Unstable angina / non ST elevation myocardial infarction anticoagulant therapy

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Unstable Angina
Non-ST Elevation Myocardial Infarction

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Anticoagulant Therapy

Additional Management Considerations for Antiplatelet and Anticoagulant Therapy

Risk Stratification Before Discharge for Patients With an Ischemia-Guided Strategy of NSTE-ACS

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-in-Chief: Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.; Smita Kohli, M.D.

Overview

Anticoagulation, traditionally with unfractionated heparin (UFH), is a cornerstone of therapy for patients with unstable angina]]/[[NSTEMI. Some of the agents available in this category include unfractionated heparin, low molecular weight heparin, direct thrombin inhibitors (e.g., bivalirudin) factor Xa Inhibitors (e.g., fondaparinux), and warfarin. These agents are also sometimes referred to as antithrombins, although, it should be noted that they often inhibit one or more proteins in the coagulation cascade before thrombin.

Anticoagulant Therapy in UA/NSTEMI

You can read in greater detail about each of the therapies specifically in relation to unstable angina and NSTEMI, by clicking on the link for that therapy:

2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes (DO NOT EDIT) [1]

Initial Parenteral Anticoagulant Therapy in Patients With Definite NSTE-ACS

Class I

"1.In patients with NSTE-ACS, anticoagulation, in addition to antiplatelet therapy, is recommended for all patients irrespective of initial treatment strategy. Treatment options include:

  • Enoxaparin: 1 mg/kg subcutaneous (SC) every 12 hours (reduce dose to 1 mg/kg SC once daily in patients with creatinine clearance [CrCl] <30 mL/min), continued for the duration of hospitalization or until PCI is performed. An initial intravenous loading dose is 30 mg. (Level of Evidence: A)
  • Bivalirudin: 0.10 mg/kg loading dose followed by 0.25 mg/kg per hour (only in patients managed with an early invasive strategy), continued until diagnostic angiography or PCI, with only provisional use of GP IIb/IIIa inhibitor, provided the patient is also treated with DAPT. (Level of Evidence: B)
  • If PCI is performed while the patient is on fondaparinux, an additional anticoagulant with anti-IIa activity (either UFH or bivalirudin) should be administered because of the risk of catheter thrombosis. (Level of Evidence: B)
  • UFH IV: initial loading dose of 60 IU/kg (maximum 4,000 IU) with initial infusion of 12 IU/kg per hour (maximum 1,000 IU/h) adjusted per activated partial thromboplastin time to maintain therapeutic anticoagulation according to the specific hospital protocol, continued for 48 hours or until PCI is performed. (Level of Evidence: B)"

PCI—General Considerations

Anticoagulant Therapy in Patients Undergoing PCI

Class I
"1. An anticoagulant should be administered to patients with NSTE-ACS undergoing PCI to reduce the risk of intracoronary and catheter thrombus formation. (Level of Evidence: C)"
"2. Intravenous UFH is useful in patients with NSTE-ACS undergoing PCI. (Level of Evidence: C)"
"3. Bivalirudin is useful as an anticoagulant with or without prior treatment with UFH in patients with NSTE-ACS undergoing PCI. (Level of Evidence: B)"
"4. An additional dose of 0.3 mg/kg IV enoxaparin should be administered at the time of PCI to patients with NSTE-ACS who have received fewer than 2 therapeutic subcutaneous doses (e.g., 1 mg/kg SC) or received the last subcutaneous enoxaparin dose 8 to 12 hours before PCI. (Level of Evidence: B)"
"5. If PCI is performed while the patient is on fondaparinux, an additional 85 IU/kg of UFH should be given intravenously immediately before PCI because of the risk of catheter thrombosis (60 IU/kg IV if a GP IIb/IIIa inhibitor used with UFH dosing based on the target-activated clotting time). (Level of Evidence: B)"
"6. In patients with NSTE-ACS, anticoagulant therapy should be discontinued after PCI unless there is a compelling reason to continue such therapy. (Level of Evidence: C)"
Class III (No Benefit)
"1. Fondaparinux should not be used as the sole anticoagulant to support PCI in patients with NSTEACS due to an increased risk of catheter thrombosis. (Level of Evidence: B)"
Class IIa
"1. In patients with NSTE-ACS undergoing PCI who are at high risk of bleeding, it is reasonable to use bivalirudin monotherapy in preference to the combination of UFH and a GP IIb/IIIa receptor antagonist. (Level of Evidence: B)"
Class IIb
"1. Performance of PCI with enoxaparin may be reasonable in patients treated with upstream subcutaneous enoxaparin for NSTE-ACS. (Level of Evidence: B)"

Medical Regimen and Use of Medications at Discharge

Combined Oral Anticoagulant Therapy and Antiplatelet Therapy in Patients With NSTEACS

Class I
"1. The duration of triple antithrombotic therapy with a vitamin K antagonist, aspirin, and a P2Y12 receptor inhibitor in patients with NSTE-ACS should be minimized to the extent possible to limit the risk of bleeding. (Level of Evidence: C)"
"2. Proton pump inhibitors should be prescribed in patients with NSTE-ACS with a history of gastrointestinal bleeding who require triple antithrombotic therapy with a vitamin K antagonist, aspirin, and a P2Y12 receptor inhibitor. (Level of Evidence: C)"
Class IIa
"1. Proton pump inhibitor use is reasonable in patients with NSTE-ACS without a known history of gastrointestinal bleeding who require triple antithrombotic therapy with a vitamin K antagonist, aspirin, and a P2Y12 receptor inhibitor. (Level of Evidence: C)"
Class IIb
"1. Targeting oral anticoagulant therapy to a lower international normalized ratio (INR) (e.g., 2.0 to 2.5) may be reasonable in patients with NSTE-ACS managed with aspirin and a P2Y12 inhibitor. (Level of Evidence: C)"

2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non -ST-Elevation Myocardial Infarction (DO NOT EDIT)[2]

Anticoagulant Therapy (DO NOT EDIT)[2]

Class I

"1. Anticoagulant therapy should be added to antiplatelet therapy in UA / NSTEMI patients as soon as possible after presentation.

a) For patients in whom an invasive strategy is selected, regimens with established efficacy at a (Level of Evidence: A) include enoxaparin and UFH, and those with established efficacy at a (Level of Evidence: B) include bivalirudin and fondaparinux.

b) For patients in whom a conservative strategy is selected, regimens using either enoxaparin or UFH (Level of Evidence: A) or fondaparinux (Level of Evidence: B) have established efficacy. See also Class IIa recommendation below.

c) In patients in whom a conservative strategy is selected and who have an increased risk of bleeding, fondaparinux is preferable. (Level of Evidence: B)"

Class IIa

"1. For UA / NSTEMI patients in whom an initial conservative strategy is selected, enoxaparin or fondaparinux is preferable to UFH as anticoagulant therapy, unless CABG is planned within 24 h. (Level of Evidence: B)"

Limited data are available for the use of other LMWHs (e.g., dalteparin) in UA/NSTEMI.

References

  1. Ezra A. Amsterdam, MD, FACC; Nanette K. Wenger, MD et al.2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. JACC. September 2014 (ahead of print)
  2. 2.0 2.1 Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE; et al. (2011). "2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.". Circulation. 123 (18): e426–579. PMID 21444888. doi:10.1161/CIR.0b013e318212bb8b. 

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