the Evaluation of Tissue Plas-
0 to 11 days]; p ¼ 0.028) (38). The study did minogen Activator (tPA) in comparition of anti-
not have sufficient power to compare all-cause coagulation for treatment of critical COVID 19 patient
mortality between the study groups. Bleeding may [IRCT20200415047080N1]) evaluating the safety and
have been underestimated due to barriers in per- efficacy of fibrinolytic therapy (tenecteplase or alte-
forming imaging testing, including computed to- plase) on COVID-19–related respiratory failure in a
mography scanning to identify a source, in critically total of 485 patients (59). Most of these trials include
ill patients (57). patients with severe disease (severe acute respiratory
CHARTER-Irl (Patients with SARS-CoV-2 Requiring distress syndrome, elevated troponin levels, and
Mechanical Ventilation in Ireland), CHARTER-MT elevated D-dimer levels). The primary outcomes in 5
(Can Nebulised Heparin Reduce Mortality and of these trials include the improvement in PaO 2/FiO 2
Time to Extubation in Patients With COVID-19 ratio or ventilator-free days. The time frame for
Requiring Mechanical Ventilation Meta-Trial), and studies evaluating the change in PaO 2/FiO2 ratio is
Nebulized Heparin for the Treatment of COVID-19 between 48 and 72 h; for those evaluating ventilator-
Induced Lung Injury (NCT04397510) are evaluating free days, it is 28 days. Patients receiving therapeutic
the utility of nebulized UFH in 292 mechanically anticoagulation, and those with thrombocytopenia or
ventilated critically ill patients with COVID-19. The a history of intracranial or gastrointestinal bleeding,
primary outcome for CHARTER-Irl is the alterations in are excluded from fibrinolytic therapy trials.
D-dimer area under the curve within a 10-day follow- The role of antiplatelet agents is under investiga-
up, and for CHARTER-MT is ventilator-free days with tion in critically ill patients in 4 trials. As previously
a follow-up duration of 28 days; the primary outcome described, dipyridamole (TOLD) and aspirin (RE-
for the Nebulized Heparin for the Treatment of COVERY and CAM-Covid-19) are under evaluation.
COVID-19 Induced Lung Injury study (NCT04397510) COVID-PACT is a multicenter, open-label study that
is improvement in the PaO 2/FiO 2 ratio within 10 days. will randomize 750 patients with a 2 2 factorial design
The use of parenteral anticoagulant agents trial to receive full-dose anticoagulation versus
other than UFH and LMWHs in COVID-19 is being standard-dose prophylactic anticoagulation with
studied in 2 trials. IMPACT will randomize 100 heparin-based regimens (first randomization) and to
ICU patients with COVID-19 into 4 arms to compare antiplatelet therapy with clopidogrel versus no anti-
fondaparinux, argatroban, intermediate-dose hepa- platelet therapy (second randomization). The primary
rin, and therapeutic-dose heparin (UFH/LMWH) with efficacy outcome is the incidence of VTE or arterial
the primary outcomes of 30-day mortality. In ANTI- thrombosis incidence 28 days after enrollment.
CO, bivalirudin is being investigated in 100 critically Nafamostat is under evaluation in 4 studies in
ill patients for the primary outcome of improvement critically ill patients with COVID-19 (DEFINE [Rapid
in oxygenation as determined by the PaO2/FiO2 Experimental Medicine for COVID-19; NCT04473053],
ratio (58). RACONA [RAndomized Clinical Trial in COvid19 Pa-
There are 6 RCTs (AtTAC [Tissue Plasminogen tients to Assess the Efficacy of the Transmembrane
Activator (tPA) Treatment for an Atypical Acute Res- Protease Serine 2 (TMPRSS2) Inhibitor NAfamostat;
piratory Distress Syndrome (Microvascular COVID-19 NCT04352400], Clinical Efficacy of Nafamostat
Lung Vessels Obstructive Thromboinflammatory Mesylate for COVID-19 Pneumonia [NCT04418128],
Syndrome (MicroCLOTS): A Multicentral Random- and A Study Evaluating the Efficacy and Safety of CKD-
ized; NCT04453371), STARS [Fibrinolytic Therapy to 314 (Nafabelltan) in Hospitalized Adult Patients Diag-
Treat ARDS in the Setting of COVID-19 Infection; nosed With COVID-19 Pneumonia [NCT04623021])
NCT04357730], TRISTARDS [ThRombolysIS Therapy with 650 participants in total.
for ARDS A Phase IIb/III Operationally Seamless, Research in the ICU faces several challenges for
Open-label, Randomised, Sequential, Parallel-group study design, data/sample collection, and patient
Adaptive Study to Evaluate the Efficacy and Safety of follow-up (60). In many cases, patients are uncon-
Daily Intravenous Alteplase Treatment Given up to 5 scious, and obtaining informed consent requires
Days on Top of Standard of Care (SOC) Compared discussion with health care proxies. This situation is
With SOC Alone, in Patients With Acute Respiratory further complicated because visitors are prohibited.
Distress Syndrome (ARDS) Triggered by COVID-19; The strengths of the aforementioned studies in the
NCT04640194], TACOVID [Evaluation of Tissue Plas- ICU include the diversity of studied antithrombotic
minogen Activator (tPA) in comparition of anti- agents and sample size in many RCTs. There are also
coagulation for treatment of critical COVID 19 patient; a number of notable limitations to these trials.
F I G U R E 4 Illustration of How Vulnerable Populations Were or Were Not Included in the Existing Trials
Categorizing the RCTs evaluating different agents in vulnerable populations, including patients with advanced kidney disease, end-stage kidney disease (ESKD), pa-
tients with liver failure, and obese patients. Further details are illustrated in Supplemental Figure 1. Obesity is defined differently in different RCTs; body mass index
>30, 35, and 40 kg/m2 and weight >100 and 120 kg are among the most-used definitions among RCTs. Others: dociparstat, nafamostat, and sulodexide. Abbreviations
as in Figure 2.
The most important limitation is the small sample ONGOING CLINICAL TRIALS IN POST-DISCHARGE
size in several studies, raising the possibility of a type PATIENTS. ACTIV-4c (COVID-19 Thrombosis Preven-
II error. The small sample size will mostly influence tion Trials: Post-hospital Thromboprophylaxis;
trials of thrombolytic therapy and nonheparin NCT04650087) is a double-blind, placebo-controlled
anticoagulants. RCT that will evaluate the impact of apixaban 2.5 mg
C E N T R A L IL L U ST R A T I O N Simplified Summary of Ongoing Antithrombotic Therapy Trials

in Coronavirus Disease-2019*
Talasaz, A.H. et al. J Am Coll Cardiol. 2021;-(-):-–-.
Heparin-based regimens are the most frequently studied antithrombotic agents in patients with coronavirus disease-2019. Trials of fibri-
nolytic therapy are reserved for patients admitted to the intensive care unit (ICU). *Additional details are provided in Figure 2 and
Supplemental Table 2. LMWH ¼ low-molecular-weight heparin; UFH ¼ unfractionated heparin.
BID on the rate of all-cause mortality and arterial and or 20 mg QD) is being investigated in 680 participants
venous thromboembolism on 5,320 post-discharge enrolled in general medical wards to measure the
patients. MICHELLE (Medically Ill Hospitalized Pa- incidence of VTE at 30 to 35 days after discharge. In
tients for COVID-19 THrombosis Extended Prophy- the HERO-19 study, edoxaban 60 mg QD or placebo
Laxis With Rivaroxaban ThErapy: The MICHELLE will continue after discharge in 172 patients who were
Trial; NCT04662684) is an open-label RCT with 320 randomized to treatment in the ICU or non-ICU set-
participants; it aims to evaluate the safety and effi- tings to evaluate all-cause mortality rate and VTE
cacy of rivaroxaban 10 mg QD for 35 4 days versus incidence at 42 days. Finally, aspirin in the PEAC
no intervention after hospital discharge with a com- study, and dipyridamole extended-release plus
posite efficacy outcome of VTE and VTE- aspirin in the ATTAC-19 study, will be continued after
related death. discharge in patients randomized to treatment in the
In addition, there are 7 RCTs with a projected total non-ICU general wards.
of 1,452 participants that will continue the already
assigned antithrombotic therapy after discharge in INCORPORATION OF VULNERABLE POPULATIONS
patients who were randomized in the general medical IN THE ONGOING TRIALS. Most of the ongoing RCTs
wards or in the ICU. In the INSPIRATION study, an are excluding patients at increased risk of bleeding, or
intermediate or standard prophylactic dose of enox- with acute and chronic hepatic failure. In >50% of the
aparin will be continued after discharge in 600 pa- trials designed to evaluate escalated dose anti-
tients who were randomized in the ICU to evaluate coagulation, patients with CrCl levels <15 ml/min are
the rate of VTE. In the COVID-PREVENT, XACT, and excluded. CoV-Hep is an open-label study that eval-
Effect of the Use of Anticoagulant Therapy During uates the role of low-dose (10 IU/kg per hour) intra-
Hospitalization and Discharge in Patients With venous UFH on the rate of clotted dialyzers in 90
COVID-19 Infection (NCT04508439) RCTs, post- critically ill patients with COVID-19 undergoing
discharge thromboprophylaxis with rivaroxaban (10 continuous venous–venous hemodialysis with a
T A B L E 1 Expected Knowledge Gains From Ongoing Antithrombotic Therapy Trials in COVID-19 and Ongoing Knowledge Gaps
Outpatient Noncritical Inpatient ICU Post-Discharge
Expected knowledge gain

The safety/efficacy of standard pro- The safety/efficacy of intermediate- The safety/efficacy of intermediate- The safety/efficacy of extended
phylactic doses of LMWHs and dose and therapeutic-dose heparin dose and therapeutic-dose anticoagulation with DOACs or
DOACs compared with standard derivatives or DOACs compared with anticoagulation compared with LMWHs after hospital discharge
of care or placebo in high-risk standard prophylactic prophylactic anticoagulation
patients with early stages of anticoagulation Effects of short-term infusion of
COVID-19 Proof-of-concept data of the role of bivalirudin on the PaO2/FiO2 ratio
The impact of aspirin administration inhaled antithrombotic therapy in The impacts of antiplatelet agents on
on rate of MACE, disease pro- patients with COVID-19 thrombotic outcomes and mortality
gression, hospitalization, and The impacts of antiplatelet agents on Proof-of-concept data on the role of
death in patients with acute, all-cause mortality fibrinolytic therapy in critically ill
symptomatic COVID-19 The safety/efficacy of dociparstat and patients
nafamostat in hospitalized patients Proof-of-concept data on the role of
The safety/efficacy of sulodexide in with COVID-19 inhaled antithrombotic therapy in
patients with acute, symptom- mechanically ventilated patients
atic COVID-19 with COVID-19
Remaining knowledge gap
PMA needed to understand the rela- The efficacy/safety of fondaparinux, The impact of antiplatelet therapy on The role of antiplatelet agents on VTE
tive efficacy of antiplatelet DTIs, and danaparoid compared survival in critically ill patients with incidence in post-discharge patients
agents, standard prophylactic with standard prophylactic COVID-19 The safety/efficacy of antithrombotic
dose of enoxaparin compared anticoagulation PMA needed to understand the therapy regimens in vulnerable
with DOACs PMA needed to understand the tradeoffs of various investigational subgroups, including obese
The safety/efficacy of antithrombotic tradeoffs of various investigational antithrombotic regimens patients, pregnant women, and
therapy regimens in vulnerable antithrombotic regimens Best assay for LMWH/UFH monitoring those with advanced kidney disease
subgroups, including obese pa- Best assay for LMWH/UFH monitoring in critically ill patients with COVID-
tients, pregnant women, and in noncritically ill patients with 19
those with advanced kidney COVID-19 The safety/efficacy of antithrombotic
disease The safety/efficacy of antithrombotic therapy regimens in vulnerable
therapy regimens in vulnerable subgroups, including obese
subgroups, including obese patients, pregnant women, and
patients, pregnant women, and those with advanced kidney disease
those with advanced kidney disease
COVID-19 ¼ coronavirus disease-2019; DOAC ¼ direct oral anticoagulants; DTI ¼ direct thrombin inhibitor; ICU ¼ intensive care unit; LMWH ¼ low-molecular-weight heparin; MACE ¼ major adverse
cardiovascular events; PaO2/FiO2 ¼ partial arterial pressure of oxygen/fraction of inspired oxygen; PMA ¼ prospective meta-analysis; UFH ¼ unfractionated heparin; VTE ¼ venous thromboembolism.
follow-up duration of 3 days. Specific dose adjust- definitions (61,62). Although observational evidence
ment for obesity is considered for 10 of 34 trials of suggests low rates of major bleeding (33,63), obser-
systemic heparin compounds. Pregnant women are vational studies have the potential for under-re-
excluded from 25 of 34 trials of systemic heparin ported outcomes, and therefore RCTs with systematic
compounds. Although patient selection in these and prospective capture of both thrombotic and
studies is based on practical considerations, it is un- bleeding events will help determine the true risk–
likely that high-quality evidence will soon be avail- benefit ratio for treatments. This is especially the
able for antithrombotic therapy in such vulnerable case because risk factors for thrombosis in COVID-19
subgroups (Figure 4, Supplemental Figure 2). With (e.g., D-dimer) may also predict bleeding (33).
limited high-quality data on the horizon for these Although results from the individual trials may
vulnerable and high-risk subgroups, decision-making inform interim practice, some challenges persist.
for optimal management in these patients will The large number of antithrombotic agents under
continue to be challenging. investigation, the variable dosing regimens tested,
THE IMPACT OF RCTs ON THE FUTURE PRACTICE OF and variability in trial conduct as well as methods
ANTITHROMBOTIC THERAPY. A large number of of outcome detection and adjudication may
RCTs will help to delineate the efficacy and safety of complicate the identification of the optimal regi-
antithrombotic agents in patients with COVID-19 mens. A prospective meta-analysis of RCTs, ideally
(Central Illustration). Until the results accrue, partici- with individual participant data, will help to assess
pation in these RCTs is encouraged. Efficacy out- the effects of distinct agents across the spectrum of
comes vary based on the location of enrollment (i.e., disease severity and may address the clinical and
between outpatient trials and inpatient trials). As for statistical heterogeneity of the upcoming results.
safety outcomes, many of the trials are systematically Efforts to harmonize endpoints have been advo-
assessing major bleeding by using the International cated, with creation of common data elements for
Society on Thrombosis and Haemostasis criteria or VTE, for example, to aid in pooling trial results
the Bleeding Academic Research Consortium (64,65). In addition, there are few head-to-head
T A B L E 2 Antithrombotic Therapy Trial Design Before and During the COVID-19 Pandemic
Before COVID-19 Pandemic During COVID-19 Pandemic
Investigators Single specialty-based collaboration common Specialty-based and multispecialty collaboration common
Focused, often established study groups Frequent ad hoc collaborations within and between institutions and countries
Study design Diverse research priorities Distinct focus on COVID-19–related trials; some adaptations required for pre–
Patient enrollment over a long time period; COVID-19 trials
recruitment time could be slow or fast Time-sensitive trial design (to provide rapid access to high-quality evidence).
Long-term follow-up a routine feature of many trials Trial design in short period of time may lead to multiple smaller and
underpowered trials rather than larger multicenter collaborations.
Urgently needed medical solutions necessitate relatively fast patient enrollment
Incorporation of pragmatic design features
Multiple projects around the world occasionally leading into several smaller
trials rather than fewer large-scale trials
Short-term follow-up most common
Applicability for adaptive platform design for multiple aspects of COVID-19
trials. Multiple interventions, quick enrollment, and the possibility of re-
estimation of the optimal sample size during the study
Higher certain event rates (death or re-admission) than excepted from protocol
Funding/ financial Time-consuming review and approval process for Accelerated review, prioritizing trials that affect the response to the pandemic
support funding allocation
IRB approval Time-consuming process with occasional long de- IRBs meeting more frequently, often resulting in rapid review and approval
lays before approval More permissive regulations may expedite trial initiation
Informed consent Based on paper forms; may be cumbersome In-person or remote electronic informed consent available in many trials
Participant Variable willingness for trial participation by Patients willing to participate and engage in trials as partners
enrollment and patients Periodic slowdown or interruptions in enrollment for some non–COVID-19 trials;
engagement in COVID-19 trials, there may be changes in enrollment rate with COVID-19
disease waves
Monitoring and On-site session for multiple predefined monitoring Frequent off-site online sessions with more restricted on-site visits
auditing visits Remote monitoring and follow-up
On-site or in-person data audits Rapid enrollment makes keeping up to date with monitoring difficult, with risk of
greater numbers of protocol deviations going unnoticed
Ascertainment of events other than all-cause mortality may be challenging due
to limitations in testing strategies during the pandemic
Clinical events Central blinded outcome adjudication common Some trials not able to incorporate endpoint adjudication (not recommended if
adjudication Face-to-face meetings resources allow)
High costs Systematic and blinded adjudication in online meeting for assessment endpoints
Time-consuming process to request ad hoc data Remote periodic meetings
from sites, summarize, and send back to adjudication Less expensive and quicker than face-to-face adjudication
meetings
DSMB meetings Face-to-face meetings Many trials using online platforms for DSMB meetings
High costs Less costly
Follow-up Face-to-face visits or telephone calls Remote monitoring and follow-up in many trials by telephone calls and use of
More costly digital technology
Cost-saving and more efficient
Dissemination of Longer peer review process Fast-track peer review process expedites the dissemination of completed
results More strict criteria for publication studies. However, very quick peer review has occasionally missed important
Uncommon use of pre-print servers flaws of submitted reports
Frequent use of pre-print servers to share the early results of the studies The
benefits of rapid dissemination and potential limitations with lack of peer
review should be considered among the audience of the results
Similar to the pre–COVID-19 era, some studies may report preliminary results by
press release, with full results becoming available days or weeks later
COVID-19 ¼ coronavirus disease-2019; DSMB ¼ Data and Safety Monitoring Board; IRB ¼ institutional review board; RCT ¼ randomized controlled trial.
comparisons for many of the experimental thera- Anti-inflammatory properties and activity against
pies, such as intermediate-dose regimens compared thromboinflammation have been attributed to several
with fully therapeutic heparin-based regimens. antithrombotic regimens, including heparin de-
Network meta-analytic techniques might generate rivatives and antiplatelet agents (30,67,68), with the
insights into the comparative tradeoffs of these potential to reduce large-vessel thrombosis and
regimens (66). Additional biomarker and clinical improve outcomes. Another evolving concept is the
risk prediction substudies can also further elucidate role of microthrombosis and pulmonary intravascular
subgroups with more favorable net benefit profiles coagulopathy (7,8,69) in the pathophysiology of res-
from distinct regimens. Moreover, the remaining piratory failure in COVID-19 (70). Results from the
knowledge gaps summarized in Table 1 should small HESACOVID study suggested improved arterial
be kept in mind so that the design of additional oxygenation (PaO 2/FiO 2) with therapeutic versus
studies could be considered. standard-dose prophylaxis anticoagulation in
critically ill patients with COVID-19 (38). However, have tested different steroid and antiviral regimens,
combined investigation of 3 large-scale randomized respectively, and have some additional agents under
trials of therapeutic anticoagulation (ACTIV-4a, investigation, including aspirin in one of the hy-
REMAP CAP, and ATTACC) paused enrollment of potheses from RECOVERY. REMAP-CAP is testing
critically ill patients for futility; we await further several interventions, including steroids, antiviral
clarifications (40). agents, biologic agents, simvastatin, and antiplatelet
Therapeutic drug monitoring of the investigational therapy. The ACTIV4 platform is similarly using an
agents is also important. Even when an agent is adaptive design for antithrombotic agents.
selected (e.g., UFH), the best method for dose titra- Notwithstanding the good will of investigators, the
tion or adjustment remains uncertain (71). Some ex- constant pressure to provide a rapid pandemic
perts recommend measuring anti–factor Xa levels in response may pose challenges as well. In some cases,
those receiving intravenous UFH, because the high multiple small single-center RCTs underpowered for
levels of factor VIII observed among critically ill pa- their clinical points or using surrogate endpoints with
tients with COVID-19 may interfere with activated short follow-up have been designed (74,82) and may
partial thromboplastin time assays. The necessity and compete against larger multicenter, and potentially
optimal method for dosing and monitoring of hepa- more definitive, studies. The large numbers of these
rins and LMWHs, in particular for patients with kid- trials alone, in addition to the intense pressure to
ney disease or obesity, have yet to be elucidated and present broadly and publish these findings, suggests
are even understudied outside COVID-19 (72). Ideally, at least some potential for type I error with amplifi-
future strategy trials should test the merits and lim- cation of these results through rapid dissemination of
itations of these monitoring tests. the results.
Additional methodological aspects deserve atten-
CLINICAL TRIAL ENTERPRISE DURING COVID-19 tion. Interpretation of these trial results may be
PANDEMIC: IS A QUANTUM LEAP TAKING PLACE? limited by underutilization of placebo (perhaps
The clinical trial enterprise has been significantly except for the outcome of mortality) (57,82). Some
affected during the COVID-19 pandemic (73). Patient experts consider that the pressures of working during
recruitment in many ongoing pre–COVID-19 trials was a global pandemic make the use of placebo more
temporarily halted. Notable challenges such as bar- aspirational than realistic. Nevertheless, when
riers to follow-up and site monitoring persist. How- feasible, placebo control improves the internal val-
ever, the desire to provide an evidence-based idity of a trial. Furthermore, appropriate endpoint
response has been one of the key drivers of positive assessment, including blinded adjudication when
changes during the pandemic (74). These changes feasible, and pre-specified analysis methods will
include multispecialty study teams, harmonization of remain of importance (57).
multicenter protocols, expedited multi-institutional Institutional Review Boards and independent
agreement execution and institutional review board ethics committees may experience the burden of
and governmental agency approvals, accelerated numerous protocol submissions and amendments
informed consent, and enrollment with digital during the pandemic. Burnout of health care systems
contact-free technology, expeditious outcomes during the pandemic, and the risks to the research
ascertainment, remote monitoring, and dissemina- teams are unique challenges that should also be
tion of the findings via fast-track publications, pre- considered when designing and executing study
prints, and social media accounts from scientific so- protocols (75). Investigators should attempt to fore-
cieties or investigators (Table 2) (75–77). see some of the challenges to minimize the need for
Although traditional RCTs have provided a great protocol amendments (83–85). Moreover, the
deal of knowledge for modern medicine, they are informed consent process has become adapted to
confined to testing a limited number of interventions. facilitate discussions by telephone or video confer-
Because COVID-19 has multiorgan involvement and ence, followed by verbal confirmation, and docu-
broad manifestations (including inflammation, acute mentation of consent using approved software
respiratory distress syndrome, thrombosis, and programs and electronic signature, where acceptable
others), adaptive platform trials, which allow for (83,86).
testing multiple interventions in a single disease Monitoring of efficacy and safety outcomes is also
based on a decisive algorithm, have gained attention critical. Execution of online Clinical Event Committee
(78). This type of trial has a perpetual and multiarm, and Data and Safety Monitoring Board meetings for
multistage design (79). The RECOVERY trial (80) and assessing the adverse events is a fast, safe, and effi-
the World Health Organization Solidarity trial (81) cient alternative to face-to-face meetings. If done
with appropriate planning to adhere to standards of ACKNOWLEDGMENT The authors express their
high-quality Clinical Event Committee and Data and sincere gratitude to Fatemeh Esmaeili, MS, for her
Safety Monitoring Board meetings, such approaches kind assistance in graphic designs.
may be considered even when society transitions out
FUNDING SUPPORT AND AUTHOR DISCLOSURES
of the pandemic (84,86).
Peer review and dissemination of the studies have Dr. Van Tassell has received research support from Novartis, Swed-
had unique challenges and advancements as well. ish Orphan Biovitrum, Olatec Therapeutics, and Serpin Pharma; and
Journal editors and reviewers have been pressured is a consultant of R-Pharm and Serpin Pharma. Dr. Monreal has
served as an advisor or consultant for Sanofi, Leo Pharma, and
for rapid release of the results of completed studies.
Daiichi-Sankyo; and has received a nonrestricted educational grant
This has activated the fast-track peer review process by Sanofi and Bayer to sponsor the Computerized Registry of Pa-
more than ever. Despite its merits, the “COVID-19 tients with Venous Thromboembolism. Dr. Jimenez has served as an
fatigue” created by the fast-track review process advisor or consultant for Bayer HealthCare Pharmaceuticals, Boeh-
ringer Ingelheim, Bristol Myers Squibb, Daiichi-Sankyo, Leo Pharma,
might negatively affect the quality of peer review, as
Pfizer, ROVI, and Sanofi; has served as a speaker or a member of a
noted by occurrence of post-publication major re- speaker bureau for Bayer HealthCare Pharmaceuticals, Boehringer
visions and retractions, including in major journals Ingelheim, Bristol Myers Squibb, Daiichi-Sankyo, Leo Pharma, ROVI,
and Sanofi; and has received grants for clinical research from
(87). In a recent study, only 29% of the clinical trials
Daiichi-Sankyo, Sanofi, and ROVI. Dr. Piazza has received research
of patients with COVID-19 reviewed on Clinical- grant support from Boston Scientific Corporation, Bayer, Bristol
Trials.gov met the Oxford Centre for Evidence-Based Myers Squibb/Pfizer, Portola/Alexion Pharmaceuticals, and Janssen
Medicine Level 2 evidence (88). The process of peer Pharmaceuticals; and has received consulting fees from Amgen,
Pfizer, Agile, and Prairie Education and Research Cooperative. Dr.
review remains an imperfect, yet essential, step in the
Parikh has received institutional research support from Abbott
evaluation and reporting of results (89). Pre-print Vascular, TriReme Medical, SurModics, and Shockwave Medical; is
servers include full drafts of research studies shared an advisory board member for Abbott Vascular, Boston Scientific,
publicly before peer review. Pre-prints have the po- Cardinal Health, Medtronic, Janssen, CSI, and Philips; and receives
honoraria from Abiomed and Terumo. Dr. Kirtane has received
tential benefit of early dissemination and opportunity
institutional funding from Medtronic, Boston Scientific, Abbott
for feedback and discussion, and could be of sub- Vascular, Abiomed, CSI, CathWorks, Siemens, Philips, and ReCor
stantial benefit during the pandemic. With a pre- Medical; and has received travel expenses/meals from Medtronic,
print, key researchers in the field can discover find- Boston Scientific, Abbott Vascular, Abiomed, CSI, CathWorks,
Siemens, Philips, ReCor Medical, Chiesi, OpSens, Zoll, and Regen-
ings sooner, indicate critical errors, or suggest new
eron, all outside the submitted work. Dr. Eikelboom has received
studies or data that strengthen the argument (90). honoraria and grant support from AstraZeneca, Bayer, Boehringer
The limitations of pre-prints should be also commu- Ingelheim, Bristol Myers Squibb/Pfizer, Daiichi-Sankyo, Glax-
nicated transparently, so that similar weight is not oSmithKline, Janssen, Sanofi, and Eli Lilly, as well as a personal
award from the Heart and Stroke Foundation. Dr. Konstantinides has
placed on pre-print and peer-reviewed literature by
received research grants from Bayer AG, Boehringer Ingelheim, and
the lay people, the press, health care workers, or Actelion-Janssen; has received educational grants from Bio-
policy makers. Indeed, many retracted papers were compatibles Group UK, Boston Scientific, and Daiichi-Sankyo; and
has received lecture fees from Bayer AG, Bristol Myers Squibb/Pfizer,
from pre-print servers (87).
and Merck Sharp and Dohme. Dr. Weitz serves as a consultant and
Prospectively planned meta-analyses would be of has received honoraria from Bayer, Janssen, Johnson & Johnson,
particular help during the pandemic. Such studies can Bristol Myers Squibb, Pfizer, Boehringer Ingelheim, Novartis,
help understand the heterogeneity of the findings Daiichi-Sankyo, Merck, Servier, Anthos, Ionis, and PhaseBio. Dr.
Stone has received speaker or other honoraria from Cook, Terumo,
between interventions, between distinct studies, and
and Orchestra Biomed; has been a consultant to Valfix, TherOx,
within subgroups. Prospective meta-analysis can also Vascular Dynamics, Robocath, HeartFlow, Gore, Ablative Solutions,
help with pooled comparisons for interventions with Miracor, Neovasc, V-Wave, Abiomed, Ancora, MAIA Pharmaceuticals,
small individual studies, as well as indirect compari- Vectorious, Reva, Matrizyme, and CardioMech; and has equity/op-
tions from Ancora, Cagent, Applied Therapeutics, Biostar family of
sons for interventions that do not have sufficiently
funds, SpectraWave, Orchestra Biomed, Aria, Cardiac Success, Med-
large head-to-head comparisons in existing studies. Focus family of funds, and Valfix. Dr. Krumholz has received per-
sonal fees from UnitedHealth, IBM Watson Health, Element Science,
CONCLUSIONS Aetna, Facebook, Siegfried & Jensen Law Firm, Arnold & Porter Law
Firm, Ben C. Martin Law Firm, and the National Center for Cardio-
vascular Diseases (Beijing, China); has ownership in Hugo Health
Optimal antithrombotic therapy in patients with
and Refactor Health; and has contracts from the U.S. Centers for
COVID-19 has yet to be determined. Results of these Medicare & Medicaid Services; and has received grants from Med-
ongoing RCTs, and prospective meta-analyses of the tronic, the U.S. Food and Drug Administration, Johnson & Johnson,
completed studies, will help clarify whether any of and the Shenzhen Center for Health Information, outside the sub-
mitted work. Dr. Lip is a consultant for Bayer/Janssen, Bristol Myers
the plentiful antithrombotic regimens under investi-
Squibb/Pfizer, Medtronic, Boehringer Ingelheim, Novartis, Verseon,
gation can safely mitigate thrombotic complications and Daiichi-Sankyo; and is a speaker for Bayer, Bristol Myers Squibb/
and improve patient outcomes. Pfizer, Medtronic, Boehringer Ingelheim, and Daiichi-Sankyo (no
fees are directly received personally). Dr. Goldhaber has received

research support from Bayer, Boehringer Ingelheim, Bristol Myers ADDRESS FOR CORRESPONDENCE: Dr. Behnood
Squibb, Boston Scientific, Daiichi-Sankyo, Janssen, the National
Bikdeli, Cardiovascular Medicine Division, Brigham
Heart, Lung, and Blood Institute, and the Thrombosis Research
Institute; and has received consulting fees from Bayer, Agile, Boston
and Women’s Hospital, 75 Francis Street, Shapiro 5,
Scientific, and Boehringer Ingelheim. Dr. Bikdeli is a consulting Suite 5156, Boston, Massachusetts 02115, USA. E-mail:
expert, on behalf of the plaintiff, for litigation related to 2 specific [email protected] OR Behnood.bikdeli@
brand models of inferior vena cava filters. All other authors have
yale.edu. Twitter: @AzitaTalasaz, @bbikdeli, @Brigh-
reported that they have no relationships relevant to the contents of
this paper to disclose.
amResearch, @harvardmed, @crfheart.
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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. -, NO.

JACC STATE-OF-THE-ART REVIEW

Recent Randomized Trials of

Azita H. Talasaz, PHARMD,a,b Parham Sadeghipour, MD,c Hessam Kakavand, PHARMD,a,b

THROMBOEMBOLISM IN PATIENTS WITH patients (1–4). Pooled analyses have helped in

ISSN 0735-1097/$36.00 https://doi.org/10.1016/j.jacc.2021.02.035

ABBREVIATIONS in the intensive care units (ICUs) compared

Manuscript received January 29, 2021; accepted February 5, 2021.

limited mobility and venous stasis (25,26). All the METHODS

F I G U R E 1 Virchow’s Triad and COVID-19 Associated Coagulopathy

F I G U R E 2 Summary of RCTs of Antithrombotic Agents in COVID-19 Categorized Based on Pharmacological Class

C E N T R A L IL L U ST R A T I O N Simpliﬁed Summary of Ongoing Antithrombotic Therapy Trials

Talasaz, A.H. et al. J Am Coll Cardiol. 2021;-(-):-–-.

Outpatient Noncritical Inpatient ICU Post-Discharge

Expected knowledge gain

Before COVID-19 Pandemic During COVID-19 Pandemic

fees are directly received personally). Dr. Goldhaber has received

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