Anticoagulation in Patients With COVID-19: JACC Review Topic of the Week

J Am Coll Cardiol. 2022 Mar 8;79(9):917-928. doi: 10.1016/j.jacc.2021.12.023.


Clinical, laboratory, and autopsy findings support an association between coronavirus disease-2019 (COVID-19) and thromboembolic disease. Acute COVID-19 infection is characterized by mononuclear cell reactivity and pan-endothelialitis, contributing to a high incidence of thrombosis in large and small blood vessels, both arterial and venous. Observational studies and randomized trials have investigated whether full-dose anticoagulation may improve outcomes compared with prophylactic dose heparin. Although no benefit for therapeutic heparin has been found in patients who are critically ill hospitalized with COVID-19, some studies support a possible role for therapeutic anticoagulation in patients not yet requiring intensive care unit support. We summarize the pathology, rationale, and current evidence for use of anticoagulation in patients with COVID-19 and describe the main design elements of the ongoing FREEDOM COVID-19 Anticoagulation trial, in which 3,600 hospitalized patients with COVID-19 not requiring intensive care unit level of care are being randomized to prophylactic-dose enoxaparin vs therapeutic-dose enoxaparin vs therapeutic-dose apixaban. (FREEDOM COVID-19 Anticoagulation Strategy [FREEDOM COVID]; NCT04512079).

Keywords: COVID-19; anticoagulation; clinical trial; coagulopathy.

Publication types

  • Research Support, Non-U.S. Gov't
  • Review

MeSH terms

  • Anticoagulants / therapeutic use*
  • COVID-19 / complications*
  • COVID-19 / therapy
  • Critical Care
  • Enoxaparin / therapeutic use
  • Hospitalization
  • Humans
  • Pyrazoles / therapeutic use
  • Pyridones / therapeutic use
  • Thromboembolism / prevention & control*
  • Thromboembolism / virology
  • Thrombosis / prevention & control*
  • Thrombosis / virology


  • Anticoagulants
  • Enoxaparin
  • Pyrazoles
  • Pyridones
  • apixaban

Associated data