Clinical question: Do antiplatelet agents improve organ support-free days among critically ill adults with COVID-19?
Background: COVID-19 is known to increase the risk for thrombotic events, and patients with COVID-19-associated thrombotic events are more likely to have worse outcomes. Recent findings indicated that therapeutic heparin improved outcomes in noncritically ill patients with COVID-19, but therapeutic heparin was not found to improve outcomes in critically ill patients. The potential benefits of antiplatelet agents in reducing the risk of thrombotic events and subsequent poorer outcomes were unknown.
Study design: This study was an adaptive platform trial that utilized an open-label, control design for the intervention in question.
Setting: This study took place at 105 hospital sites in eight countries between October 2020 and June 2021
Synopsis: 1,557 critically ill adults with polymerase chain reaction-confirmed COVID-19 were randomly assigned to receive either open-label aspirin, an open-label P2Y12 inhibitor, or no antiplatelet therapy. This was in addition to standard deep venous thrombosis prophylaxis. Patients receiving antiplatelet therapy were treated for 14 days or until hospital discharge, whichever came first. Patients were followed for a total of 90 days after initiation of the study. The primary outcome was respiratory and cardiovascular organ support-free days up to day 21. A secondary outcome was survival to day 90. The authors found that the median for organ support-free days was seven in all groups (OR 1.02, 95% CI, 0.86-1.23) with a 95.7% posterior probability of futility. Major bleeding events were recorded in 2.1% of patients on antiplatelet agents and 0.4% of those in the control group. This represented an adjusted OR of 2.97 (95% CI 1.23-8.28) representing a 99.4% probability of harm.
Limitations included that the results of four of the antiplatelet agents were pooled together, limiting the ability to draw conclusions regarding any single agent, and the open-label design.
Bottom line: Antiplatelet therapy does not improve outcomes in critically ill adults with COVID-19 and increases the risk of bleeding.
Citation: REMAP-CAP writing committee for the REMAP-CAP investigators. Effect of antiplatelet therapy on survival and organ support–free days in critically ill patients with COVID-19: A randomized clinical trial. JAMA. 2022;327(13):1247–1259. doi:10.1001/jama.2022.2910
Dr. Freedle is an assistant professor of internal medicine at Saint Louis University Hospital, St. Louis., Mo.