Highlights from

ACC 2021

American College of Cardiology Annual Congress 2021

Virtual 15-17 May 2021

Therapeutic anticoagulation inferior to prophylactic anticoagulation in COVID-19

Summary: Rivaroxaban did not demonstrate improved clinical outcomes when compared with in-hospital prophylactic anticoagulation in patients who were hospitalised with COVID-19 and had elevated D-dimer levels. Furthermore, those treated with rivaroxaban showed increased rates of bleeding compared with those receiving prophylactic anticoagulation in the ACTION trial.1

Patients with COVID-19 experience frequent venous and arterial thromboembolisms. Elevated levels of D-dimer, a thrombotic biomarker, are harbingers of poorer clinical outcomes (ie disease progression and mortality). Data regarding type, dosage and duration of an anticoagulation strategy is needed. Prof Renato Lopes (Duke University Medical Center, US) presented the ACTION Coalition trial (NCT04394377), which was designed to investigate the effectiveness of a full anticoagulation strategy as compared with a prophylactic anticoagulation strategy in patients who had been hospitalised for COVID-19 and had elevated levels of D-dimer. One group (n=311) received a 30-day course of rivaroxaban (20 mg once daily); the comparison group (n=304) received the standard in-hospital prophylactic venous thromboembolism protocol. The primary outcome was a hierarchical analysis of mortality, length of hospital stay, and duration of oxygen therapy over the 30-day intervention period.

Results were analysed using an unmatched win ratio method, stratified by clinical severity. At 30 days, analysis of primary outcome data demonstrated that 41.3% of participants in the prophylactic group had won, as compared with only 34.8% of participants in the rivaroxaban group who had won. The remaining 23.9% were tied. Major bleeds occurred in 10/310 patients in the rivaroxaban group (3.2%), as compared with only 4/304 (1.3%) of patients in the prophylactic group. In terms of all-cause mortality, 35/310 patients (11.3%) in the rivaroxaban group died, as compared with 23/304 patients in the prophylactic anticoagulation group (7.6%; relative risk ratio 1.49; 95% CI 0.90-2.46).

  1. Lopes RD. Randomized clinical trial to evaluate a routine full anticoagulation strategy in patients with coronavirus infection (SARS-CoV-2) admitted to hospital: the Coalition ACTION Trial. Abstract 409-14, ACC 2021 Scientific Session, 15-17 May 2021

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