Initial therapeutic anticoagulation with rivaroxaban compared to prophylactic therapy with heparins in moderate to severe COVID-19: results of the COVID-PREVENT randomized controlled trial

Publikation: Beitrag in FachzeitschriftForschungsartikelBeigetragenBegutachtung


  • Ursula Rauch-Kröhnert - , DRK Kliniken Berlin Köpenick (Autor:in)
  • Marianna Puccini - , DRK Kliniken Berlin Köpenick (Autor:in)
  • Marius Placzek - , Deutsches Zentrum für Herz-Kreislaufforschung (DZHK) (Autor:in)
  • Jan Beyer-Westendorf - , Medizinische Klinik und Poliklinik I, Universitätsklinikum Carl Gustav Carus Dresden (Autor:in)
  • Kai Jakobs - , DRK Kliniken Berlin Köpenick (Autor:in)
  • Julian Friebel - , DRK Kliniken Berlin Köpenick (Autor:in)
  • Selina Hein - , Katholisches Klinikum Koblenz·Montabaur gGmbH (Autor:in)
  • Mirko Seidel - , BG Klinikum Unfallkrankenhaus Berlin (Autor:in)
  • Burkert Pieske - , Deutsches Zentrum für Herz-Kreislaufforschung (DZHK) (Autor:in)
  • Steffen Massberg - , Department of Medicine I Thrombosis Research (Autor:in)
  • Martin Witzenrath - , Charité – Universitätsmedizin Berlin (Autor:in)
  • Andreas Zeiher - , Universitätsklinikum Frankfurt (Autor:in)
  • Tim Friede - , Deutsches Zentrum für Herz-Kreislaufforschung (DZHK) (Autor:in)
  • Stefan D Anker - , Deutsches Zentrum für Herz-Kreislaufforschung (DZHK) (Autor:in)
  • Ulf Landmesser - , DRK Kliniken Berlin Köpenick (Autor:in)


BACKGROUND: COVID-19 is associated with a prothrombotic state. Current guidelines recommend prophylactic anticoagulation upon hospitalization.

METHODS: COVID-PREVENT, an open-label, multicenter, randomized, clinical trial enrolled patients (≥ 18 years) with moderate to severe COVID-19 and age-adjusted D-dimers > 1.5 upper limit of normal (ULN). The participants were randomly assigned (1:1) to receive either therapeutic anticoagulation with rivaroxaban 20 mg once daily or thromboprophylaxis with a heparin (SOC) for at least 7 days followed by prophylactic anticoagulation with rivaroxaban 10 mg once daily for 28 days or no thromboprophylaxis. The primary efficacy outcome was the D-dimer level and the co-primary efficacy outcome the 7-category ordinal COVID-19 scale by WHO at 7 days post randomization. The secondary outcome was time to the composite event of either venous or arterial thromboembolism, new myocardial infarction, non-hemorrhagic stroke, all-cause death or progression to intubation and invasive ventilation up to 35 days post randomization.

RESULTS: The primary efficacy outcome D-dimer at 7 days was not different between patients assigned to therapeutic (n = 55) or prophylactic anticoagulation (n = 56) (1.21 mg/L [0.79, 1.86] vs 1.27 mg/L [0.79, 2.04], p = 0.78). In the whole study population D-dimer was significantly lower at 7 days compared to baseline (1.05 mg/L [0.75, 1.48] vs 1.57 mg/L [1.13, 2.19], p < 0.0001). Therapy with rivaroxaban compared to SOC was not associated an improvement on the WHO 7-category ordinal scale at 7 days (p = 0.085). Rivaroxaban improved the clinical outcome measured by the score in patients with a higher baseline D-dimer  > 2.0 ULN (exploratory analysis; 0.632 [0.516, 0.748], p = 0.026). The secondary endpoint occurred in 6 patients (10.9%) in the rivaroxaban group and in 12 (21.4%) in the SOC group (time-to-first occurrence of the components of the secondary outcome: HR 0.5; 95% CI 0.15-1.67; p = 0.264). There was no difference in fatal or non-fatal major or clinically relevant non-major bleeding between the groups.

CONCLUSIONS: Therapeutic anticoagulation with rivaroxaban compared to prophylactic anticoagulation with a heparin did not improve surrogates of clinical outcome in patients with moderate to severe COVID-19. Whether initial rivaroxaban at therapeutic doses might be superior to thromboprophylaxis in patients with COVID-19 and a high risk as defined by D-dimer  > 2 ULN needs confirmation in further studies.


Seiten (von - bis)1620-1638
FachzeitschriftClinical Research in Cardiology
PublikationsstatusVeröffentlicht - Nov. 2023

Externe IDs

PubMedCentral PMC10584737
Scopus 85164179232



  • Humans, COVID-19, Rivaroxaban/therapeutic use, Anticoagulants, SARS-CoV-2, Venous Thromboembolism/prevention & control, Heparin, Treatment Outcome