ST elevation myocardial infarction deep vein thrombosis prophylaxis and anticoagulation: Difference between revisions

Jump to navigation Jump to search
VisualWikitext
(/* II. Recommendation for Adjunctive treatment with UFH or LMWH following AMI (ACC/AHA Guidelines and ESC Guidelines){{cite journal |author=Silber S, Albertsson P, Avilés FF, et al. |title=Guidelines for percutaneous coronary interventions. The T...)
(/* 2013 Revised ACCF/AHA Guidelines for the Management of ST-Elevation Myocardial Infarction (DO NOT EDIT){{cite journal |author=O'Gara PT, Kushner FG, Ascheim DD, et al. |title=2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infa...)
 
(23 intermediate revisions by 2 users not shown)
Line 1: Line 1:
__NOTOC__
__NOTOC__
{{ST elevation myocardial infarction}}
{{ST elevation myocardial infarction}}
'''Editors-In-Chief:''' Alexandra Lansky, M.D. and [[C. Michael Gibson| C. Michael Gibson, M.S., M.D.]]<br>
'''Editors-In-Chief:''' [[C. Michael Gibson| C. Michael Gibson, M.S., M.D.]]


==Overview==
==Overview==
[[DVT|Deep venous thromboembolism]] and embolic prophylaxis are key considerations in determining the appropriate care for a STEMI patient. A number of guidelines, recommendations and current practice patterns exist to allow physicians to weigh various considerations and ensure proper delivery of care.
[[DVT|Deep venous thromboembolism]] ([[DVT]]) prophylaxis and embolic prophylaxis should be considered in the management of the [[STEMI]] patient.


==I.Recommendations for Long-Term Oral Anticoagulation Following AMI<ref name="pmid15383483">{{cite journal |author=Harrington RA, Becker RC, Ezekowitz M, ''et al.'' |title=Antithrombotic therapy for coronary artery disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy |journal=Chest |volume=126 |issue=3 Suppl |pages=513S–548S |year=2004 |month=September |pmid=15383483 |doi=10.1378/chest.126.3_suppl.513S |url=}}</ref>==
==DVT Prophylaxis==
Antithrombotic regimens to prevent venous thrombo embolism in the medically ill patient include all the following<ref name="pmid15222649">{{cite journal |author=Ramzi DW, Leeper KV |title=DVT and pulmonary embolism: Part II. Treatment and prevention |journal=Am Fam Physician |volume=69 |issue=12 |pages=2841–8 |year=2004 |month=June |pmid=15222649 |doi= |url=}}</ref>:


1. In most health-care settings, for moderate- and low-risk patients with an [[MI]], we recommend [[aspirin]] alone over oral vitamin K antagonists (VKAs) plus aspirin (Grade 2B).
1. [[Unfractionated heparin]] 5000 units subcutaneously every 12 hours.


Underlying values and preferences: This recommendation places a relatively low value on prevention of [[thromboembolism]], and a relatively high value on avoiding the inconvenience, expense, and bleeding associated with VKA therapy.
2. [[Low molecular weight heparin]]s have been show to be as effective as unfractionated heparin.
 
2. In health-care settings in which meticulous [[INR]] monitoring is standard and routinely accessible, for both high- and low-risk patients after MI, we recommend long-term (up to 4 years) high-intensity oral VKA (target INR, 3.5; range, 3.0 to 4.0) without concomitant aspirin, or moderate-intensity oral VKA (target INR, 2.5; range, 2.0 to 3.0) with aspirin (both Grade 2B).
 
3. For high-risk patients with MI, including those with a large anterior MI, those with significant [[heart failure]], those with intracardiac [[thrombus]] visible on [[echocardiography]], and those with a history of a thromboembolic event, we suggest the combined use of moderate-intensity (INR, 2.0 to 3.0) oral VKA plus low-dose aspirin, ≤ 100 mg/d, for 3 months after the MI (Grade 2A).
 
Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients’ values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S–187S).
 
==II. Recommendation for Adjunctive treatment with UFH or LMWH following AMI (ACC/AHA Guidelines and ESC Guidelines)<ref name="pmid15769784">{{cite journal |author=Silber S, Albertsson P, Avilés FF, ''et al.'' |title=Guidelines for percutaneous coronary interventions. The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology |journal=Eur. Heart J. |volume=26 |issue=8 |pages=804–47 |year=2005 |month=April |pmid=15769784 |doi=10.1093/eurheartj/ehi138 |url=}}</ref><ref name="pmid19923169">{{cite journal |author=Kushner FG, Hand M, Smith SC, ''et al.'' |title=2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (updating the 2005 Guideline and 2007 Focused Update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines |journal=Circulation |volume=120 |issue=22 |pages=2271–306 |year=2009 |month=December |pmid=19923169 |doi=10.1161/CIRCULATIONAHA.109.192663 |url=}}</ref>==
 
There are no specific guideline recommendations for the use of [[UFH]] or [[LMWH]] following [[PCI]] for [[STEMI]].
 
==III. Recommendations for Venous Thromboemolic phrophylaxis in the Medical Patient<ref name="pmid15383484">{{cite journal |author=Menon V, Harrington RA, Hochman JS, ''et al.'' |title=Thrombolysis and adjunctive therapy in acute myocardial infarction: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy |journal=Chest |volume=126 |issue=3 Suppl |pages=549S–575S |year=2004 |month=September |pmid=15383484 |doi=10.1378/chest.126.3_suppl.549S |url=}}</ref>==
 
===III.a Medical Conditions===
1. For acutely ill medical patients admitted to hospital with congestive heart failure or severe respiratory disease, or who are confined to bed and have one or more additional risk factors, including active cancer, previous VTE, sepsis, acute neurologic disease, or inflammatory bowel disease, we recommend thromboprophylaxis with LMWH (Grade 1A), LDUH (Grade 1A), or fondaparinux (Grade 1A).
 
2. For medical patients with risk factors for VTE, and for whom there is a contraindication to anticoagulant thromboprophylaxis, we recommend the optimal use of mechanical thromboprophylaxis with GCS or IPC (Grade 1A).
 
===III.b Critical Care===
1. For patients admitted to a critical care unit, we recommend routine assessment for VTE risk and routine thromboprophylaxis in most (Grade 1A).
 
2. For critical care patients who are at moderate risk for VTE (eg, medically ill or postoperative general surgery patients), we recommend using LMWH or LDUH thromboprophylaxis (Grade 1A).
 
3. For critical care patients who are at higher risk (eg, following major trauma or orthopedic surgery), we recommend LMWH thromboprophylaxis (Grade 1A).
 
4. For critical care patients who are at high risk for bleeding, we recommend the optimal use of mechanical thromboprophylaxis with GCS and/or IPC at least until the bleeding risk decreases (Grade 1A). When the high bleeding risk decreases, we recommend that pharmacologic thromboprophylaxis be substituted for or added to the mechanical thromboprophylaxis (Grade 1C).
 
==IV. Antithrombin Selection and Dosing Recommendations<ref name="pmid15222649">{{cite journal |author=Ramzi DW, Leeper KV |title=DVT and pulmonary embolism: Part II. Treatment and prevention |journal=Am Fam Physician |volume=69 |issue=12 |pages=2841–8 |year=2004 |month=June |pmid=15222649 |doi= |url=}}</ref>==
Medical prevention of Thromboembolic Disease in the medical patient include all the following:
 
1. Unfractionated Heparin 5000units subcutaneously every 12 hours.
 
Low Molecular Heparin have been show to be as effective as unfractionated heparin.


{| border="1"
{| border="1"
|-
|-
| Enoxaparin
| [[Enoxaparin]]
| 40mg SC daily
| 40mg SC daily
|-
|-
| Dalteparin
| [[Dalteparin]]
| 2500 units SC daily
| 2500 units SC daily
|-
|-
| Nadroparin
| [[Nadroparin]]
| 2850 units SC daily
| 2850 units SC daily
|}
|}


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


==V. Regional Differences in Prophylaxis Practices<ref name="pmid17573514">{{cite journal |author=Tapson VF, Decousus H, Pini M, ''et al.'' |title=Venous thromboembolism prophylaxis in acutely ill hospitalized medical patients: findings from the International Medical Prevention Registry on Venous Thromboembolism |journal=Chest |volume=132 |issue=3 |pages=936–45 |year=2007 |month=September |pmid=17573514 |doi=10.1378/chest.06-2993 |url=}}</ref>==
==2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: Executive Summary(DO NOT EDIT)<ref name="pmid23256913">{{cite journal| author=American College of Emergency Physicians. Society for Cardiovascular Angiography and Interventions. O'Gara PT, Kushner FG, Ascheim DD, Casey DE et al.| title=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. | journal=J Am Coll Cardiol | year= 2013 | volume= 61 | issue= 4 | pages= 485-510 | pmid=23256913 | doi=10.1016/j.jacc.2012.11.018 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23256913  }} </ref>==
 
===Anticoagulation After STEMI (DO NOT EDIT)<nowiki>¶</nowiki><ref name="pmid23256913">{{cite journal| author=American College of Emergency Physicians. Society for Cardiovascular Angiography and Interventions. O'Gara PT, Kushner FG, Ascheim DD, Casey DE et al.| title=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. | journal=J Am Coll Cardiol | year= 2013 | volume= 61 | issue= 4 | pages= 485-510 | pmid=23256913 | doi=10.1016/j.jacc.2012.11.018 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23256913  }} </ref>===
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Anticoagulant therapy with a [[vitamin K antagonist]] should be provided to patients with [[STEMI]] and [[atrial fibrillation]] with CHADS2<nowiki>*</nowiki> score greater than or equal to 2, [[mechanical heart valve]]s, [[venous thromboembolism]], or hypercoagulable disorder.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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]].<nowiki>**</nowiki>''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
|}


The ACCP consensus group guidelines recommend appropriate prophylaxis in high risk medically treated patient groups. An analysis of DVT prophylaxis in subsets of the IMPROVE study patients who met the ACCP guideline criteria for prophylaxis, provide a benchmark comparison for the real-world practices observed in the entire IMPROVE study population (N=15,156). These subsets of patients are those in whom pharmacologic prophylaxis has been shown to be effective, and our observed prophylaxis rates highlight an underuse of prophylaxis in these populations of patients.
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[Anticoagulant]] therapy with a vitamin K antagonist is reasonable for patients with STEMI and asymptomatic LV mural thrombi.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}


IMPROVE is an ongoing, multinational, observational study of DVT prophylaxis practices. From July 2002 to September 30, 2006, 15,156 patients were enrolled from 52 hospitals in 12 countries, of whom 50% received in-hospital pharmacologic and/or mechanical VTE prophylaxis. In the United States and other participating countries, 52% and 43% of patients, respectively, should have received prophylaxis according to guideline recommendations from the American College of Chest Physicians (ACCP). Only approximately 60% of patients who either met the ACCP criteria for requiring prophylaxis or were eligible for enrollment in randomized clinical trials that have shown the benefits of pharmacologic prophylaxis actually received prophylaxis. Practices varied considerably. Intermittent pneumatic compression was the most common form of medical prophylaxis utilized in the United States, although it was used very rarely in other countries (22% vs 0.2%, respectively). Unfractionated heparin was the most frequent pharmacologic approach used in the United States (21% of patients), with low-molecular-weight heparin used most frequently in other participating countries (40%). There was also variable use of elastic stockings in the United States and other participating countries (3% vs 7%, respectively).
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Anticoagulant therapy may be considered for patients with STEMI and anterior apical [[akinesis]] or [[dyskinesis]].''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}


==2013 Revised ACCF/AHA Guidelines for the Management of ST-Elevation Myocardial Infarction (DO NOT EDIT)<ref name="pmid23247303">{{cite journal |author=O'Gara PT, Kushner FG, Ascheim DD, ''et al.'' |title=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 |journal=Circulation |volume= |issue= |pages= |year=2012 |month=December |pmid=23247303 |doi=10.1161/CIR.0b013e3182742c84|url=}}</ref>==
==2013 Revised ACCF/AHA Guidelines for the Management of ST-Elevation Myocardial Infarction (DO NOT EDIT)<ref name="pmid23247303">{{cite journal |author=O'Gara PT, Kushner FG, Ascheim DD, ''et al.'' |title=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 |journal=Circulation |volume= |issue= |pages= |year=2012 |month=December |pmid=23247303 |doi=10.1161/CIR.0b013e3182742c84|url=}}</ref>==
Line 79: Line 70:
|-
|-


| bgcolor="LightGreen"|<nowiki>"</nowiki><nowiki>*</nowiki> CHADS2 ([[Congestive heart failure]], [[Hypertension]], Age >75 years, [[Diabetes mellitus]], previous [[Stroke]]/[[transient ischemic attack]] [doubled risk weight]) score.
| bgcolor="LightGreen"|<nowiki>"</nowiki><nowiki>*</nowiki> [[CHADS2]] ([[Congestive heart failure]], [[Hypertension]], Age >75 years, [[Diabetes mellitus]], previous [[Stroke]]/[[Transient ischemic attack]] [doubled risk weight]) score.
|-
|-


| bgcolor="LightGreen"|<nowiki>"</nowiki><nowiki>**</nowiki> 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.<ref name="pmid22315271">{{cite journal |author=You JJ, Singer DE, Howard PA, ''et al.'' |title=Antithrombotic therapy for atrial fibrillation: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines |journal=Chest |volume=141 |issue=2 Suppl |pages=e531S–75S |year=2012 |month=February |pmid=22315271 |doi=10.1378/chest.11-2304 |url=}}</ref><ref name="pmid22315274">{{cite journal |author=Vandvik PO, Lincoff AM, Gore JM, ''et al.'' |title=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 |journal=Chest |volume=141 |issue=2 Suppl |pages=e637S–68S |year=2012 |month=February |pmid=22315274 |doi=10.1378/chest.11-2306 |url=}}</ref><ref name="pmid20447945">{{cite journal |author=Lip GY, Huber K, Andreotti F, ''et al.'' |title=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) |journal=Eur. Heart J. |volume=31 |issue=11 |pages=1311–8 |year=2010 |month=June |pmid=20447945 |doi=10.1093/eurheartj/ehq117 |url=}}</ref><ref name="pmid21785808">{{cite journal |author=Faxon DP, Eikelboom JW, Berger PB, ''et al.'' |title=Consensus document: antithrombotic therapy in patients with atrial fibrillation undergoing coronary stenting. A North-American perspective |journal=Thromb. Haemost. |volume=106 |issue=4 |pages=572–84 |year=2011 |month=October |pmid=21785808 |doi=10.1160/TH11-04-0262 |url=}}</ref>
| bgcolor="LightGreen"|<nowiki>"</nowiki><nowiki>**</nowiki> 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.<ref name="pmid22315271">{{cite journal |author=You JJ, Singer DE, Howard PA, ''et al.'' |title=Antithrombotic therapy for atrial fibrillation: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines |journal=Chest |volume=141 |issue=2 Suppl |pages=e531S–75S |year=2012 |month=February |pmid=22315271 |doi=10.1378/chest.11-2304 |url=}}</ref><ref name="pmid22315274">{{cite journal |author=Vandvik PO, Lincoff AM, Gore JM, ''et al.'' |title=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 |journal=Chest |volume=141 |issue=2 Suppl |pages=e637S–68S |year=2012 |month=February |pmid=22315274 |doi=10.1378/chest.11-2306 |url=}}</ref><ref name="pmid20447945">{{cite journal |author=Lip GY, Huber K, Andreotti F, ''et al.'' |title=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) |journal=Eur. Heart J. |volume=31 |issue=11 |pages=1311–8 |year=2010 |month=June |pmid=20447945 |doi=10.1093/eurheartj/ehq117 |url=}}</ref><ref name="pmid21785808">{{cite journal |author=Faxon DP, Eikelboom JW, Berger PB, ''et al.'' |title=Consensus document: antithrombotic therapy in patients with atrial fibrillation undergoing coronary stenting. A North-American perspective |journal=Thromb. Haemost. |volume=106 |issue=4 |pages=572–84 |year=2011 |month=October |pmid=21785808 |doi=10.1160/TH11-04-0262 |url=}}</ref>
|}
|}


Line 89: Line 80:
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Anticoagulant therapy with a vitamin K antagonist is reasonable for patients with STEMI and asymptomatic LV mural thrombi.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[Anticoagulant]] therapy with a vitamin K antagonist is reasonable for patients with STEMI and asymptomatic LV mural thrombi.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
|}


Line 96: Line 87:
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Anticoagulant therapy may be considered for patients with STEMI and anterior apical akinesis ordyskinesis.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Anticoagulant therapy may be considered for patients with STEMI and anterior apical [[akinesis]] or [[dyskinesis]].''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
|}


* <nowiki>¶</nowiki> = 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.<ref name="pmid16143706">{{cite journal |author=Andreotti F, Testa L, Biondi-Zoccai GG, Crea F |title=Aspirin plus warfarin compared to aspirin alone after acute coronary syndromes: an updated and comprehensive meta-analysis of 25,307 patients |journal=Eur. Heart J. |volume=27 |issue=5 |pages=519–26 |year=2006 |month=March |pmid=16143706 |doi=10.1093/eurheartj/ehi485 |url=}}</ref>
* <nowiki>¶</nowiki> = 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.<ref name="pmid16143706">{{cite journal |author=Andreotti F, Testa L, Biondi-Zoccai GG, Crea F |title=Aspirin plus warfarin compared to aspirin alone after acute coronary syndromes: an updated and comprehensive meta-analysis of 25,307 patients |journal=Eur. Heart J. |volume=27 |issue=5 |pages=519–26 |year=2006 |month=March |pmid=16143706 |doi=10.1093/eurheartj/ehi485 |url=}}</ref>


==Sources==
==Sources==

Latest revision as of 16:01, 31 October 2016

Acute Coronary Syndrome Main Page

ST Elevation Myocardial Infarction Microchapters

Home

Patient Information

Overview

Pathophysiology

Pathophysiology of Vessel Occlusion
Pathophysiology of Reperfusion
Gross Pathology
Histopathology

Causes

Differentiating ST elevation myocardial infarction from other Diseases

Epidemiology and Demographics

Risk Factors

Triggers

Natural History and Complications

Risk Stratification and Prognosis

Pregnancy

Diagnosis

Diagnostic Criteria

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

EKG Examples

Chest X Ray

Cardiac MRI

Echocardiography

Coronary Angiography

Treatment

Pre-Hospital Care

Initial Care

Oxygen
Nitrates
Analgesics
Aspirin
Beta Blockers
Antithrombins
The coronary care unit
The step down unit
STEMI and Out-of-Hospital Cardiac Arrest
Pharmacologic Reperfusion
Reperfusion Therapy (Overview of Fibrinolysis and Primary PCI)
Fibrinolysis
Reperfusion at a Non–PCI-Capable Hospital:Recommendations
Mechanical Reperfusion
The importance of reducing Door-to-Balloon times
Primary PCI
Adjunctive and Rescue PCI
Rescue PCI
Facilitated PCI
Adjunctive PCI
CABG
Management of Patients Who Were Not Reperfused
Assessing Success of Reperfusion
Antithrombin Therapy
Antithrombin therapy
Unfractionated heparin
Low Molecular Weight Heparinoid Therapy
Direct Thrombin Inhibitor Therapy
Factor Xa Inhibition
DVT prophylaxis
Long term anticoagulation
Antiplatelet Agents
Aspirin
Thienopyridine Therapy
Glycoprotein IIbIIIa Inhibition
Other Initial Therapy
Inhibition of the Renin-Angiotensin-Aldosterone System
Magnesium Therapy
Glucose Control
Calcium Channel Blocker Therapy
Lipid Management

Pre-Discharge Care

Recommendations for Perioperative Management–Timing of Elective Noncardiac Surgery in Patients Treated With PCI and DAPT

Post Hospitalization Plan of Care

Long-Term Medical Therapy and Secondary Prevention

Overview
Inhibition of the Renin-Angiotensin-Aldosterone System
Cardiac Rehabilitation
Pacemaker Implantation
Long Term Anticoagulation
Implantable Cardioverter Defibrillator
ICD implantation within 40 days of myocardial infarction
ICD within 90 days of revascularization

Case Studies

Case #1

Case #2

Case #3

Case #4

Case #5

ST elevation myocardial infarction deep vein thrombosis prophylaxis and anticoagulation On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on ST elevation myocardial infarction deep vein thrombosis prophylaxis and anticoagulation

CDC on ST elevation myocardial infarction deep vein thrombosis prophylaxis and anticoagulation

ST elevation myocardial infarction deep vein thrombosis prophylaxis and anticoagulation in the news

Blogs on ST elevation myocardial infarction deep vein thrombosis prophylaxis and anticoagulation

Directions to Hospitals Treating ST elevation myocardial infarction

Risk calculators and risk factors for ST elevation myocardial infarction deep vein thrombosis prophylaxis and anticoagulation

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. doi:10.1016/j.jacc.2012.11.018. PMID 23256913.
  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. doi:10.1161/CIR.0b013e3182742c84. PMID 23247303. 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. doi:10.1378/chest.11-2304. PMID 22315271. 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. doi:10.1378/chest.11-2306. PMID 22315274. 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. doi:10.1093/eurheartj/ehq117. PMID 20447945. 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. doi:10.1160/TH11-04-0262. PMID 21785808. 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. doi:10.1093/eurheartj/ehi485. PMID 16143706. Unknown parameter |month= ignored (help)

Template:WH Template:WS

Retrieved from "https://www.wikidoc.org/index.php?title=ST_elevation_myocardial_infarction_deep_vein_thrombosis_prophylaxis_and_anticoagulation&oldid=1265428"