ST elevation myocardial infarction deep vein thrombosis prophylaxis and anticoagulation

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Editors-In-Chief: C. Michael Gibson, M.S., M.D.

Overview

Deep venous thromboembolism (DVT) prophylaxis and embolic prophylaxis should be considered in the management of the STEMI patient.

DVT Prophylaxis

Antithrombotic regimens to prevent venous thrombo embolism in the medically ill patient include all the following[1]:

1. Unfractionated heparin 5000 units subcutaneously every 12 hours.

2. Low molecular weight heparins have been show to be as effective as unfractionated heparin.

Enoxaparin 40mg SC daily
Dalteparin 2500 units SC daily
Nadroparin 2850 units SC daily

The duration of prophylactic therapy depends upon the patient risk. Intermittent pneumatic leg compression are alternatives in patients with contraindications to anticoagulants.

2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: Executive Summary(DO NOT EDIT)[2]

Anticoagulation After STEMI (DO NOT EDIT)¶[2]

Class I
"1. Anticoagulant therapy with a vitamin K antagonist should be provided to patients with STEMI and atrial fibrillation with CHADS2* score greater than or equal to 2, mechanical heart valves, venous thromboembolism, or hypercoagulable disorder.(Level of Evidence: C)"
"2. The duration of triple-antithrombotic therapy with a vitamin K antagonist, aspirin, and a P2Y12 receptor inhibitor should be minimized to the extent possible to limit the risk of bleeding.**(Level of Evidence: C)"
Class IIa
"1. Anticoagulant therapy with a vitamin K antagonist is reasonable for patients with STEMI and asymptomatic LV mural thrombi.(Level of Evidence: C)"
Class IIb
"1. Anticoagulant therapy may be considered for patients with STEMI and anterior apical akinesis or dyskinesis.(Level of Evidence: C)"
"2. Targeting vitamin K antagonist therapy to a lower international normalized ratio (eg, 2.0 to 2.5) might be considered in patients with STEMI who are receiving DAPT.(Level of Evidence: C)"

2013 Revised ACCF/AHA Guidelines for the Management of ST-Elevation Myocardial Infarction (DO NOT EDIT)[3]

Anticoagulation After STEMI (DO NOT EDIT)¶[3]

Class I
"1. Anticoagulant therapy with a vitamin K antagonist should be provided to patients with STEMI and atrial fibrillation with CHADS2* score greater than or equal to 2, mechanical heart valves, venous thromboembolism, or hypercoagulable disorder.(Level of Evidence: C)"
"2. The duration of triple-antithrombotic therapy with a vitamin K antagonist, aspirin, and a P2Y12 receptor inhibitor should be minimized to the extent possible to limit the risk of bleeding.**(Level of Evidence: C)"
"* CHADS2 (Congestive heart failure, Hypertension, Age >75 years, Diabetes mellitus, previous Stroke/Transient ischemic attack [doubled risk weight]) score.
"** Individual circumstances will vary and depend on the indications for triple therapy and the type of stent placed during PCI. After this initial treatment period, consider therapy with a vitamin K antagonist plus a single antiplatelet agent. For patients treated with fibrinolysis, consider triple therapy for 14 days, followed by a vitamin K antagonist plus a single antiplatelet agent.[4][5][6][7]
Class IIa
"1. Anticoagulant therapy with a vitamin K antagonist is reasonable for patients with STEMI and asymptomatic LV mural thrombi.(Level of Evidence: C)"
Class IIb
"1. Anticoagulant therapy may be considered for patients with STEMI and anterior apical akinesis or dyskinesis.(Level of Evidence: C)"
"2. Targeting vitamin K antagonist therapy to a lower international normalized ratio (eg, 2.0 to 2.5) might be considered in patients with STEMI who are receiving DAPT.(Level of Evidence: C)"
  • ¶ = These recommendations apply to patients who receive intracoronary stents during PCI for STEMI. Among individuals with STEMI who do not receive an intracoronary stent, the duration of DAPT beyond 14 days has not been studied adequately for patients who undergo balloon angioplasty alone, are treated with fibrinolysis alone, or do not receive reperfusion therapy. In this subset of patients with STEMI who do not receive an intracoronary stent, the threshold for initiation of oral anticoagulation for secondary prevention, either alone or in combination with aspirin, may be lower, especially if a shorter duration (ie, 14 days) of DAPT is planned.[8]

Sources

  • 2013 Revised ACCF/AHA Guidelines for the Management of ST-Elevation Myocardial Infarction[3]

References

  1. Ramzi DW, Leeper KV (2004). "DVT and pulmonary embolism: Part II. Treatment and prevention". Am Fam Physician. 69 (12): 2841–8. PMID 15222649.  Unknown parameter |month= ignored (help)
  2. 2.0 2.1 American College of Emergency Physicians. Society for Cardiovascular Angiography and Interventions. O'Gara PT, Kushner FG, Ascheim DD, Casey DE; et al. (2013). "2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.". J Am Coll Cardiol. 61 (4): 485–510. PMID 23256913. doi:10.1016/j.jacc.2012.11.018. 
  3. 3.0 3.1 3.2 O'Gara PT, Kushner FG, Ascheim DD; et al. (2012). "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. PMID 23247303. doi:10.1161/CIR.0b013e3182742c84.  Unknown parameter |month= ignored (help)
  4. You JJ, Singer DE, Howard PA; et al. (2012). "Antithrombotic therapy for atrial fibrillation: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e531S–75S. PMID 22315271. doi:10.1378/chest.11-2304.  Unknown parameter |month= ignored (help)
  5. Vandvik PO, Lincoff AM, Gore JM; et al. (2012). "Primary and secondary prevention of cardiovascular disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e637S–68S. PMID 22315274. doi:10.1378/chest.11-2306.  Unknown parameter |month= ignored (help)
  6. Lip GY, Huber K, Andreotti F; et al. (2010). "Antithrombotic management of atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing coronary stenting: executive summary--a Consensus Document of the European Society of Cardiology Working Group on Thrombosis, endorsed by the European Heart Rhythm Association (EHRA) and the European Association of Percutaneous Cardiovascular Interventions (EAPCI)". Eur. Heart J. 31 (11): 1311–8. PMID 20447945. doi:10.1093/eurheartj/ehq117.  Unknown parameter |month= ignored (help)
  7. Faxon DP, Eikelboom JW, Berger PB; et al. (2011). "Consensus document: antithrombotic therapy in patients with atrial fibrillation undergoing coronary stenting. A North-American perspective". Thromb. Haemost. 106 (4): 572–84. PMID 21785808. doi:10.1160/TH11-04-0262.  Unknown parameter |month= ignored (help)
  8. Andreotti F, Testa L, Biondi-Zoccai GG, Crea F (2006). "Aspirin plus warfarin compared to aspirin alone after acute coronary syndromes: an updated and comprehensive meta-analysis of 25,307 patients". Eur. Heart J. 27 (5): 519–26. PMID 16143706. doi:10.1093/eurheartj/ehi485.  Unknown parameter |month= ignored (help)

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