• Renato D Lopes, de Barros E SilvaPedro Gabriel MeloPGMBrazilian Clinical Research Institute, São Paulo, Brazil; HCOR Research Institute, São Paulo, Brazil; Hospital Samaritano Paulista, São Paulo, Brazil., Remo H M Furtado, Ariane Vieira Scarlatelli Macedo, Eduardo Ramacciotti, Lucas Petri Damini, Bruna Bronhara, Alexandre B Cavalcanti, Regis G Rosa, AzevedoLuciano C PLCPHospital Moinhos de Vento, Porto Alegre, Brazil; Hospital Sírio Libanês Research and Education Institute, São Paulo, Brazil., Viviane C Veiga, Flávia R Machado, Luiz Eduardo Ritt, Priscilla de Aquino Martins, John H Alexander, Alvaro Avezum, Otavio Berwanger, and Coalition COVID-19 Brazil IV Investigators.
• Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Brazilian Clinical Research Institute, São Paulo, Brazil. Electronic address: renato.lopes@dm.duke.edu.
• Am. Heart J. 2021 Aug 1; 238: 1-11.

BackgroundObservational studies have suggested a higher risk of thrombotic events in patients with coronavirus disease 2019 (COVID-19). Moreover, elevated D-dimer levels have been identified as an important prognostic marker in COVID-19 directly associated with disease severity and progression. Prophylactic anticoagulation for hospitalized COVID-19 patients might not be enough to prevent thrombotic events; therefore, therapeutic anticoagulation regimens deserve clinical investigation.DesignACTION is an academic-led, pragmatic, multicenter, open-label, randomized, phase IV clinical trial that aims to enroll around 600 patients at 40 sites participating in the Coalition COVID-19 Brazil initiative. Eligible patients with a confirmed diagnosis of COVID-19 with symptoms up to 14 days and elevated D-dimer levels will be randomized to a strategy of full-dose anticoagulation for 30 days with rivaroxaban 20 mg once daily (or full-dose heparin if oral administration is not feasible) vs standard of care with any approved venous thromboembolism prophylaxis regimen during hospitalization. A confirmation of COVID-19 was mandatory for study entry, based on specific tests used in clinical practice (RT-PCR, antigen test, IgM test) collected before randomization, regardless of in the outpatient setting or not. Randomization will be stratified by clinical stability at presentation. The primary outcome is a hierarchical analysis of mortality, length of hospital stay, or duration of oxygen therapy at the end of 30 days. Secondary outcomes include the World Health Organization's 8-point ordinal scale at 30 days and the following efficacy outcomes: incidence of venous thromboembolism , acute myocardial infarction, stroke, systemic embolism, major adverse limb events, duration of oxygen therapy, disease progression, and biomarkers. The primary safety outcomes are major or clinically relevant non-major bleeding according to the International Society on Thrombosis and Haemostasis criteria.SummaryThe ACTION trial will evaluate whether in-hospital therapeutic anticoagulation with rivaroxaban for stable patients, or enoxaparin for unstable patients, followed by rivaroxaban through 30 days compared with standard prophylactic anticoagulation improves clinical outcomes in hospitalized patients with COVID-19 and elevated D-dimer levels.Copyright © 2021 Elsevier Inc. All rights reserved.

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