Utility of a weight‐based heparin nomogram for patients with acute coronary syndromes

Zimmermann, Anthony; Jeffries, William S.; McElroy, H; Horowitz, John D.

doi:10.1046/j.1445-5994.2002.00297.x

Cited by 18 publications

(26 citation statements)

References 26 publications

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“…Time to achieve threshold aPTT in the control group of our study was comparable to findings of previous studies evaluating standard care weight-base nomogram in nonobese patients (23)(24)(25)(26)(27). Few studies have addressed the issues of UFH dosing in the obese (21,25,(27)(28)(29).…”

Section: Obesitysupporting

confidence: 78%

“…Interestingly, they did not find a difference in the time to first therapeutic aPTT between obese and nonobese patient. This may be explained by a time to therapeutic aPTT for nonobese patients of 30.0 6 77.0 hours, which is at odd with our results and previous studies (23)(24)(25)(26)(27) involving nonobese patients. This could be since, unlike the present study, most patients in the study from Riney et al (20) did not receive an initial bolus.…”

Section: Obesitycontrasting

confidence: 56%

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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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Section: Obesitysupporting

confidence: 78%

Section: Obesitycontrasting

confidence: 56%

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

View full text Add to dashboard Cite

show abstract

“…Proposed mechanisms for differences in heparin dosing requirements based on disease state have included differing levels of fibrinogen, cryoprecipitate, vitronectin, platelet factor 4 and differing degrees of platelet activation [23][24][25]. As such, weight based nomograms have been developed for both acute coronary syndromes and venous thromboembolic disease to address the disease specific differences in coagulation [8,9]. Guidelines recommend an intravenous heparin bolus dose of 80 U/kg and an initial infusion rate of 18 U/kg/h in patients with acute venous thromboembolic disease [5].…”

Section: Discussionmentioning

confidence: 99%

“…Supra-and sub-therapeutic levels of anticoagulation can lead to an increased propensity for & Robert O. Roswell roswer01@nyumc.org 1 bleeding and thromboembolic phenomena respectively. When patients at risk for stroke with AF/AFL are hospitalized, physicians often combine their knowledge of UFH nomograms that are available for acute coronary syndrome and venous thromboembolism to best guide initial therapy [6][7][8][9]. Such dosing regimens do not take into account the specific underlying disease process which can alter steadystate heparin requirements [10].…”

Section: Introductionmentioning

confidence: 99%

Intravenous heparin dosing strategy in hospitalized patients with atrial dysrhythmias

Roswell

Greet

Shah

et al. 2016

J Thromb Thrombolysis

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Patients with non-valvular atrial fibrillation (AF) have an elevated stroke risk that is 2-7 times greater than in those without AF. Intravenous unfractionated heparin (UFH) is commonly used for hospitalized patients with atrial fibrillation and atrial flutter (AFL) to prevent stroke. Dosing strategies exist for intravenous anticoagulation in patients with acute coronary syndromes and venous thromboembolic diseases, but there are no data to guide providers on a dosing strategy for intravenous anticoagulation in patients with AF/AFL. 996 hospitalized patients with AF/AFL on UFH were evaluated. Bolus dosing and initial infusion rates of UFH were recorded along with rates of stroke, thromboemobolic events, and bleeding events as defined by the International Society on Thrombosis and Haemostasis criteria. Among 226 patients included in the analysis, 76 bleeding events occurred. Using linear regression analysis, initial rates of heparin infusion ranging from 9.7 to 11.8 units/kilogram/hour (U/kg/h) resulted in activated partial thromboplastin times that were within therapeutic range. The median initial infusion rate in patients with bleeding was 13.3 U/kg/h, while in those without bleeding it was 11.4 U/kg/h; p = 0.012. An initial infusion rate >11.0 U/kg/h yielded an OR 1.95 (1.06-3.59); p = 0.03 for any bleeding event. Using IV heparin boluses neither increased the probability of attaining a therapeutic aPTT (56.1 vs 56.3 %; p = 0.99) nor did it significantly increase bleeding events in the study (35.7 vs 31.3 %; p = 0.48). The results suggest that higher initial rates of heparin are associated with increased bleeding risk. From this dataset, initial heparin infusion rates of 9.7-11.0 U/kg/h without a bolus can result in therapeutic levels of anticoagulation in hospitalized patients with AF/AFL without increasing the risk of bleeding.

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“…[1][2][3][4][5][6][7][8][9][10] In 1996, the authors' hospital developed a weight-based heparin protocol. A formal assessment revealed that, relative to traditional non-weight-based dosing, the weight-based protocol was superior in terms of the time required to achieve a minimum level of therapeutic anticoagulation, without an increase in adverse events.…”

Section: Introductionmentioning

confidence: 99%

Evaluation of 2 Weight-Based Protocols for Administration of Heparin

Tsang

Shalansky

Lum

2009

CJHP

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Utility of a weight‐based heparin nomogram for patients with acute coronary syndromes

Cited by 18 publications

References 26 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

Intravenous heparin dosing strategy in hospitalized patients with atrial dysrhythmias

Evaluation of 2 Weight-Based Protocols for Administration of Heparin

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