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Fanikos J, Tawfik Y, Almheiri D, Sylvester K, Buckley LF, Dew C, Dell'Orfano H, Armero A, Bejjani A, Bikdeli B, Campia U, Davies J, Fiumara K, Hogan H, Khairani CD, Krishnathasan D, Lou J, Makawi A, Morrison RH, Porio N, Tristani A, Connors JM, Goldhaber SZ, Piazza G. Anticoagulation-Associated Adverse Drug Events in Hospitalized Patients Across Two Time Periods. Am J Med 2023; 136:927-936.e3. [PMID: 37247752 DOI: 10.1016/j.amjmed.2023.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 05/05/2023] [Accepted: 05/14/2023] [Indexed: 05/31/2023]
Abstract
PURPOSE Anticoagulants often cause adverse drug events (ADEs), comprised of medication errors and adverse drug reactions, in patients. Our study objective was to determine the clinical characteristics, types, severity, cause, and outcomes of anticoagulation-associated ADEs from 2015-2020 (a contemporary period following implementation of an electronic health record, infusion device technology, and anticoagulant dosing nomograms) and to compare them with those of a historical period (2004-2009). METHODS We reviewed all anticoagulant-associated ADEs reported as part of our hospital-wide safety system. Reviewers classified type, severity, root cause, and outcomes for each ADE according to standard definitions. Reviewers also assessed events for patient harm. Patients were followed up to 30 days after the event. RESULTS Despite implementation of enhanced patient safety technology and procedure, ADEs increased in the contemporary period. In the contemporary period, we found 925 patients who had 984 anticoagulation-associated ADEs, including 811 isolated medication errors (82.4%); 13 isolated adverse drug reactions (1.4%); and 160 combined medication errors, adverse drug reactions, or both (16.2%). Unfractionated heparin was the most frequent ADE-related anticoagulant (77.7%, contemporary period vs 58.3%, historical period). The most frequent anticoagulation-associated medication error in the contemporary period was wrong rate or frequency of administration (26.1%, n = 253), with the most frequent root cause being prescribing errors (21.3%, n = 207). The type, root cause, and harm from ADEs were similar between periods. CONCLUSIONS We found that anticoagulation-associated ADEs occurred despite advances in patient safety technologies and practices. Events were common, suggesting marginal improvements in anticoagulant safety over time and ample opportunities for improvement.
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Affiliation(s)
- John Fanikos
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
| | - Yahya Tawfik
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Danya Almheiri
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Katelyn Sylvester
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Leo F Buckley
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Chris Dew
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Heather Dell'Orfano
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Andre Armero
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Antoine Bejjani
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Behnood Bikdeli
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Umberto Campia
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Julia Davies
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Karen Fiumara
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Heather Hogan
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Candrika Dini Khairani
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Darsiya Krishnathasan
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Junyang Lou
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Alaa Makawi
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Ruth H Morrison
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Nicole Porio
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Anthony Tristani
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Jean M Connors
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Samuel Z Goldhaber
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Gregory Piazza
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
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Frazer A, Rowland J, Mudge A, Barras M, Martin J, Donovan P. Systematic review of interventions to improve safety and quality of anticoagulant prescribing for therapeutic indications for hospital inpatients. Eur J Clin Pharmacol 2019; 75:1645-1657. [PMID: 31511939 DOI: 10.1007/s00228-019-02752-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 08/23/2019] [Indexed: 12/19/2022]
Abstract
PURPOSE Anticoagulation-associated adverse drug events are common in hospitalised patients and result in morbidity, mortality, increased length of hospital stay and higher costs of care. Many are preventable. We reviewed the literature to identify and assess interventions intended to improve safety or quality anticoagulant prescribing. METHODS A systematic search of EMBASE, MEDLINE, the Cochrane Library, Pretty Darn Quick-Evidence and Health Systems Evidence was undertaken to identify controlled studies assessing system-level interventions to improve prescribing of oral or parenteral therapeutic anticoagulation for any indication in hospitalised adults. Data were extracted for safety and quality outcomes, with studies grouped by intervention type for meta-analysis and narrative review. RESULTS Of 10,640 records screened, 19 trials evaluating 12,742 participants were included for analysis. No study specifically evaluated prescribing of low molecular weight heparins (LMWHs) or direct acting oral anticoagulants (DOACs). Our findings suggest that physician-led anticoagulation consultation services may reduce bleeding rates in high-risk patients. On meta-analysis, decision supported warfarin dosing resulted in higher proportion of time with international normalised ratio in therapeutic range (p = 0.0007). Studies of other clinical decision support systems and heparin monitoring systems did not demonstrate improved safety, and quality findings were inconsistent. Systematic education and feedback programs were not efficacious. CONCLUSIONS There is currently insufficient high-quality evidence to recommend any reviewed intervention, though several warrant closer evaluation. Adequately powered controlled trials assessing safety outcomes and evidence-based quality markers in high-risk patient groups and studies of interventions to improve safety of LMWH and DOAC prescribing are needed.
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Affiliation(s)
- Andrew Frazer
- Department of Internal Medicine and Aged Care, The Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD, 4029, Australia.
| | - James Rowland
- Department of Internal Medicine and Aged Care, The Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD, 4029, Australia
| | - Alison Mudge
- Department of Internal Medicine and Aged Care, The Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD, 4029, Australia
| | - Michael Barras
- University of Queensland School of Pharmacy, 20 Cornwall Street, Woolloongabba, QLD, 4102, Australia
| | - Jennifer Martin
- Chair of Clinical Pharmacology, University of Newcastle School of Medicine and Public Health, University Drive, Callaghan, NSW, 2308, Australia
| | - Peter Donovan
- Director of Clinical Pharmacology, The Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD, 4029, Australia
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Abstract
Non-ST elevation acute coronary syndromes (NSTE-ACS) encompass the clinical entities of unstable angina and non-ST elevation myocardial infarction. Several advances have occurred over the past decade, including the emergence of new antiplatelet and antithrombotic therapies and novel treatment strategies, leading to marked improvements in mortality. However, there has also been an increased incidence in NSTE-ACS as a result of the use of high-sensitivity troponins and the increase in cardiovascular risk factors. This article provides a focused update on contemporary management strategies pertaining to antiplatelet, antithrombotic, and anti-ischemic therapies and to revascularization strategies in patients with ACS.
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Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Zoghbi WA, Arend TE, Oetgen WJ, May C, Bradfield L, Keller S, Ramadhan E, Tomaselli GF, Brown N, Robertson RM, Whitman GR, Bezanson JL, Hundley J. 2012 ACCF/AHA Focused Update Incorporated Into the ACCF/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction. Circulation 2013; 127:e663-828. [DOI: 10.1161/cir.0b013e31828478ac] [Citation(s) in RCA: 181] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Jneid H, Ettinger SM, Ganiats TG, Philippides GJ, Jacobs AK, Halperin JL, Albert NM, Creager MA, DeMets D, Guyton RA, Kushner FG, Ohman EM, Stevenson W, Yancy CW. 2012 ACCF/AHA focused update incorporated into the ACCF/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. J Am Coll Cardiol 2013; 61:e179-347. [PMID: 23639841 DOI: 10.1016/j.jacc.2013.01.014] [Citation(s) in RCA: 373] [Impact Index Per Article: 33.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Holbrook A, Schulman S, Witt DM, Vandvik PO, Fish J, Kovacs MJ, Svensson PJ, Veenstra DL, Crowther M, Guyatt GH. Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e152S-e184S. [PMID: 22315259 DOI: 10.1378/chest.11-2295] [Citation(s) in RCA: 889] [Impact Index Per Article: 74.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND High-quality anticoagulation management is required to keep these narrow therapeutic index medications as effective and safe as possible. This article focuses on the common important management questions for which, at a minimum, low-quality published evidence is available to guide best practices. METHODS The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement. RESULTS Most practical clinical questions regarding the management of anticoagulation, both oral and parenteral, have not been adequately addressed by randomized trials. We found sufficient evidence for summaries of recommendations for 23 questions, of which only two are strong rather than weak recommendations. Strong recommendations include targeting an international normalized ratio of 2.0 to 3.0 for patients on vitamin K antagonist therapy (Grade 1B) and not routinely using pharmacogenetic testing for guiding doses of vitamin K antagonist (Grade 1B). Weak recommendations deal with such issues as loading doses, initiation overlap, monitoring frequency, vitamin K supplementation, patient self-management, weight and renal function adjustment of doses, dosing decision support, drug interactions to avoid, and prevention and management of bleeding complications. We also address anticoagulation management services and intensive patient education. CONCLUSIONS We offer guidance for many common anticoagulation-related management problems. Most anticoagulation management questions have not been adequately studied.
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Affiliation(s)
- Anne Holbrook
- Division of Clinical Pharmacology and Therapeutics, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.
| | - Sam Schulman
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Daniel M Witt
- Department of Pharmacy, Kaiser Permanente Colorado, Denver, CO
| | - Per Olav Vandvik
- Department of Medicine, Innlandet Hospital Trust, Gjøvik, Norway
| | - Jason Fish
- Department of Internal Medicine, University of California Los Angeles, Los Angeles, CA
| | - Michael J Kovacs
- Department of Medicine, University of Western Ontario, London, ON, Canada
| | - Peter J Svensson
- Department for Coagulation Disorders, University of Lund, University Hospital, Malmö, Sweden
| | | | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Gordon H Guyatt
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
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Abstract
A thorough understanding of the pharmacology, pharmacokinetics, and pharmacodynamics of the most commonly prescribed anticoagulants is necessary to ensure optimal therapeutic outcomes and patient safety. Evidence is available to guide some, but not all aspects of anticoagulation therapy initiation. Issues related to the initiation of anticoagulation therapy, including the resumption of therapy following interruption of anticoagulation for invasive procedures, are reviewed. Initiating unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), or fondaparinux is challenging for patients with renal dysfunction and obesity. UFH is preferred in patients with severe renal dysfunction. Morbidly obese patients may require higher than usual prophylactic doses of LMWH. Therapeutic doses of LMWH should be based on actual body weight, even in obese patients. Currently available evidence does not demonstrate the superiority of one initial warfarin dose over another. All anticoagulants increase the risk of bleeding and should therefore only be initiated in appropriately selected patients with sufficiently low underlying bleeding risk.
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Wright RS, Anderson JL, Adams CD, Bridges CR, Casey DE, Ettinger SM, Fesmire FM, Ganiats TG, Jneid H, Lincoff AM, Peterson ED, Philippides GJ, Theroux P, Wenger NK, Zidar JP, Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Zidar JP. 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 developed in collaboration with the American Academy of Family Physicians, Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons. J Am Coll Cardiol 2011; 57:e215-367. [PMID: 21545940 DOI: 10.1016/j.jacc.2011.02.011] [Citation(s) in RCA: 301] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC. 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 2011; 123:e426-579. [PMID: 21444888 DOI: 10.1161/cir.0b013e318212bb8b] [Citation(s) in RCA: 349] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Krishnaswamy A, Lincoff AM, Cannon CP. Bleeding complications of unfractionated heparin. Expert Opin Drug Saf 2010; 10:77-84. [DOI: 10.1517/14740338.2011.521150] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Perry DJ, Fitzmaurice DA, Kitchen S, Mackie IJ, Mallett S. Point-of-care testing in haemostasis. Br J Haematol 2010; 150:501-14. [PMID: 20618331 DOI: 10.1111/j.1365-2141.2010.08223.x] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Point-of-care testing (POCT) in haematology has seen a significant increase in both the spectrum of tests available and the number of tests performed annually. POCT is frequently undertaken with the belief that this will reduce the turnaround time for results and so improve patient care. The most obvious example of POCT in haemostasis is the out-of-hospital monitoring of the International Normalized Ratio in patients receiving a vitamin K antagonist, such as warfarin. Other areas include the use of the Activated Clotting Time to monitor anticoagulation for patients on cardio-pulmonary bypass, platelet function testing to identify patients with apparent aspirin or clopidogrel resistance and thrombelastography to guide blood product replacement during cardiac and hepatic surgery. In contrast to laboratory testing, POCT is frequently undertaken by untrained or semi-trained individuals and in many cases is not subject to the same strict quality control programmes that exist in the central laboratory. Although external quality assessment programmes do exist for some POCT assays these are still relatively few. The use of POCT in haematology, particularly in the field of haemostasis, is likely to expand and it is important that systems are in place to ensure that the generated results are accurate and precise.
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Affiliation(s)
- David J Perry
- Department of Haematology, Addenbrooke's Hospital, Cambridge, UK.
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Abstract
Despite the development of newer anticoagulants, unfractionated heparin remains an indispensible agent in the treatment of thrombotic disorders. Heparin exerts its major effect via antithrombin, converting antithrombin to a more efficient inhibitor of circulating thrombin (factor IIa), factor Xa, factor IXa, factor XIIa, and kallikrein. However, due to the multiple anticoagulant mechanisms of heparin, differential molecular weight-based clearance, issues of heparin resistance, and patient-specific characteristics (age, weight, gender, and tobacco), attaining therapeutic anticoagulation is complicated. As a result, a minority of patients in major clinical trials achieve an activated partial thromboplastin time within the target window in an appropriate time-frame despite the use of weight-based titration nomograms. The resultant under- or over-therapeutic anticoagulation is associated with increased risks of ischemic and bleeding complications, suggesting the importance of maintaining heparin anticoagulation within a relatively narrow therapeutic range. In this review we discuss the mechanisms of heparin action, clinical ramifications of incorrect dosing in major trials, and attempts to improve the achievement of therapeutic anticoagulation.
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Sado DM, Price D, Sarvananthan S. Practical prescribing of intravenous unfractionated heparin. Br J Hosp Med (Lond) 2009; 70:391-3. [PMID: 19584780 DOI: 10.12968/hmed.2009.70.7.43121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Intravenous unfractionated heparin is sometimes poorly managed in NHS hospitals. This article investigates why this is so and reviews the evidence for optimal unfractionated heparin prescribing, using it to make some suggestions as to how doctors can improve this.
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Abstract
Anticoagulant therapy for acute coronary syndromes is becoming more complex as newer agents are added to unfractionated heparin and warfarin. The anticoagulants used in current clinical practice are low molecular weight heparins, direct thrombin inhibitors, and heparinoids. Properties of and recent clinical trial data regarding these newer anticoagulants are reviewed in reference to current American College of Cardiology/American Heart Association guidelines.
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Affiliation(s)
- L Veronica Lee
- Division of Cardiology, Yale University School of Medicine, 789 Howard Avenue, FMP3, New Haven, CT 06437, USA.
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Treating acute pulmonary embolism: outpatient or inpatient or somewhere in between. Thromb Res 2008; 123 Suppl 1:S22-8. [PMID: 18930310 DOI: 10.1016/j.thromres.2008.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Unfractionated heparin dosing and risk of major bleeding in non-ST-segment elevation acute coronary syndromes. Am Heart J 2008; 156:209-15. [PMID: 18657648 DOI: 10.1016/j.ahj.2008.03.023] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2007] [Accepted: 03/26/2008] [Indexed: 11/23/2022]
Abstract
BACKGROUND Unfractionated heparin (UFH) is a mainstay of treatment for patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS), but the practice of weight-adjusted bolus and infusion dosing has not been carefully evaluated. METHODS Using data from 31,445 high-risk patients with NSTE ACS enrolled at 420 hospitals in the CRUSADE initiative, we evaluated initial UFH dosing relative to guideline recommendations and determined factors associated with excess weight-adjusted dosing and major bleeding, overall and among subgroups. Excess dose was defined as >70 U/kg for bolus or >15 U/kg per hour for infusion. RESULTS The most frequent bolus dose was 5,000 U (42.7%) and infusion dose was 1,000 U/h (46%). An excess weight-adjusted UFH bolus or infusion dose was administered 35% of the time. Factors strongly associated with excess weight-adjusted dosing were age (per 10-year increase) (odds ratio [OR] 1.11, 95% CI 1.08-1.15) and female sex (OR 1.45, 95% CI 1.33-1.59). Rate of major bleeding increased proportionally in relation to dose of UFH for both bolus and infusion, specifically when dose was above the recommended weight-adjusted range (>70 U/kg for bolus or >15 U/kg per hour for infusion). Both excess bolus (OR 1.03, 95% CI 1.00-1.06) and infusion (OR 1.16, 95% CI 1.05-1.28) were individually associated with increased bleeding. The relationship between weight-adjusted UFH dose and major bleeding did not vary independently by sex or age. CONCLUSIONS In high-risk patients with NSTE ACS, initial UFH bolus and infusion dosing were frequently higher than recommended weight-adjusted ranges, particularly in patients with lower body weight. Excess bolus and infusion rate dosing was associated with more bleeding and was common among elderly and females. Attention to dosing by weight rather than standard bolus and infusion dosing should lead to improved safety in the use of UFH.
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Harrington RA, Becker RC, Cannon CP, Gutterman D, Lincoff AM, Popma JJ, Steg G, Guyatt GH, Goodman SG. Antithrombotic Therapy for Non–ST-Segment Elevation Acute Coronary Syndromes. Chest 2008; 133:670S-707S. [DOI: 10.1378/chest.08-0691] [Citation(s) in RCA: 116] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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Bhatheja R, Mukherjee D. Acute coronary syndromes: unstable angina/non-ST elevation myocardial infarction. Crit Care Clin 2008; 23:709-35, v. [PMID: 17964360 DOI: 10.1016/j.ccc.2007.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Acute coronary syndrome is a major health problem affecting approximately 1.5 million individuals a year. Early diagnosis and appropriate evidence-based therapies improve clinical outcomes significantly. Current data suggest that an early invasive therapy may improve intermediate-term and long-term outcomes, particularly in high-risk individuals. The last few years also have seen significant advances in antiplatelet and antithrombotic therapies for the management of patients who have acute coronary syndrome.
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Affiliation(s)
- Rohit Bhatheja
- Gill Heart Institute, Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY 40536-0200, USA
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Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B. 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/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. J Am Coll Cardiol 2007; 50:e1-e157. [PMID: 17692738 DOI: 10.1016/j.jacc.2007.02.013] [Citation(s) in RCA: 1285] [Impact Index Per Article: 75.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction: Executive Summary. Circulation 2007. [DOI: 10.1161/circulationaha.107.185752] [Citation(s) in RCA: 150] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC, Jacobs AK, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B. 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/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons: endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. Circulation 2007; 116:e148-304. [PMID: 17679616 DOI: 10.1161/circulationaha.107.181940] [Citation(s) in RCA: 813] [Impact Index Per Article: 47.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B. ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction—Executive Summary. J Am Coll Cardiol 2007. [DOI: 10.1016/j.jacc.2007.02.028] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Rich JD, Maraganore JM, Young E, Lidon RM, Adelman B, Bourdon P, Charenkavanich S, Hirsh J, Theroux P, Cannon CP. Heparin resistance in acute coronary syndromes. J Thromb Thrombolysis 2007; 23:93-100. [PMID: 17221324 DOI: 10.1007/s11239-006-9049-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2006] [Accepted: 12/01/2006] [Indexed: 02/04/2023]
Abstract
BACKGROUND Maintaining a therapeutic level of anticoagulation with unfractionated heparin remains a major challenge for clinicians because of the wide variability of patient responses, which may be explained by variable binding of heparin to plasma proteins. Direct thrombin inhibitors may offer an advantage in more predictable anticoagulation. METHODS Plasma samples from normal volunteers, stable coronary artery disease (CAD) patients, unstable angina patients, and acute myocardial infarction patients were obtained. A fixed concentration of heparin (.13 U/ml) or bivalirudin (1.6 microg/ml) was added to plasma from each of the four study groups and measurement of the APTT was performed. In addition, a pool of plasma from patients with acute MI was diluted in pooled normal plasma, and heparin or bivalirudin was added to the plasma preparation and APTT measurements performed. RESULTS In heparin-treated plasma samples, mean APTT values were 443 +/- 137% baseline for normal volunteers, 347 +/- 116% for patients with stable CAD, 290 +/- 124% for patients with unstable angina (p < 0.05), and 230 +/- 120% for patients with acute MI (p < 0.05). APTT did not differ across the four groups treated with bivalirudin. There was a much higher degree of variability in APTT values in heparin treated controls (272%-671%, SD approximately 30%) compared to bivalirudin treated controls (284-499%, SD approximately 12%). When the "acute MI pool" was diluted in pooled normal plasma at fixed concentrations of either bivalirudin (1.6 mug/ml) or heparin (0.13 U/ml), there was a sharp decrease in heparin activity from 407% baseline (at 0% acute MI pool) to values as low as 126% baseline (at 100% acute MI pool). A markedly different pattern was seen in the bivalirudin treated samples, where a trend towards decreased APTT values was seen only at the 100% acute MI pool. CONCLUSION Both heparin variability and resistance may limit optimal antithrombotic therapy with heparin in patients with ACS and constitutes a potential advantage of direct antithrombin blockade with bivalirudin.
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Affiliation(s)
- Jonathan D Rich
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
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26
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Westaway KP, Cruickshank M. Heparin dosing and therapeutic activated partial thromboplastin times (aPTT) in acute coronary syndrome (ACS). Aust Crit Care 2006; 19:6-8, 10-4. [PMID: 16544673 DOI: 10.1016/s1036-7314(06)80017-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
This study assessed the current practices of heparin dosing and determined the extent of therapeutic activated partial thromboplastin times (aPTT) achieved, utilising a standard heparin nomogram in the coronary care unit and step-down cardiac ward of a health care facility in South Australia. The study also examined the effect of actual body weight (ABW), body mass index (BMI), smoking, concomitant intravenous glycerine trinitrate, age, gender and creatinine levels, individually, on the time taken to attain a therapeutic aPTT in acute coronary syndrome (ACS) patients receiving a heparin infusion. A retrospective correlational research design was utilised to include the collection of quantitative data from 66 men and women of all ages and background consecutively admitted into the coronary care unit and the step-down cardiac ward and receiving a continuous heparin infusion. The quantitative data included demographic details plus all information regarding treatment and results of heparin therapy from the patients' medical records. Descriptive analysis of the data revealed 32% of the participants attained a therapeutic level with the first aPTT taken and that, successively, 35% and 45% of the participants attained a therapeutic level with the second and third aPTT taken. The majority of participants were found to be outside of the therapeutic range at any one time during the study. A generalised linear model (log-binomial model) applied to the data revealed that increased ABW (p=0.002), creatinine levels (p=0.033) and, in particular, BMI (p=0.000) were significant risk factors that contributed to the failure of participants attaining a therapeutic aPTT level. Age (p=0.668), gender (p=0.623), smoking (p=0.993) and the use of concomitant intravenous glycerine trinitrate (p=0.897) did not have a significant effect on the time to reach a therapeutic aPTT. The results provide noteworthy information for the re-evaluation of the use of the standard heparin nomogram. A robust randomised clinical trial is required to further examine BMI as the best predictor for heparin requirements in ACS patients receiving a heparin infusion.
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Affiliation(s)
- Kerrie P Westaway
- Coronary Care Unit and Step-Down Cardiac Ward, Wakefield Hospital, Adelaide SA
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27
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O'Hanlon R, Reddan DN. Treatment of acute coronary syndromes in patients who have chronic kidney disease. Med Clin North Am 2005; 89:563-85. [PMID: 15755468 DOI: 10.1016/j.mcna.2004.11.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Patients with CKD and CAD have traditionally been a difficult population to diagnose and treat in the setting of ACS. In addition to having poorer outcomes post-ACS, data are lacking regarding best treatments available. Aggressive interventional and medical treatments in this group with already poor outcomes are not necessarily contraindicated and should always be considered. The appalling outcome for CKD patients post-ACS is improved by many therapies shown to benefit in the non-CKD patients. Data suggest that troponins are useful markers in CKD patients, that major bleeding is not increased with the use of GP IIb-IIIa antagonists, that thrombolytics have been used successfully in CKD patients, and that PCI electively and as a primary treatment for ACS is successful and probably more beneficial to treatment.
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Affiliation(s)
- Rory O'Hanlon
- Division of Cardiology, University College Galway Hospital, Galway, Ireland
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Harrington RA, Becker RC, Ezekowitz M, Meade TW, O'Connor CM, Vorchheimer DA, Guyatt GH. Antithrombotic therapy for coronary artery disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126:513S-548S. [PMID: 15383483 DOI: 10.1378/chest.126.3_suppl.513s] [Citation(s) in RCA: 159] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
This chapter about antithrombotic therapy for coronary artery disease (CAD) is part of the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence Based Guidelines. 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). Among the key recommendations in this chapter are the following: For patients presenting with non-ST-segment elevation (NSTE) acute coronary syndrome (ACS), we recommend immediate and then daily oral aspirin (Grade 1A). For patients with an aspirin allergy, we recommend immediate treatment with clopidogrel, 300-mg bolus po, followed by 75 mg/d indefinitely (Grade 1A). In all NSTE ACS patients in whom diagnostic catheterization will be delayed or when coronary bypass surgery will not occur until > 5 days, we recommend clopidogrel as bolus therapy (300 mg), followed by 75 mg/d for 9 to 12 months in addition to aspirin (Grade 1A). In NSTE ACS patients in whom angiography will take place within 24 h, we suggest beginning clopidogrel after the coronary anatomy has been determined (Grade 2A). For patients who have received clopidogrel and are scheduled for coronary bypass surgery, we recommend discontinuing clopidogrel for 5 days prior to the scheduled surgery (Grade 2A). In moderate- to high-risk patients presenting with NSTE ACS, we recommend either eptifibatide or tirofiban for initial (early) treatment in addition to treatment with aspirin and heparin (Grade 1A). For the acute treatment of NSTE ACS, we recommend low molecular weight heparins over unfractionated heparin (UFH) [Grade 1B] and UFH over no heparin therapy use with antiplatelet therapies (Grade 1A). We recommend against the direct thrombin inhibitors as routine initial antithrombin therapy (Grade 1B). For patients after myocardial infarction, after ACS, and with stable CAD, we recommend aspirin in doses from 75 to 325 mg as initial therapy and in doses of 75 to 162 mg as indefinite therapy (Grade 1A). For patients with contraindications to aspirin, we recommend long-term clopidogrel (Grade 1A). For primary prevention in patients with at least moderate risk for a coronary event, we recommend aspirin, 75 to 162 mg/d, over either no antithrombotic therapy or vitamin K antagonist (VKA) [Grade 2A]; for patients at particularly high risk of events in whom the international normalized ratio (INR) can be monitored without difficulty, we suggest low-dose VKA (target INR, 1.5) [Grade 2A].
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Comp PC. Treatment and management of acute venous thromboembolic disease. Thromb Res 2003; 111:3-8. [PMID: 14644071 DOI: 10.1016/s0049-3848(03)00349-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Venous thromboembolic (VTE) disease consists of deep vein thrombosis and/or pulmonary embolism. Either low molecular weight heparin given subcutaneously or unfractionated heparin administered intravenously are used for the initial treatment. Simultaneously, warfarin therapy is initiated. Thrombolytic therapy plays a limited role. Following the initial heparin treatment, anticoagulation clinics provide an excellent means of monitoring the oral anticoagulation. Patient education is important and patients should be well versed in the basic features of oral anticoagulation. The duration of oral anticoagulation is dependent on a number of factors including the presence of inherited risk factors, bleeding risk and patient reliability. Residual thrombus in the affected vein may indicate the need for prolonged anticoagulation. The low intensity oral anticoagulation (INR 1.5-2.0) is useful in preventing recurrent thrombosis following the initial treatment period with full intensity oral anticoagulation.
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Affiliation(s)
- Philip C Comp
- University of Oklahoma Health Sciences Center, 921 NE 13th Street (151), Oklahoma City, OK 73104, USA.
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Newby LK, Harrington RA, Bhapkar MV, Van de Werf F, Hochman JS, Granger CB, Simes RJ, Davis CG, Topol EJ, Califf RM, Moliterno DJ. An automated strategy for bedside aPTT determination and unfractionated heparin infusion adjustment in acute coronary syndromes: insights from PARAGON A. J Thromb Thrombolysis 2002; 14:33-42. [PMID: 12652148 DOI: 10.1023/a:1022062204490] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Intravenous unfractionated heparin remains a cornerstone of anticoagulation therapy for patients with acute coronary syndromes, but regulation to a target aPTT is challenging. We assessed unfractionated heparin infusion regulation by bedside, whole-blood aPTT testing and computerized, algorithmic infusion adjustment, and further evaluated the relationship of achieving the target aPTT with clinical outcomes. METHODS AND RESULTS We studied 1,275 patients randomized to unfractionated heparin in PARAGON-A, which tested lamifiban with or without unfractionated heparin versus unfractionated heparin. All patients had baseline and 6-hour blinded, bedside aPTTs, then aPTTs per algorithm. A central computer translated encrypted values to algorithmic dose-adjustment commands. We assessed the ability to achieve and maintain aPTTs of 50-70 seconds and associations of 6- and 12-hour aPTTs and time-to-target with 30-day outcomes.Overall, the median 6-hour aPTT was 50-70 seconds and remained so throughout infusion. Individually, only 33.6% of patients achieved 6-hour target-range aPTTs, and only 40% of all aPTTs were in-range. After achieving target, only 42% of subsequent measures were in-range. Thirty-day death or myocardial infarction (death/MI) increased non-significantly as time-to-target increased (p = 0.08). Thirty-day mortality was similar if target aPTT was reached, regardless of timing. Death/MI trended lower if target aPTT was reached by 8 hours (p = 0.10). The best clinical outcomes were associated with in-range aPTTs. CONCLUSIONS This study represents the most systematic monitoring and regulation of unfractionated heparin anticoagulation to date. Although average anticoagulation achieved target range, wide inter- and intra-patient variability may have important implications for clinical outcomes.
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Affiliation(s)
- L Kristin Newby
- Duke Clinical Research Institute, Durham, NC 27715-7969, USA.
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31
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Le Nguyen MT, Spencer FA. Low molecular weight heparin and unfractionated heparin in the early pharmacologic management of acute coronary syndromes: a meta-analysis of randomized clinical trials. J Thromb Thrombolysis 2001; 12:289-95. [PMID: 11981112 DOI: 10.1023/a:1015287311065] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The standard of care in Acute Coronary Syndromes (ACS) includes a full complement of antischemic and antithrombotic therapy. Although aspirin is used widely and concomitant anticoagulation is recommended, the comparative benefits of low molecular weight heparin (LMWH) and unfractionated heparin (UFH) have not been defined. METHODS/RESULTS A meta-analysis including all randomized clinical trials comparing LMWH and UFH for the treatment of non-ST segment elevation acute coronary syndromes was performed. Risk ratios (RR), using the DerSimonian-Laird Model, were calculated from a total of 13,320 patients. Death (RR 0.98, 95% CI 0.73-1.31), death and myocardial infarction (MI) (RR 0.86, 95% CI 0.74-1.01), death, MI, recurrent angina or revascularization (RR 0.89, 95% CI 0.74-1.07) and major hemorrhage (RR 1.01, 95% CI 0.81-1.25) occurred with similar frequencies for the anticoagulant-based strategies. CONCLUSIONS Fixed dose LMWH therapy given subcutaneously compares favorably with UFH titrated to a target level of anticoagulation and should be considered a safe, effective, and clinically acceptable alternative in the early management of patients with non-ST segment elevation ACS. The superiority of LMWH preparations characterized by high in vitro factor Xa to thrombin inhibitory capacity is supported by clinic trial data but requires further investigation.
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Affiliation(s)
- M T Le Nguyen
- Cardiovascular Thrombosis Research Center, Department of Medicine, University of Massachusetts Medical School, Worcester, MA 01655, USA
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Ferring M, Reber G, de Moerloose P, Merlani P, Diby M, Ricou B. Point of care and central laboratory determinations of the aPTT are not interchangeable in surgical intensive care patients. Can J Anaesth 2001; 48:1155-60. [PMID: 11744594 DOI: 10.1007/bf03020384] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE The objective of the study was to compare a bedside whole blood activated partial thromboplastin time (aPTT) performed by a point of care (POC) apparatus (CoaguCheck(R) Pro) in surgical intensive care (SIC) patients with a conventional aPTT obtained from the central laboratory. METHODS The prospective concomitant measurements of the two aPTT were performed in 233 samples from 46 consecutive patients admitted after cardiovascular or major abdominal surgery. RESULTS Inter-operator, inter-instrument and inter-cartridge variability of the new device measured in three healthy volunteers and in nine patients in stable condition (controls) was low (F test: P=0.86). The agreement by Bland and Altman between POC and central laboratory aPTT (-20.2 +/- 18.8 sec) was not satisfactory. The agreement between POC and central laboratory aPTT in patients after surgery was worst (-17 +/- 33.1 sec). Heparin treatment or timing of blood sampling after intensive care admission (<48 hr vs >48 hr) did not influence the agreement. The correlation between POC or central laboratory aPTT and anti-factor Xa activity was poor (r(2) 0.077 and 0.181 respectively). The test which correlated the best to heparin doses was anti-factor Xa activity (r(2) 0.714). CONCLUSION POC aPTT and central laboratory aPTT showed a poor agreement in SIC patients admitted after surgery, although in healthy volunteers or in control patients, this agreement was better. The best test to monitor heparin treatment in this setting was anti-factor Xa activity.
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Affiliation(s)
- M Ferring
- Divisions of Surgical Intensive Care, Department of Anesthesiology, Pharmacology and Surgical Intensive Care and the Hemostasis unit, Division of Angiology and Hemostasis, Department of Medicine, University Hospital of Geneva, Geneva, Switzerland
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Folstad J, Caron MF, Nguyen I, White CM. Assessment of weight-based versus standard dosing of heparin in patients with unstable angina. J Clin Pharm Ther 2001; 26:283-6. [PMID: 11493371 DOI: 10.1046/j.1365-2710.2001.00359.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess whether a weight-based dosing regimen (80 u/kg + 18 u/kg/h) or a standard-fixed dose regimen (5000 u + 1000 u/h) of heparin is more appropriate in patients with unstable angina (UA). METHOD A drug use evaluation was conducted. Patient data for all patients weighing less than 100 kg who were in the coronary care unit of a Veterans Administration Hospital and who received heparin for UA (>24 h) over a 7-month period were included. For the first 4 months, patients were given standard heparin dosing and in the final 3 months patients were given heparin based on weight. The proportion of patients achieving activated partial thromboplastin times (aPTTs) that were at least therapeutic during therapy, the time to achieve the aPTT at a level that was at least therapeutic, and the number of patients with aPTTs over the therapeutic range were compared between groups. RESULTS Patients in the group receiving weight-based heparin therapy (n = 23) were significantly more likely to achieve an aPTT that was at least therapeutic than patients receiving standard therapy (n = 42, 100% vs. 76%, respectively, P = 0.011). When all the patients in each group who achieved an aPTT that was at least therapeutic were compared, the weight-based group achieved the levels significantly faster than the standard-fixed dosing group (7.3 +/- 6.1 vs. 22.6 +/- 17.6 h, respectively, P = 0.0003). However, the use of weight-based dosing was associated with a higher incidence of achieving supertherapeutic aPTTs than standard therapy (78.3% vs. 50.0%, respectively, P = 0.049). CONCLUSION Patients with UA may achieve therapeutic aPTTs faster than those on standard therapy but they also have a higher risk of achieving a supertherapeutic aPTT.
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Affiliation(s)
- J Folstad
- University of Connecticut School of Pharmacy, Storrs, CT, USA
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Menon V, Berkowitz SD, Antman EM, Fuchs RM, Hochman JS. New heparin dosing recommendations for patients with acute coronary syndromes. Am J Med 2001; 110:641-50. [PMID: 11382373 DOI: 10.1016/s0002-9343(01)00715-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Despite major innovations in antithrombotic and antiplatelet therapy, unfractionated intravenous heparin is widely used to treat acute coronary syndromes. Recommendations for unfractionated heparin dosing in acute myocardial infarction and unstable angina have been issued in two recent American College of Cardiology/American Heart Association guidelines. An initial heparin bolus of 60 U/kg (maximum, 4000 U) followed by a 12-U/kg/h infusion (maximum 1000 U/h) is recommended with alteplase for ST-elevation myocardial infarction. When intravenous heparin is administered for myocardial infarction with non-ST elevation and unstable angina, an initial bolus of 60 to 70 U/kg (maximum, 5000 U) followed by a 12- to 15-U/kg/h infusion is recommended. The goal is to achieve an activated partial thromboplastin time of 50 to 70 seconds. Here, we review these new dosing regimens and explain the rationale for their use. We also review the risk of bleeding with heparin, especially when administered concurrently with aspirin, thrombolytic agents, and glycoprotein IIb/IIIa antagonists, and the relationship between activated partial thromboplastin time and cardiac events.
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Affiliation(s)
- V Menon
- Division of Cardiology, St. Luke's-Roosevelt Hospital Center, Columbia University, New York, NY 10025, USA.
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35
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36
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Hicks JM, Haeckel R, Price CP, Lewandrowski K, Wu AH. Recommendations and opinions for the use of point-of-care testing for hospitals and primary care: summary of a 1999 symposium. Clin Chim Acta 2001; 303:1-17. [PMID: 11163017 DOI: 10.1016/s0009-8981(00)00400-9] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
As part of a symposium on laboratory medicine, a colloquium on point-of-care testing was held in June 1999 where four experts were invited to produce recommendations and opinions on the use of point-of-care testing under various clinical venues. Each commented on costs for providing POCT services. A total of eleven recommendations and four opinions were rendered and discussed in an open forum. While one expert concluded that some forms of POCT are less expensive than central laboratory testing if entire laboratory workstations are eliminated, another expert suggested that POCT offered little advantage if rapid transport systems are available. A recommendation was made that POCT be considered for analytes that have a required reporting turnaround time of <30 min, and that the goals for precision and accuracy should be dictated by the clinical need and not by analytical limitations. Recommendations for POCT in specific clinical situations include use of glycated hemoglobin and urine albumin testing with personal glucose monitoring at the time of consultation, use of glycated albumin for gestational diabetes, leukocyte esterase and nitrite testing in urine to screen for urinary tract infections, coagulation tests for monitoring patients on oral anticoagulant therapy and in the operating room, testing for H. pylori for patients with dyspepsia, and cardiac markers and urine drugs-of-abuse testing in the emergency department.
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Affiliation(s)
- J M Hicks
- Department of Laboratory Medicine, Children's National Medical Center and the George Washington University School of Medicine, Washington, DC 20010, USA
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37
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Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Hochman JS, Jones RH, Kereiakes D, Kupersmith J, Levin TN, Pepine CJ, Schaeffer JW, Smith EE, Steward DE, Theroux P, Alpert JS, Eagle KA, Faxon DP, Fuster V, Gardner TJ, Gregoratos G, Russell RO, Smith SC. ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina). J Am Coll Cardiol 2000; 36:970-1062. [PMID: 10987629 DOI: 10.1016/s0735-1097(00)00889-5] [Citation(s) in RCA: 561] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Affiliation(s)
- R C Becker
- Cardiovascular Thrombosis Research Center, University of Massachusetts Medical School, Worcester 01655, USA
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39
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Salamonson Y. The ineffectiveness of a non-weight based heparin regimen in achieving therapeutic activated partial thromboplastin time (aPTT) in acute coronary syndrome. Aust Crit Care 2000; 13:128-33. [PMID: 16948203 DOI: 10.1016/s1036-7314(00)70640-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Although low molecular weight heparin (LMWH) is increasingly being used in the treatment of acute coronary syndrome (ACS), unfractionated intravenous (IV) heparin infusion is still widely used in Australian hospitals for the treatment of ACS. This paper evaluates the effectiveness of a non-weight based heparin regimen in achieving a therapeutic activated partial thromboplastin time (aPTT) within 24 hours of IV heparin commencement. A sequential retrospective chart review of 99 medical records of ACS patients in a district hospital in south western Sydney, Australia, was performed. These patients were prescribed IV heparin and did not receive thrombolytic or warfarin therapy. Only 35 per cent reached a therapeutic aPTT level within 24 hours of commencement of IV heparin therapy. Comparison of therapeutic aPTT and non-therapeutic aPTT groups revealed that body weight was the only factor that was significantly different in the two groups. Patients who reached the therapeutic aPTT threshold within 24 hours weighed significantly less (mean body weight: 70.3 kg versus 80.3 kg) than those who did not reach the therapeutic threshold within 24 hours of heparin commencement (t = 3.80, d.f. = 86, p < 0.001). Given that a significant proportion of patients who require IV heparin therapy exceed the 70 kg body weight, the findings from this study suggest that a non-weight based heparin regimen is ineffective in the rapid achievement of therapeutic aPTT.
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Affiliation(s)
- Y Salamonson
- Division of Nursing, Faculty of Health, University of Western Sydney, Campbelltown, NSW
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40
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Zimmerman CR. The role of point-of-care anticoagulation monitoring in arterial and venous thromboembolic disorders. J Thromb Thrombolysis 2000; 9:187-98. [PMID: 10728016 DOI: 10.1023/a:1018744124955] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- C R Zimmerman
- Henry Ford Hospital, Department of Pharmacy Services, Detroit, MI 48202, USA.
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41
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42
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Zed PJ. Low molecular weight heparins and coronary artery disease. Curr Cardiol Rep 2000; 2:61-8. [PMID: 10980874 DOI: 10.1007/s11886-000-0027-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Coronary artery disease encompasses a wide spectrum of conditions including silent ischemia, exertional angina, unstable angina, and myocardial infarction. Acute coronary syndromes (unstable angina and myocardial infarction) are caused by the rupture of an atherosclerotic plaque, platelet activation, and fibrin deposition resulting in thrombosis. Aspirin and unfractionated heparin (UFH) have traditionally been the treatment of choice in patients with acute coronary syndromes; however, low molecular weight heparins (LMWHs) offer potential advantages over UFH. Available evidence indicates that LMWH is superior to UFH in reducing ischemic events or death in the acute phase of unstable angina or non-Q-wave myocardial infarction. Long-term therapy with lower doses of LMWH may not offer any advantage to aspirin in the prevention of coronary events or death. Major bleeding complications are similar for LMWH and UFH although minor bleeding complications are more common with LMWH, primarily due to injection-site hematomas. Finally, use of LMWH appears to be cost- effective compared with UFH. The available evidence supports improved clinical outcomes, favorable safety profile, and cost savings associated with LMWH use in the management of unstable angina and non-Q-wave myocardial infarction and should be favored over UFH.
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Affiliation(s)
- P J Zed
- CSU Pharmaceutical Sciences, Vancouver Hospital and Health Sciences Center, BC, Canada.
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43
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Affiliation(s)
- C P Cannon
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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44
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Becker RC, Spencer FA, Li Y, Ball SP, Ma Y, Hurley T, Hebert J. Thrombin generation after the abrupt cessation of intravenous unfractionated heparin among patients with acute coronary syndromes: potential mechanisms for heightened prothrombotic potential. J Am Coll Cardiol 1999; 34:1020-7. [PMID: 10520784 DOI: 10.1016/s0735-1097(99)00322-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVES The purpose of this study was to determine the mechanistic basis for thrombin generation and increased prothrombotic potential after the abrupt cessation of intravenous (i.v.) unfractionated heparin among patients with acute coronary syndromes. BACKGROUND A "rebound" increase in prothrombotic potential has been observed biochemically and clinically after the abrupt cessation of unfractionated heparin (UFH) among patients with acute coronary syndromes. Although the mechanism is unknown, tissue factor and the extrinsic coagulation cascade, both operative in atherosclerotic vascular disease and arterial thrombosis, are thought to be centrally involved. METHODS In a single-center, pilot study, 30 patients with either unstable angina or non-ST segment elevation myocardial infarction who had received a continuous i.v. infusion of UFH for 48 h were randomly assigned to: 1) abrupt cessation, 2) i.v. weaning over 12 h or 3) subcutaneous weaning over 12 h. RESULTS Thrombin generation (prothrombin fragment 1.2) was evident within 1 h of UFH cessation, increased progressively (by nearly two-fold) at 24 h (p = 0.002) and correlated inversely with tissue factor pathway inhibitor concentration (r = -0.61). Thrombin generation was greatest among patients randomized to abrupt cessation (1.6-fold increase at 24 h) and least in those with i.v. weaning. CONCLUSIONS Thrombin generation after the abrupt cessation of UFH may represent a drug-induced impairment of physiologic vascular thromboresistance in response to locally generated tissue factor. A dosing strategy of abbreviated i.v. weaning attenuates but does not prevent heparin rebound among patients with acute coronary syndromes.
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Affiliation(s)
- R C Becker
- Cardiovascular Thrombosis Research Center, Laboratory for Vascular Biology Research, University of Massachusetts Medical School, Worcester 01655, USA.
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