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The current pandemic of COVID-19 infection [1] has caused major shifts in healthcare organization, towards far more and acute attention for patients suspected from COVID-19 infection at the potential cost of less attention for “regular” care. Obviously, the occurrence of this pandemic does not diminish the burden of other diseases, rather the focus is temporarily shifted towards infectious diseases; while this shift in focus is fully appreciable and also necessary to deal with the huge impact of COVID-19 infections throughout the world, it is important not to forget some essential matters that are part of our regular work. For those dealing with patients at risk of thrombosis, it is essential that care is taken not to miss the occasional patient with pulmonary embolism (PE); why would this happen? At our hospital and many others, the triage of patients suspected from possible COVID-19 infection get a workup including physical examination, routine lab tests and a “blank” computed tomography (CT) scan of the thorax, to exclude the presence of findings suggestive for viral pneumonia. In practice, subjects with a low suspicion for viral pneumonia, eg patients with chest pain but associated dyspnea that could also fit with a diagnosis of angina or PE, will still get a CT scan without contrast agent upon triage, to exclude viral pneumonia; if there is no further workup for the initial complaints (thoracic pain), a diagnosis of PE may be missed. While normally, a Wells rule or similar algorithm will be applied to work up such patients (and ECG recording of course) with a d-dimer test in case of a low suspicion for PE, the threat is that in the present situation this part of the diagnostic pathway is forgotten. Hence, it remains critically important to remain alert for the possibility of alternative diagnoses, including PE [2]. Unfortunately, the d-dimer test is also elevated in those with Covid-19 infection, in particular related to poor prognosis [3] so that an abnormal test result will not discriminate in the acute phase (due to poor specificity, like for other acute diseases, including bacterial pneumonia, acute coronary syndrome and aorta dissecans). Early addition of cardiac ultrasound may theoretically be an option to at least detect significant right ventricle overload, but logistically this may not be easy in the busy triage setting. Even more than before, a clinical suspicion of PE by the GP is essential in order to at least suggest the possibility of PE upon referral. This way the radiology workup could be modified to also include a CT angiography. Severe viral infection is associated with a coagulopathy, in severe cases this may take the form of disseminated intravascular coagulation (DIC) [4, 5]. Thrombocytopenia is a frequent finding in COVID-19 infection and while the etiology may be multifactorial, the occurrence of DIC is one possible mechanism. Like in any other acute and severe infections, there is a risk of venous thromboembolism (VTE) and for this reason thrombosis prophylaxis in regular doses is pivotal, in principle without need for adjustment of low molecular weight heparin (LMWH) doses in case of thrombocytopenia (although in individual cases this should of course always be balanced against bleeding risk) [2]. Early findings also indicate a possible protective effect of LMWH in those with most severe COVID-19 infections [6]. In our country (the Netherlands), there still is a substantial fraction of patients treated with a vitamin K antagonist (VKA; about 300.000 at the moment), for good reasons (indications like mechanical heart valves), or sometimes less strict reasons (elderly subject with atrial fibrillation and acceptable renal function). Given the requirement of laboratory control (to obtain an international normalized ratio, INR) in all patients on VKA,

Thrombosis management in times of COVID-19 epidemy; a Dutch perspective