Parenteral Anticoagulants

Hirsh, Jack; Bauer, Kenneth A.; Donati, Maria Benedetta; Gould, Michael K.; Samama, M; Weitz, Jeffrey I.

doi:10.1378/chest.08-0689

Cited by 651 publications

(228 citation statements)

References 178 publications

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“…This therapeutic threshold is consistent with current guidelines (1,9). Secondary end point was the number of dosing adjustment to threshold aPTT and the infusion rate at threshold aPTT.…”

Section: Methods and Proceduressupporting

confidence: 68%

“…Therefore, a cutoff value of 110 kg was chosen as it represents the weight at which both ACS and VTE protocols used in our institution reach capped initial dose. However, it has been decided later not to include patients presenting with VTE as recommended initial doses differ from ACS (9) and that only a small number of patients with VTE were available for analysis.…”

Section: Methods and Proceduresmentioning

confidence: 99%

“…Hence, the use of weight-based nomograms to determine the initial IV bolus and continuous IV infusion is now considered as standard care for anticoagulation of patients treated with UFH (1,9).…”

Section: Introductionmentioning

confidence: 99%

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Delayed efficient anticoagulation with heparin in patients with a weight of 110 kg and more treated for acute coronary syndrome

Joncas

Poirier

Ardilouze

et al. 2013

Obesity

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Objective: The use of a weight-based nomogram is considered as standard care for prescribing appropriate doses of unfractionated heparin (UFH). Because of the need for multiple other medications that may affect bleeding and that clinical data have relied on similar dosing algorithms, maximum initial bolus and infusion rates have been suggested (capped initial dose). Whether these weight-based heparin nomograms properly address therapeutic dosing in obese patients remains questionable. Design and Methods: Thirty patients treated for acute coronary syndrome and weighing !110 kg were retrospectively compared with 90 controls (three groups of 30 patients, weighting 50-69.9, 70-89.9, or 90-109.9 kg), all treated with UFH, July 2008 to April 2009. The primary end point was the time required to obtain a threshold activated partial thromboplastin time (aPTT). Results: Mean time to achieve threshold aPTT was longer for obese patients weighing !110 kg than for controls (31.47 vs. 12.89 hours; P < 0.0001). At 24 hours, 63% of obese patients weighing !110 kg had not reached threshold aPTT vs. 7% of controls (P < 0.0001). However, threshold infusion rate did not differ between weight categories (13.0 vs. 13.1 U/kg/h; P ¼ NS) and approximated the initial infusion rate recommended by nomograms without applying the dose cap (12 U/kg/h). Conclusions: Adequate anticoagulation time doubled in patients weighing !110 kg, suggesting that these patients were not receiving appropriate heparin doses initially to achieve threshold aPTT rapidly. Using initial infusion rate recommended by a nomogram without capping for total body weight is suggested as acceptable in this study. This approach should be further evaluated in a prospective study.

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“…This therapeutic threshold is consistent with current guidelines (1,9). Secondary end point was the number of dosing adjustment to threshold aPTT and the infusion rate at threshold aPTT.…”

Section: Methods and Proceduressupporting

confidence: 68%

Section: Methods and Proceduresmentioning

confidence: 99%

See 1 more Smart Citation

Delayed efficient anticoagulation with heparin in patients with a weight of 110 kg and more treated for acute coronary syndrome

Joncas

Poirier

Ardilouze

et al. 2013

Obesity

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“…Initially, 5 weeks of course time focused on applying therapeutic principles from recent guidelines on antithrombotic therapy (parenteral anticoagulants, vitamin K antagonists, treatment of venous thromboembolism, prevention of venous thromboembolism, and perioperative anticoagulation management). [12][13][14][15][16][17] Although some student assignments (experiential site visit and team topic presentation) required an understanding of anticoagulation issues in valvular heart disease and atrial fibrillation, these topics were not included due to time constraints, the desire to keep the course workload manageable, and the goal to maximize other active-learning techniques. These topics will be added to the next course offering.…”

Section: Discussionmentioning

confidence: 99%

An Innovative Elective Course in Anticoagulation Management

Garwood¹,

Bishja²,

Smythe

2010

American Journal of Pharmaceutical Education

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Objective. To develop and implement an elective pharmacy course in anticoagulation management and assess student learning. Design. Students participated in active-learning activities including evaluating a patient receiving outpatient or inpatient anticoagulation therapy, participating in a team project and presentation, and completing a ''living with anticoagulation'' assignment that included modeling both the health care provider's and the patient's role. Assessment. A precourse and postcourse standardized examination on anticoagulation along with a short answer midterm and final examination were administered. Performance between precourse and postcourse examination improved by approximately 25%, and 90% of students scored $ 90% on the final examination. Reflective narratives provided support that students found the ''living with anticoagulation'' assignment a valuable learning experience which developed empathy towards patients.Conclusion. An elective course in anticoagulation management that included multiple active-learning assignments was successful in increasing both students' knowledge and empathy.

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“…(45) There have been no studies on the use of protamine in patients with NSTE ACS. Its efficacy in reversing the anticoagulant effect of UFH is well established, (46) and it has a smaller effect on the reversal of enoxaparin (Table 3).…”

Section: Treatment Of Bleeding In Nste Acsmentioning

confidence: 99%

Sangramento em síndrome coronariana aguda sem supradesnivelamento de segmento ST

Moraes¹,

Chammas²,

Neto³

et al. 2012

Rev. bras. ter. intensiva

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The development of antiplatelet and antithrombotic therapies, in addition to interventionist strategy, has resulted in great improvements in the outcomes of patients with non-ST-segment elevation acute coronary syndrome. Parallel to therapeutic advances, bleeding, which can be induced during management, increases the risk of recurrent ischemia, myocardial infarction and death. The present literature review describes the benefits and bleeding risks of each medication or intervention strategy and suggests guidelines for managing these patients. arteries) scores are prominent. The TIMI score was the first to be developed and is widely used; however, it has low sensitivity, given that hemoglobin needs to be reduced by 5 g/dL for bleeding to be considered severe. The GUSTO score has a higher sensitivity and better correlation with death and reinfarction at 30 days and at 6 months compared to TIMI.(8) The variety of scores (Table 1) has complicated comparisons between studies.With the purpose of standardizing the definitions of bleeding, North American institutions have recently created the Bleeding Academic Research Consortium (BARC).(9) This score stratifies bleeding on a scale from 0 (no bleeding) to 5 (fatal bleeding) and, as a major advantage, provides the ability to assess patients subjected to myocardial revascularization surgery (MRS).(9) Because BARC's definitions of bleeding have been achieved by consensus, it still requires validation, and new studies on ACS are encouraged to use this score together with previous scores so that such validation may be achieved in the near future.(9) For now, comparisons between studies of bleeding outcomes demand caution. BENEFITS AND RISKS OF NSTE ACS TREATMENTKnowledge of the risk-benefit ratio of the various tools used in the treatment of ACS is essential for the individualization of therapy (Table 2).Acetylsalicylic acid (ASA) was one of the first medications assessed for the treatment of NSTE ACS and was established as a proven method after demonstrating a 56% reduction in cardiovascular death.(10) The antiplatelet effect of ASA is irreversible and results from its inhibition of thromboxane A2. In the long run, smaller daily doses of 75 to 100 mg provide the same benefit as do larger doses of 200 mg and reduce the incidence of major bleeding by 1.8%, according to the CURE (Clopidogrel in Unstable angina to prevent Recurrent Events) criteria.(11) The gastrointestinal tract is the most common site of bleeding caused by ASA, and its chronic use increases absolute risk by 0.12% a year.(12) Acetylsalicylic acid increases the risk of intracranial bleeding 1.65-fold for an increase in absolute annual risk of 0.03%.(12) Given the great benefit on mortality provided by ASA in treatment and secondary prevention, the risk of bleeding hardly justifies its nonprescription. Therefore, ASA is contraindicated only in cases of known hypersensitivity, active peptic ulcers, blood dyscrasias or severe liver disease. (13) Clopidogrel, a thienopyridine, is an alternative for patient...

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Parenteral Anticoagulants

Cited by 651 publications

References 178 publications

Delayed efficient anticoagulation with heparin in patients with a weight of 110 kg and more treated for acute coronary syndrome

Delayed efficient anticoagulation with heparin in patients with a weight of 110 kg and more treated for acute coronary syndrome

An Innovative Elective Course in Anticoagulation Management

Sangramento em síndrome coronariana aguda sem supradesnivelamento de segmento ST

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