Summary of findings 1. Antiplatelets in hospitalised adults with moderate to severe COVID‐19.
| Antiplatelets (plus standard care) compared to standard care (with/without placebo) in hospitalised adults with COVID‐19 (moderate to severe disease) | ||||||
|
Patient or population: hospitalised adults with COVID‐19 (moderate to severe disease) Setting: inpatients Intervention: antiplatelets (plus standard care) Comparison: standard care (with/without placebo) | ||||||
| Outcomes | Estimated absolute effectsa (95% CI) | Relative effect (95% CI) | № of participants (studies) | Certainty of the evidence (GRADE) | Comments | |
| Risk with standard care (with/without placebo) | Risk with antiplatelets (plus standard care) | |||||
| 28‐day all‐cause mortality | 177 per 1000 | 168 per 1000 (151 to 186) | RR 0.95 (0.85 to 1.05 |
17,249b,c (3 RCTs) |
⊕⊕⊕⊖ Moderated |
Antiplatelets probably result in little to no difference in mortality up to day 28. |
| Worsening up to day 28: participants with new need for invasive mechanical ventilation or death | 230 per 1000 | 218 per 1000 (207 to 232) | RR 0.95 (0.90 to 1.01) |
15,266 (2 RCTs) |
⊕⊕⊕⊖ Moderated |
Antiplatelets probably result in little to no difference in worsening up to day 28. |
| Improvement up to day 28: participants discharged alive | 743 per 1000 | 743 per 1000 (714 to 773) | RR 1.00 (0.96 to 1.04) |
15,454 (2 RCTs) |
⊕⊕⊕⊖ Moderated |
Antiplatelets probably result in little to no difference in improvement up to day 28. |
| Thrombotic events at longest follow‐up* | 57 per 1000 | 52 per 1000 (46 to 58) |
RR 0.90 (0.80 to 1.02) |
17,518 (4 RCTs) |
⊕⊕⊕⊖ Moderated |
Antiplatelets probably result in a slight reduction in thrombotic events. |
| Serious adverse events at longest follow‐up** | 5 per 1000 | 7 per 1000 (2 to 24) | Peto OR 1.57 (0.48 to 5.14) |
1815 (1 RCT) |
⊕⊕⊖⊖ Lowe |
Antiplatelets may result in a slight increase in serious adverse events. |
| Adverse events during study treatment | Not reported | — | — | — | — | We did not identify any study reporting this outcome. |
| Major bleeding events at longest follow‐up*** | 10 per 1000 | 16 per 1000 (12 to 21) | Peto OR 1.68 (1.29 to 2.19) |
17,527 (4 RCTs) |
⊕⊕⊕⊖ Moderated |
Antiplatelets probably increase the occurrence of major bleeding events. |
| CI: confidence interval; COVID‐19: coronavirus disease 2019; OR: odds ratio, RCT: randomised controlled trial, RR: risk ratio | ||||||
| GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect. | ||||||
aThe risk in the control group was assumed from the pooled effects of the control group from included studies; the intervention risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). bAdditionally, there was a study with 292 participants reporting all‐cause mortality at longest follow‐up (RR 1.11, 95% CI 0.75 to 1.64) (Bohula 2022 (COVID‐PACT)). We did not include this study in the meta‐analysis due to an unclear duration of follow‐up and high risk of bias. cREMAP‐CAP 2022 reported 180‐day mortality in a second publication. Treatment with antiplatelets may result in little to no difference in 180‐day mortality (RR 0.97, 95% CI 0.82 to 1.15; 1,312 participants; low‐certainty evidence). dDowngraded one level for serious risk of bias: in Horby 2021 (RECOVERY), an open‐label study, 10% in the intervention group did not receive acetylsalicylic acid; in the open‐label study Bohula 2022 (COVID‐PACT), where 30% in the intervention group discontinued the intervention, the co‐intervention (therapeutic or prophylactic anticoagulation) showed a high level of discontinuation or cross‐over. eDowngraded two levels for very serious imprecision: only one out of three studies contributed data, with very low event rates and a very wide CI.
*The time frames for 'the longest follow‐up' were 28 days (Berger 2022; Bohula 2022 (COVID‐PACT); Horby 2021 (RECOVERY)) or unclear (REMAP‐CAP 2022).
**The time frames for 'the longest follow‐up' were reported for up to 28 days in three studies (Berger 2022; Horby 2021 (RECOVERY); REMAP‐CAP 2022).
***The time frames for 'the longest follow‐up' were reported for up to 28 days in three studies (Berger 2022; Horby 2021 (RECOVERY)). The longest follow‐up in REMAP‐CAP 2022 for major bleeding was 14 days.