Summary of COVID-19 medicines guidance: Cardiovascular system disorders

Eimear Maguire, Senior Medicines Information Pharmacist, North West Medicines Information CentrePublished

This page summarises and signposts to medicine related guidance we’re aware of from professional and government bodies relating to coronavirus and cardiovascular system disorders.

Our advice is constantly reviewed as the pandemic situation evolves.

Whilst we have tried to ensure that the information on this page is complete, please report a concern if you feel anything is omitted or inaccurate.

To see our professional guidance summaries for other clinical areas, click here

Advice in this area includes:

NHS England/ NHS Improvement: Clinical guide for the management of cardiology patients during the coronavirus pandemic

Last updated 20 March 2020 [Re-added 25 November]

  • Issues requiring admission and ongoing management will be prioritised eg myocardial infarction, class IV heart failure, arrhythmias (such as uncontrolled AF or VT), endocarditis; pathways must be expedited to allow rapid treatment and discharge.
  • All elective admissions and day cases should be deferred unless absolutely necessary.
  • For outpatients, consideration should be given to the urgency of appointment, the requirement for diagnostics and the need for face-to-face contact; where possible, appointments should be conducted remotely and non-urgent appointments deferred, particularly those requiring diagnostics for surveillance.
  • Advises on specific areas of cardiology services e.g. bradycardia pacing, ICD and CRT implants, elective and primary PCI, ablation etc.

NHS England/ NHS Improvement: Clinical guide for the management of anticoagulant services during the coronavirus pandemic

Last updated February 2021 [Re-added 25 November 2021]

  • Take the opportunity to review if long-term warfarin therapy is still indicated eg in patients with prior DVT or PE for whom the risk of recurrence is now considered low.
  • Consider if patients taking warfarin are suitable for treatment with a DOAC instead; if a DOAC is unsuitable, could they be switched to LMWH instead? (Note that in view of recognised supply issues with LMWH, these should only be used if there are no other appropriate options).
  • Consider prioritising patients with poor control of INR as this cohort will need the most frequent INR checks. Address non-adherence if this an underlying reason for poor INR control.
  • Consider if patients could be trained to self-test INR in their own homes.
  • As a last resort, for individual patients for whom INR testing is not possible and therefore warfarin cannot be dosed safely, warfarin therapy could be temporarily stopped after weighing the benefit and risk and discussion with the patient. Regular review should be undertaken with a view to restarting warfarin therapy as soon as it is safe to do so. (Note: patients’ with mechanical heart valves MUST be initiated on, or stay on warfarin).

NICE: COVID-19 rapid evidence summary: angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) in people with or at risk of COVID-19

Last updated 21 May 2020

  • The purpose of this review is to assess the best available evidence to determine If there is any increased risk of developing COVID-19 due to ACEIs or ARBs and if ACEIs or ARBs can lead to an increased risk of developing more severe symptoms of COVID-19.
  • The review identified 2 retrospective observational studies that met the inclusion criteria; these studies found no increase in risk of developing COVID-19 or more severe disease. However, the studies were of poor quality and subject to bias and confounding.
  • Therefore, conclusions cannot be drawn on whether ACEIs or ARBs increase the risk of developing COVID-19 or developing more severe COVID-19.

Public Health England: COVID-19 vaccination: blood clotting information for healthcare professionals

Last updated 8 April 2021 [Added 9 April 2021]

  • Public Health England (PHE) advise of a small number of reports from the UK and internationally of an extremely rare condition characterised by thromboembolic events (blood clots) accompanied by thrombocytopenia (low platelets) following the first dose of the AstraZeneca COVID-19 vaccination; the most notable presentation is cerebral venous sinus thromboses (CVST) where blood clots develop in the cerebral veins occurring together with low platelet counts. Whilst the cases reported to date have primarily been venous clots, arterial clots have also been reported.
  • All cases reported in the UK to date have occurred after the first dose of the AstraZeneca COVID-19 vaccine. The underlying risk factors have not yet been fully established; however a detailed review of suspected cases of this condition following COVID vaccination is on-going by the MHRA, supported by PHE and other professional groups; this will help to understand the risk factors for developing this condition.
  • The current data suggests that the overall incidence is around 4 per million first doses of the AstraZeneca COVID-19 vaccine administered. Although cases have been reported in all ages and genders, there appears to be a trend for increasing incidence with decreasing age amongst adults, with the highest incidence reported in the younger adult age groups.
  • The document answers questions, including: How many people have developed the condition; how many of those affected die; why isn’t the UK suspending use of the AstraZeneca COVID-19 vaccine; signs and symptoms; what you should do if you suspect a case; if somebody under 30 years has had AstraZeneca COVID-19 for their first dose, should they have the second; if a patient under 30 years old wants to have the AstraZeneca COVID-19 vaccine.

Public Health England: COVID-19 vaccination and blood clotting

Last updated 7 April 2021 [Added 9 April 2021]

  • This guidance, aimed at patients, summarises the benefits and risks of the COVID-19 vaccination with respect to very rare reports of blood clots and unusual bleeding following the first dose of the AstraZeneca COVID-19 vaccine.
  • It provides advice on what people should look out for from around 4 days to 4 weeks after vaccination: a new, severe headache which is not helped by usual painkillers or is getting worse; a headache which seems worse when lying down or bending over; an unusual headache that may be accompanied by blurred vision, nausea and vomiting, difficulty with your speech or weakness, drowsiness or seizures; new, unexplained pinprick bruising or bleeding; shortness of breath, chest pain, leg swelling or persistent abdominal pain.
  • Advice regarding suitability of the AstraZeneca COVID-19 vaccine in different age groups is provided for: people over 50 years of age or with underlying medical conditions; healthy people aged 30 to 50 years of age; healthy younger people aged 18 to 29 years.
  • Patients who have already had a first dose of the AstraZeneca COVID-19 vaccine without suffering any serious side effects are advised to complete the course; this includes people aged 18 to 29 years who are health and social care workers, unpaid carers and family members of those who are immunosuppressed.

British Cardiovascular Society: COVID-19 Clinician’s Resource Hub 

Last updated 14 January 2021

  • Includes a ‘COVID-19 Clinicians Resource Hub’ that is updated with cardiovascular articles pertaining to coronavirus from relevant organisations and publications.

British Cardiovascular Society (BCS) with the British Society for Heart Failure (BSH): Joint statement on ACEi or ARB in relation to COVID-19

Last updated 19 March 2020

  • Both the BCS and the BSH share the view of the European Society of Hypertension and the Renal Association that patients should continue treatment with ACEI and ARB unless specifically advised to stop by their medical team.
  • The BCS and the BSH recommend that patients taking ACEIs or ARBs and presenting unwell with suspected or known COVID-19 infection should be assessed on an individual basis and their medication managed according to established guidance.

British Heart Foundation (patient information): Coronavirus and heart medication

Last updated 24 December 2020

  • There is no evidence that ACEI/ARBs increase the risk of catching coronavirus, or make COVID-19 worse.
  • It’s really important that patients continue to take their cardiac medicines, including ACEI/ARBs, low-dose aspirin and heart transplant medicines as prescribed, even if they catch coronavirus, unless told differently by their doctor.
  • Paracetamol is the first choice of medicine to treat a fever caused by any infection and is the best choice to treat COVID-19 symptoms.

British Heart Foundation (patient information): Coronavirus vaccine: your questions answered

Last updated 8 April 2021 [Added 21 January 2021]

  • This webpage answers questions about the coronavirus vaccines, such as their safety for people taking heart medications and those taking anticoagulants or antiplatelets, and if the AstraZenece COVID-19 vaccine causes blood clots.

British Society for Haematology: Guidance produced from the Expert Haematology Panel (EHP) focussed on syndrome of Thrombosis and Thrombocytopenia occurring after coronavirus vaccination

Last updated 9 April 2021 [Added 9 April 2021]

  • There have been cases of a rare syndrome of thrombosis associated with low platelets reported in patients following COVID-19 vaccination; at the moment, any causal association with coronavirus vaccination has not been established, and there is no evidence that individuals with a prior history of thrombosis or known risk factors for thrombosis are more at risk of developing this immune complication of the AstraZeneca COVID-19 vaccine.
  • The cases are unusual because, despite the low platelets (thrombocytopenia), there is progressive thrombosis, primarily venous, with a high preponderance of cerebral venous sinus thrombosis. Some arterial thrombotic events have also been noted.
  • It is important that the correct management is applied to prevent the progression of thrombosis. Of critical note, platelet transfusions should be avoided.
  • Interim Guidance on management of this condition has been produced from the Expert Haematology Panel (EHP); contact details for advice from the EHP are included in the document. As this is an emerging area of practice, please continue to check back for updates and to monitor the literature for publications.
  • If any patients with this syndrome are identified in proximity to coronavirus vaccination, it is very important that a Yellow Card is completed – this will trigger a request from MHRA for further details.

British Society for Haematology: INR testing for out-patients on warfarin during COVID-19 restrictions

Last updated 26 March 2020

  • Advice for out-patient INR testing during COVID-19 restrictions.
  • Assess whether a DOAC that does not require monitoring can be used instead of warfarin. Note that antiplatelet therapy is not an effective alternative to anticoagulation.
  • Patients who are stably anticoagulated on warfarin with a time-in-therapeutic range of >60% can generally have long INR test intervals of 8 weeks or in some cases longer.
  • Patients in self-isolation because of possible COVID-19 exposure who are stably anticoagulated and would be due a routine test, can usually have the test safely postponed until after the period of isolation

British Society for Heart Failure: BSH position statement on the roll out of COVID-19 vaccinations 

Last updated 8 January 2021 [Added 21 January 2021]

  • People with heart failure are at increased risk of severe COVID-19.
  • The British Society for Heart Failure strongly recommends that all those eligible accept vaccination, if offered.

Cardiomyopathy UK: COVID-19 and Cardiomyopathy

Last updated 17 February 2021

Cardiomyopathy UK answers FAQs from patients, including:

  • Should I avoid non-steroidal anti-inflammatory medication like Ibuprofen?
  • I take an ACEI/ARB; should I stop?
  • I am taking immunosuppressant medications (e.g. prednisolone) for the management of my cardiomyopathy, should I stop?
  • Do any other cardiac medications cause harm?

European Society of Cardiology: Position Statement of the European Society of Cardiology Council on Hypertension, ACE-Inhibitors and Angiotensin Receptor Blockers

Last updated 13 March 2020

  • The Council on Hypertension of the European Society of Cardiology have highlighted the lack of evidence supporting harmful effect of ACEI and ARBs in the context of the pandemic COVID-19 outbreak; they strongly recommend that patients should continue treatment with their usual anti-hypertensive therapy.
  • There is evidence from studies in animals suggesting that these medications might be protective against serious lung complications in patients with COVID-19 infection, but to date there is no data in humans.

European Society of Cardiology: ESC Guidance for the Diagnosis and Management of CV Disease during the COVID-19 Pandemic

Last updated 10 June 2020

  • Guidance from the European Society of Cardiology on the diagnosis and management of cardiovascular disease during the COVID-19 pandemic.
  • Has management/treatment pathways for cardiovascular conditions, including STEMI, NSTEMI, cardiogenic shock, heart failure, valvular heart diseases, hypertension, pulmonary embolism and arrhythmias.
  • Also has a section on considerations on the use of anticoagulants in COVID-19 Patients.

European Society of Hypertension: Statement of the European Society of Hypertension (ESH) on hypertension, Renin-Angiotensin System (RAS) blockers and COVID-19

Last updated 15 April 2020

  • The currently available data on COVID-19 infections do not a support a differential use of ACEI or ARBs in COVID-19 patients.
  • In COVID-19 patients with severe symptoms or sepsis, ACEI or ARBs and other blood pressure lowering drugs should be used or discontinued on a case-by-case basis, taking into account current guidelines.
  • Further research analysing the continuously increasing data on the impact of hypertension and blood pressure lowering drugs, particularly RAS blockers, on the clinical course of COVID-19 infections is warranted.

Heart UK – The Cholesterol Charity: Information for GP’s and prescribers on how best to manage cholesterol during the coronavirus pandemic

  • Contains advice for healthcare professionals on management of patients with suspected familial hypercholesterolaemia, management of patients experiencing statin side effects and deferral of follow-up cholesterol tests following statin initiation.
  • Patients due to have a follow-up cholesterol test after starting statins who are symptom-free may have to have their appointment deferred depending on service capacity, but they should continue their medication.
  • Patients experiencing side effects should be offered a telephone appointment to review their symptoms, their dose and/or type of statin.
    Patients with suspected familial hypercholesterolaemia should be started on a statin as recommended in NICE CG71; the recommended minimum for most otherwise healthy individuals is atorvastatin 20mg daily.
  • Patients due to have a follow-up cholesterol test following lifestyle changes may need to have their treatment decision delayed. They should, however, continue with lifestyle changes, unless their most recent result met the criteria for familial hypercholesterolaemia screening. These patients would usually be prescribed atorvastatin 20mg daily.
  • Has specific COVID-19 protocols for medications such as PCSK9i, volanesorsen and lomitapide; users must log in to view this, but can sign up to a free professional membership area.

Joint Committee on Vaccination and Immunisation: Statement on use of the AstraZeneca COVID-19 vaccine

Last updated 7 April 2021 [Added 9 April 2021]

  • There have been reports of an extremely rare adverse event of concurrent thrombosis (blood clots) and thrombocytopenia (low platelet count) following vaccination with the first dose of the AstraZeneca COVID-19 vaccine; there has been no signal for thrombosis/thrombocytopenia following receipt of other COVID-19 vaccines approved for use in the UK (Pfizer-BioNTech and Moderna).
  • The available data do suggest there may be a trend for increasing incidence of this adverse event with decreasing age, with a slightly higher incidence reported in the younger adult age groups. There are currently no known risk factors for this extremely rare condition, which appears to be an idiosyncratic reaction on first exposure to the AstraZeneca COVID-19 vaccine (to date, there are no reports of these adverse events following receipt of the second dose of the AstraZeneca COVID-19 vaccine).
  • The Joint Committee on Vaccination and Immunisation (JCVI) has weighed the relative balance of benefits and risks and advise that the benefits of prompt vaccination with the AstraZeneca COVID-19 vaccine far outweigh the risk of adverse events for individuals 30 years of age and over and those who have underlying health conditions which put them at higher risk of severe COVID-19 disease; JCVI currently advise that it is preferable for adults aged under 30 years without underlying health conditions that put them at higher risk of severe COVID-19 disease, to be offered an alternative COVID-19 vaccine (i.e. Pfizer-BioNTech or Moderna), if available. However, people may make an informed choice to receive the AstraZeneca COVID-19 vaccine to receive earlier protection.
  • They also advise that there are some adults aged under 30 years without underlying health conditions who are in phase 1, who were prioritised due to an increased risk of exposure and/or to reduce the risk of passing the infection on to vulnerable individuals (e.g. health & social care workers, unpaid carers and household contacts of immunosuppressed individuals). Acting on a precautionary basis, if these persons are still unvaccinated, it is preferable for them to be offered an alternative COVID-19 vaccine, if available. JCVI is currently finalising its advice on phase 2 of the programme, particularly for healthy people under 30 years of age, and this will be published in due course.
  • JCVI advises that all individuals offered a COVID-19 vaccine should be fully informed about the benefits and risks of vaccination; this should include clear information on the extremely rare thrombosis/thrombocytopenia adverse event, how to monitor for symptoms that might be related to the adverse event, and what action should be taken by individuals and health professionals in the event of such symptoms arising (Public Health England has prepared updated information for those being offered COVID-19 vaccines, and for health professionals).

Medicines and Healthcare products Regulatory Agency (MHRA): MHRA issues new advice, concluding a possible link between COVID-19 Vaccine AstraZeneca and extremely rare, unlikely to occur blood clots

Last updated 7 April 2021 [Added 9 April 2021]

  • The MHRA has undertaken a thorough review into UK reports of a very rare and unlikely to occur specific type of blood clot in the brain, known as cerebral venous sinus thrombosis (CVST) occurring together with low levels of platelets (thrombocytopenia) following vaccination with the AstraZeneca COVID-19 vaccine; it is also considering other blood clotting cases (thromboembolic events) alongside low platelet levels.
  • It has concluded that the evidence of a link with the AstraZeneca COVID-19 vaccine is stronger but more work is still needed.
  • The data suggest there is a slightly higher incidence reported in the younger adult age groups and the MHRA advises that this evolving evidence should be taken into account when considering the use of the vaccine; however, they are not recommending age restrictions in the AstraZeneca COVID-19 vaccine use.
  • As a precaution, administration of the AstraZeneca COVID-19 vaccine in people of any age who are at higher risk of blood clots because of their medical condition should be considered only if benefits from the protection from COVID-19 infection outweighs potential risks; the Information for Healthcare Professionals for the AstraZeneca COVID-19 vaccine has been updated with more detail.
  • While the MHRA continues to investigate these cases, as a precautionary measure anyone that develops symptoms after vaccination is advised to seek prompt medical advice, such as: shortness of breath, chest or persistent abdominal pain, leg swelling; blurred vision, confusion or seizures; unexplained pin-prick rash or bruising beyond the injection site. Furthermore anybody with new onset of severe or persistent headache that does not respond to simple painkillers starting four days or more after vaccination should speak to their doctor.
  • Anyone who experienced cerebral or other major blood clots occurring with low levels of platelets after their first vaccine dose of the AstraZeneca COVID-19 vaccine should not have their second dose. Anyone who did not have these side effects should come forward for their second dose when invited.

Medicines and Healthcare products Regulatory Agency (MHRA): Warfarin and other anticoagulants – monitoring of patients during the COVID-19 pandemic 

Last updated 13 October 2020

  • The MHRA are advising of reports of an increase in the number of patients taking warfarin found to have elevated international normalised ratio (INR) values during the COVID-19 pandemic. Reasons for this are likely to be multifactorial: most, but not all, of these patients had suspected/confirmed COVID-19 infection, while others had recently been treated with antibiotics. Other causes may have been changes to diet due to lockdown (e.g. access to green leafy vegetables, increased alcohol consumption), while the psychological impact of social distancing and bereavement may have affected adherence to regular medications.
  • Advice is provided for healthcare professionals, including:
    • acute illness may exaggerate the effect of warfarin and necessitate a dose reduction. Therefore, continued INR monitoring is important in patients taking warfarin or other vitamin K antagonists (VKA) if they have suspected or confirmed COVID-19 infection, so they can be clinically managed at an early stage to reduce the risk of bleeding.
    • some patients taking warfarin may have been switched to direct-acting oral anticoagulants (DOACs) during the pandemic to avoid regular blood tests for INR monitoring – like VKA, DOACs also interact with several medicines. Patients with COVID-19 may be treated with antibiotics/antivirals. Healthcare professionals are therefore reminded of the potential for drug-drug interactions between oral anticoagulants (i.e. VKA or DOACs) and certain antibiotics/antivirals and are advised to follow existing advice in product information; this includes advice on the need for INR monitoring in patients taking VKA who have recently started taking new medications.
    • the MHRA is also aware of a small number of patients in whom warfarin treatment was continued after starting treatment with DOACs. To reduce the risk of over-anticoagulation and bleeding, healthcare professionals should ensure that warfarin treatment is stopped before DOACs are started.
  • Advice is also provided for patients taking VKA. Patients should be reminded of the need to carefully follow the instructions for use for their anticoagulant and asked to let their GP and healthcare team know:
    • if they have symptoms of or confirmed COVID-19 infection, because it is important that they continue to have their INR monitored while they are ill;
    • of any recent changes to their diet (including alcohol consumption) or lifestyle
    • if they are ill with sickness or diarrhoea or have lost their appetite, or are unable to attend their next scheduled blood test for any reason, including because they feel unwell.
  • This information is also available in Drug Safety Update [Added 28 October. Last updated October 22]
  • This information, aimed at patients, is available at: Warfarin and other blood thinners – reminder on safe use during COVID-19 pandemic [Added 28 October. Last updated October 13]

Medicines and Healthcare products Regulatory Agency (MHRA): Coronavirus (COVID-19) and high blood pressure medication

Last updated 27 March 2020

  • There is no evidence from clinical or epidemiological studies that treatment with ACE-I or ARBs might worsen COVID-19 infection.
  • It is vitally important that patients taking ACEI or ARBs to treat high blood pressure continue their usual treatment.
  • The MHRA are working closely with the Commission on Human Medicines and other regulatory bodies and will respond with further advice on this issue, should any new data emerge.

Primary Care Cardiovascular Society: COVID-19 Learning Bites

The Primary Care Cardiovascular Society has produced a number of COVID-19 ‘learning bites’, including:

  • Maintaining anticoagulation efficacy and safety during the COVID-19 crisis – should I be switching my warfarin to a DOAC?
  • Assessment of hypertension in primary care in a time of COVID-19.
  • Treatment of hypertension in primary care in a time of COVID-19.
  • Practical considerations around the diagnosis and management of patients with heart failure during the COVID-19 crisis.

Royal Pharmaceutical Society: Guidance for the safe switching of warfarin to direct oral anticoagulants (DOACs) for patients with non-valvular AF and venous thromboembolism (DVT / PE) during the coronavirus pandemic

Last updated 26 March 2020

    • Includes information on how to decide if it is appropriate to switch individual patients to DOACs, choice of DOAC, monitoring etc.
    • Advice on how to manage patients considered unsuitable for a DOAC.
    • Includes a counselling checklist for patients commenced on a DOAC.

Administration update (9th April 2021): Added ‘COVID-19 vaccination: blood clotting information for healthcare professionals’ and ‘COVID-19 vaccination and blood clotting’ from PHE; added ‘MHRA issues new advice, concluding a possible link between COVID-19 Vaccine AstraZeneca and extremely rare, unlikely to occur blood clots; added JCVI ‘Statement on use of the AstraZeneca COVID-19 vaccine’; added BSH ‘Guidance produced from the EHP focussed on syndrome of Thrombosis and Thrombocytopenia occurring after coronavirus vaccination’; deleted ‘NICE: COVID-19 rapid guideline: acute myocardial injury’ as this has been replaced by ‘COVID-19 rapid guideline: managing COVID-19’.