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Gurbel PA, Rout A, Tantry US. Monitoring and Reversal of Anticoagulation and Antiplatelet Agents. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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2
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Nicolau JC, Feitosa Filho GS, Petriz JL, Furtado RHDM, Précoma DB, Lemke W, Lopes RD, Timerman A, Marin Neto JA, Bezerra Neto L, Gomes BFDO, Santos ECL, Piegas LS, Soeiro ADM, Negri AJDA, Franci A, Markman Filho B, Baccaro BM, Montenegro CEL, Rochitte CE, Barbosa CJDG, Virgens CMBD, Stefanini E, Manenti ERF, Lima FG, Monteiro Júnior FDC, Correa Filho H, Pena HPM, Pinto IMF, Falcão JLDAA, Sena JP, Peixoto JM, Souza JAD, Silva LSD, Maia LN, Ohe LN, Baracioli LM, Dallan LADO, Dallan LAP, Mattos LAPE, Bodanese LC, Ritt LEF, Canesin MF, Rivas MBDS, Franken M, Magalhães MJG, Oliveira Júnior MTD, Filgueiras Filho NM, Dutra OP, Coelho OR, Leães PE, Rossi PRF, Soares PR, Lemos Neto PA, Farsky PS, Cavalcanti RRC, Alves RJ, Kalil RAK, Esporcatte R, Marino RL, Giraldez RRCV, Meneghelo RS, Lima RDSL, Ramos RF, Falcão SNDRS, Dalçóquio TF, Lemke VDMG, Chalela WA, Mathias Júnior W. Brazilian Society of Cardiology Guidelines on Unstable Angina and Acute Myocardial Infarction without ST-Segment Elevation - 2021. Arq Bras Cardiol 2021; 117:181-264. [PMID: 34320090 PMCID: PMC8294740 DOI: 10.36660/abc.20210180] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- José Carlos Nicolau
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Gilson Soares Feitosa Filho
- Escola Bahiana de Medicina e Saúde Pública, Salvador, BA - Brasil
- Centro Universitário de Tecnologia e Ciência (UniFTC), Salvador, BA - Brasil
| | - João Luiz Petriz
- Hospital Barra D'Or, Rede D'Or São Luiz, Rio de Janeiro, RJ - Brasil
| | | | | | - Walmor Lemke
- Clínica Cardiocare, Curitiba, PR - Brasil
- Hospital das Nações, Curitiba, PR - Brasil
| | | | - Ari Timerman
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brasil
| | - José A Marin Neto
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Ribeirão Preto, SP - Brasil
| | | | - Bruno Ferraz de Oliveira Gomes
- Hospital Barra D'Or, Rede D'Or São Luiz, Rio de Janeiro, RJ - Brasil
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brasil
| | | | | | | | | | | | | | | | | | - Carlos Eduardo Rochitte
- Hospital do Coração (HCor), São Paulo, SP - Brasil
- Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | - Edson Stefanini
- Escola Paulista de Medicina da Universidade Federal de São Paulo (UNIFESP), São Paulo, SP - Brasil
| | | | - Felipe Gallego Lima
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | | | | | | | | | - José Maria Peixoto
- Universidade José do Rosário Vellano (UNIFENAS), Belo Horizonte, MG - Brasil
| | - Juliana Ascenção de Souza
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Lilia Nigro Maia
- Faculdade de Medicina de São José do Rio Preto (FAMERP), São José do Rio Preto, SP - Brasil
| | | | - Luciano Moreira Baracioli
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Luís Alberto de Oliveira Dallan
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Luis Augusto Palma Dallan
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Luiz Carlos Bodanese
- Pontifícia Universidade Católica do Rio Grande do Sul (PUC-RS), Porto Alegre, RS - Brasil
| | | | | | - Marcelo Bueno da Silva Rivas
- Rede D'Or São Luiz, Rio de Janeiro, RJ - Brasil
- Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ - Brasil
| | | | | | - Múcio Tavares de Oliveira Júnior
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Nivaldo Menezes Filgueiras Filho
- Universidade do Estado da Bahia (UNEB), Salvador, BA - Brasil
- Universidade Salvador (UNIFACS), Salvador, BA - Brasil
- Hospital EMEC, Salvador, BA - Brasil
| | - Oscar Pereira Dutra
- Instituto de Cardiologia - Fundação Universitária de Cardiologia do Rio Grande do Sul, Porto Alegre, RS - Brasil
| | - Otávio Rizzi Coelho
- Faculdade de Ciências Médicas da Universidade Estadual de Campinas (UNICAMP), Campinas, SP - Brasil
| | | | | | - Paulo Rogério Soares
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | | | | | | | - Roberto Esporcatte
- Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ - Brasil
| | | | | | | | | | | | | | - Talia Falcão Dalçóquio
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - William Azem Chalela
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Wilson Mathias Júnior
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
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Onwordi ENC, Gamal A, Zaman A. Anticoagulant Therapy for Acute Coronary Syndromes. Interv Cardiol 2018; 13:87-92. [PMID: 29928314 PMCID: PMC5980649 DOI: 10.15420/icr.2017:26:1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 03/27/2018] [Indexed: 12/16/2022] Open
Abstract
Anticoagulation in conjunction with antiplatelet therapy is central to the management of acute coronary syndromes (ACS). When used effectively it is associated with a reduction in recurrent ischaemic events including myocardial infarction and stent thrombosis as well as a reduction in death. Effective ischaemic risk reduction whilst balancing bleeding risk remains a clinical challenge. This article reviews the current available evidence for anticoagulation in ACS and recommendations from the European Society of Cardiology.
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Affiliation(s)
| | - Amr Gamal
- Freeman Hospital and Newcastle University and Newcastle Upon Tyne Hospitals NHS TrustNewcastle, UK
| | - Azfar Zaman
- Freeman Hospital and Newcastle University and Newcastle Upon Tyne Hospitals NHS TrustNewcastle, UK
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4
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Gambhir DS. First 24 h in the management of non-ST segment elevation myocardial infarction. Eur Heart J Suppl 2018. [DOI: 10.1093/eurheartj/sux044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Daljeet S Gambhir
- Group Director, Department of Cardiology, Kailash Hospital and Heart Institute, H-33, Sector-27, Noida 201301, NCR, India
- Kailash Health Care Ltd, Noida 201301, India
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Husted S, Wallentin L, Andreotti F, Arnesen H, Bachmann F, Baigent C, Huber K, Jespersen J, Kristensen S, Lip GYH, Morais J, Rasmussen L, Siegbahn A, Verheugt FWA, Weitz JI, De Caterina R. Parenteral anticoagulants in heart disease: Current status and perspectives (Section II). Thromb Haemost 2017; 109:769-86. [DOI: 10.1160/th12-06-0403] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 12/25/2012] [Indexed: 11/05/2022]
Abstract
SummaryAnticoagulants are a mainstay of cardiovascular therapy, and parenteral anticoagulants have widespread use in cardiology, especially in acute situations. Parenteral anticoagulants include unfractionated heparin, low-molecular-weight heparins, the synthetic pentasaccharides fondaparinux, idraparinux and idrabiotaparinux, and parenteral direct thrombin inhibitors. The several shortcomings of unfractionated heparin and of low-molecular-weight heparins have prompted the development of the other newer agents. Here we review the mechanisms of action, pharmacological properties and side effects of parenteral anticoagulants used in the management of coronary heart disease treated with or without percutaneous coronary interventions, cardioversion for atrial fibrillation, and prosthetic heart valves and valve repair. Using an evidence-based approach, we describe the results of completed clinical trials, highlight ongoing research with currently available agents, and recommend therapeutic options for specific heart diseases.
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Yost GW, Steinhubl SR. Monitoring and Reversal of Anticoagulation and Antiplatelet Agents. Interv Cardiol 2016. [DOI: 10.1002/9781118983652.ch49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Wilson JM, Gilbert J, Harlan M, Bracey A, Allison P, Schooley C, Pinto K. High-dose Intravenous Dalteparin Can be Monitored Effectively Using Standard Coagulation Times. Clin Appl Thromb Hemost 2016; 11:127-38. [PMID: 15821819 DOI: 10.1177/107602960501100202] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The objective of this study was to examine the pharmacokinetics of intravenous dalteparin (Fragmin, Pharmacia-Upjohn, Peapack, NJ) and to assess the accuracy of standard coagulation-based monitoring techniques as an estimate of drug concentration with which to guide dosing. Knowledge of the kinetic behavior of low-molecular-weight heparins (LMWHs) and the possible utility of coagulation times for monitoring may aid in the development of safe and effective dosing algorithms for percutaneous coronary interventions. Twenty normal volunteers were treated at 2-week intervals with each of three intravenous dalteparin doses. Measurement of anti-IIa, anti-Xa, activated partial thromboplastin time (aPTT), activated clotting time (ACT), and low-range ACT was performed at baseline and at seven additional time points over 8 hours. The half-life of intravenous dalteparin is 77 minutes with slight dose-related variation. The aPTT, LR-ACT, and standard ACT are prolonged after dalteparin administration with the increase closely correlated to anti-Xa activity (aPTT, r = 0.85; LR-ACT, r = 0.79). Classification of anticoagulation intensity range using aPTT or LR-ACT in comparison to anti-Xa activity (0.5-0.99, 1.0-1.49, 1.5-2, >2) displays a level of agreement (kappa: aPTT = 0.69, LR-ACT = 0.59) that is comparable to values reported for coagulation time guidance of unfractionated heparin administration. Standard coagulation times are sensitive to the anticoagulant effect of dalteparin with a degree of correlation that suggests their utility for estimating drug concentration during high dose therapy. Trials establishing a relationship between monitoring and clinical efficacy, and the risk/reward of different treatment ranges alone or in combination with GPIIb/IIIa inhibitors and clopidogrel, are necessary.
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Affiliation(s)
- James M Wilson
- Department of Cardiology, St. Luke's Episcopal Hospital/Texas Heart Institute, Baylor College of Medicine, University of Houston School of Pharmacy, Houston, Texas 77030, USA.
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Elkayam U, Singh H, Irani A, Akhter MW. Anticoagulation in Pregnant Women With Prosthetic Heart Valves. J Cardiovasc Pharmacol Ther 2016; 9:107-15. [PMID: 15309247 DOI: 10.1177/107424840400900206] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Pregnancy is associated with an increased risk of thrombosis in women with mechanical prosthetic heart valves. Effective anticoagulation is therefore critical in such patients but remains problematic, since oral anticoagulation and both unfractionated and low-molecular-weight heparin may be associated with important fetal and maternal side effects. Purpose: To review information related to the use of anticoagulation with both warfarin and heparin and reassess the safety and efficacy of these therapies in pregnant women with mechanical prosthetic heart valves. Data source and selection: A MEDLINE search from 1966 to October 2003 for English and non-English language articles that reported the use of anticoagulation in pregnancy was conducted. Articles were included if they reported use of anticoagulation in pregnancy with emphasis on those that included women with mechanical prosthetic heart valves. Conclusions: Anticoagulation prophylaxis with both warfarin and heparin (unfractionated heparin and low-molecular-weight heparin) may be associated with important fetal and maternal side effects. Optional regimens for the treatment of low-risk and high-risk patients are proposed to minimize potential complications.
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Affiliation(s)
- Uri Elkayam
- Division of Cardiovascular Medicine, Department of Medicine, University of Southern California, Keck School of Medicine, Los Angeles, California 90033, USA.
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Roffi M, Patrono C, Collet JP, Mueller C, Valgimigli M, Andreotti F, Bax JJ, Borger MA, Brotons C, Chew DP, Gencer B, Hasenfuss G, Kjeldsen K, Lancellotti P, Landmesser U, Mehilli J, Mukherjee D, Storey RF, Windecker S. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2015; 37:267-315. [PMID: 26320110 DOI: 10.1093/eurheartj/ehv320] [Citation(s) in RCA: 4260] [Impact Index Per Article: 473.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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10
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Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Ganiats TG, Holmes DR, Jaffe AS, Jneid H, Kelly RF, Kontos MC, Levine GN, Liebson PR, Mukherjee D, Peterson ED, Sabatine MS, Smalling RW, Zieman SJ. 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes: Executive Summary. J Am Coll Cardiol 2014. [DOI: 10.1016/j.jacc.2014.09.016] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Ganiats TG, Holmes DR, Jaffe AS, Jneid H, Kelly RF, Kontos MC, Levine GN, Liebson PR, Mukherjee D, Peterson ED, Sabatine MS, Smalling RW, Zieman SJ. 2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 64:e139-e228. [PMID: 25260718 DOI: 10.1016/j.jacc.2014.09.017] [Citation(s) in RCA: 2089] [Impact Index Per Article: 208.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Abstract
Low-molecular-weight heparins have several important advantages over unfractionated heparin (UFH). Due to a longer plasma half life together with high bioavailability and a linear dose-response relationship, the drugs can be safely and effectively administered in the hospital or ambulatory settings without the need to monitor the anticoagulant effect. Enoxaparin (Lovenox), Aventis Pharma) is a low-molecular-weight heparin which has been studied in a variety of clinical situations. In general surgery the efficacy of enoxaparin to prevent venous thromboembolism is similar to UFH but the tolerability is better. In patients undergoing cancer, orthopedic or vascular surgery the efficacy of enoxaparin is significantly higher with similar rates of bleeding complications. The database for enoxaparin in nonsurgical patients is smaller compared with surgical groups. There is evidence that the efficacy of enoxaparin may be superior to UFH in patients with severe cardiac disease. Efficacy and safety of UFH and enoxaparin are similar for the treatment of deep vein thrombosis. However, enoxaparin can be safely administered by the patients at home which is not possible with UFH. In patients with acute coronary syndromes, enoxaparin has been shown to reduce the rate of deaths and serious cardiac events in comparison with UFH. Furthermore, exonaparin treatment has been shown to be cost-effective, and therefore is the therapy of choice in this setting. In addition, enoxaparin has been shown to be a safe and effective alternative to the combination of UFH and phenprocoumone therapy in patients undergoing electrical cardioversion for atrial fibrillation.
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Affiliation(s)
- Thomas Hofmann
- Universitätsklinikum Hamburg-Eppendorf, Herzzentrum, Medizinische Klinik III, Martinistr. 52, 20246 Hamburg, Germany.
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Abstract
Enoxaparin is a low-molecular-weight heparin (LMWH) derivative that exerts its anticoagulant activity through antithrombin III, an endogenous inhibitor of factor Xa and thrombin IIa. Unlike its unfractionated heparin (UFH) counterparts, enoxaparin has a greater bioavailability, lower incidence of heparin-induced thrombocytopenia and more stable and predictable anticoagulation, allowing fixed dosing without the need for monitoring. These advantages make it an attractive anticoagulant to be used in acute coronary syndrome management. Indeed, several clinical trials and meta-analyses have consistently demonstrated the efficacy of enoxaparin in reducing cardiovascular events and mortality in this population. Although initial clinical trials with enoxaparin during the early conservative approach suggested superior efficacy without differences in safety compared with UFH, emerging data in the current era of early revascularization approach indicate that superior effects of enoxaparin over heparin in reducing clinical events should be balanced against an increase in major hemorrhagic complications. Enoxaparin is a rational alternative to UFH in patients presenting with either unstable angina/non-ST-elevation myocardial infarction or ST-elevation myocardial infarction, with a clinically modest increase in bleeding complications.
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Affiliation(s)
- Sinjin Lee
- Beth Israel Deaconess Medical Center, Division of Cardiology, Boston, MA 02215, USA.
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Abstract
Since percutaneous transluminal coronary angioplasty was first described and the breakthrough studies of the role of stents were reported, the evolution in anticoagulation and antiplatelet therapy used during percutaneous coronary intervention (PCI) has reduced periprocedural ischemic events and stent thrombosis. Although greater combinations and doses of anticoagulation with antiplatelets seem to provide the best protection against thrombogenic and embolic events, there is a significant trade-off with a higher risk of major and minor bleeding episodes. This review article expands on each of the commonly used antiplatelet and anticoagulants used at time of PCI, focusing on drug monitoring and reversal.
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Affiliation(s)
- Gregory W Yost
- Department of Cardiology, Geisinger Medical Center, 100 North Academy Avenue, Danville, PA 17822, USA.
| | - Steven R Steinhubl
- Department of Cardiology, Geisinger Medical Center, 100 North Academy Avenue, Danville, PA 17822, 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, 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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Sun TW, Xu QY, Yao HM, Zhang XJ, Wu Q, Zhang JY, Li L, Zhang YZ, Kan QC, Guan FX, Wang LX. The predictive value of plasma cystatin C for acute coronary syndrome treated with percutaneous coronary intervention. Heart Lung 2012; 41:456-62. [DOI: 10.1016/j.hrtlng.2012.04.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Revised: 04/06/2012] [Accepted: 04/07/2012] [Indexed: 11/24/2022]
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Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Catheter Cardiovasc Interv 2012; 79:453-95. [PMID: 22328235 DOI: 10.1002/ccd.23438] [Citation(s) in RCA: 125] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Hermanides RS, Ottervanger JP, Dambrink JHE, Dill T, van Houwelingen G, Ten Berg JM, Kolkman E, Hamm C, van 't Hof AWJ. Risk of bleeding after prehospital administration of high dose tirofiban for ST elevation myocardial infarction. Int J Cardiol 2012; 157:86-90. [PMID: 21194762 DOI: 10.1016/j.ijcard.2010.12.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2010] [Revised: 10/28/2010] [Accepted: 12/04/2010] [Indexed: 11/29/2022]
Abstract
BACKGROUND In most patients with ST-elevation myocardial infarction (STEMI), antiplatelet drugs are already administrated in the ambulance, before hospital admission. We investigated the safety of prehospital initiation of a high dose of the glycoprotein IIb/IIIa inhibitor tirofiban on top of aspirin, clopidogrel and heparin. METHODS It concerns a sub-analysis of the On-TIME 2 trial. 1398 patients were enrolled and 1275 patients (91.2%) had clinical follow up. Non CABG-related bleeding was defined according to the TIMI criteria. Logistic regression was used to determine predictors of 30-day bleeding. The independent association between bleeding and mortality (30-day and 1-year) was evaluated using Cox proportional Hazard models. RESULTS Bleeding (major or minor) was observed in 47 patients (3.7%), with only 13 patients (1%) with major bleeding. The strongest independent determinants of bleeding were age (OR 1.05, 95% CI 1.01-1.08, p=0.011), Killip class >1 at admission (OR 2.5, 95% CI 1.2-5.3, p=0.020) and intra aortic balloon pump (IABP) use (OR 4.2, 95% CI 1.6-11.1, p=0.003). High dose tirofiban was not an independent predictor of bleeding (OR 1.7, 95% CI 0.9-3.2, p=0.116). Bleeding was associated with an increased risk of 30-day mortality (HR 5.5, 95% CI 1.6-7.8, p<0.001) and one-year mortality (HR 3.2, 95% CI 1.4-7.2, p=0.005). CONCLUSION Prehospital use of high dose tirofiban is safe and associated with a low risk of bleeding. Age, Killip class >1, IABP use, but not high dose tirofiban are independent determinants of bleeding in STEMI patients. Bleeding is independently associated with 30-day and 1-year mortality.
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Hamm CW, Bassand JP, Agewall S, Bax J, Boersma E, Bueno H, Caso P, Dudek D, Gielen S, Huber K, Ohman M, Petrie MC, Sonntag F, Sousa Uva M, Storey RF, Wijns W, Zahger D. Guía de práctica clínica de la ESC para el manejo del síndrome coronario agudo en pacientes sin elevación persistente del segmento ST. Rev Esp Cardiol 2012. [DOI: 10.1016/j.recesp.2011.11.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary. J Am Coll Cardiol 2011. [DOI: 10.1016/j.jacc.2011.08.006] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol 2011; 58:e44-122. [PMID: 22070834 DOI: 10.1016/j.jacc.2011.08.007] [Citation(s) in RCA: 1724] [Impact Index Per Article: 132.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH, Jacobs AK, Anderson JL, Albert N, Creager MA, Ettinger SM, Guyton RA, Halperin JL, Hochman JS, Kushner FG, Ohman EM, Stevenson W, Yancy CW. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. Catheter Cardiovasc Interv 2011; 82:E266-355. [DOI: 10.1002/ccd.23390] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Hamm CW, Bassand JP, Agewall S, Bax J, Boersma E, Bueno H, Caso P, Dudek D, Gielen S, Huber K, Ohman M, Petrie MC, Sonntag F, Uva MS, Storey RF, Wijns W, Zahger D. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2011; 32:2999-3054. [PMID: 21873419 DOI: 10.1093/eurheartj/ehr236] [Citation(s) in RCA: 2468] [Impact Index Per Article: 189.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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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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Comparison of Low Molecular Weight Heparin With Unfractionated Heparin During Percutaneous Coronary Interventions: A Meta-Analysis. Am J Ther 2011; 18:180-9. [DOI: 10.1097/mjt.0b013e3181c1218f] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Dobesh PP, Trujillo TC. Anticoagulation in the management of non-ST-segment elevation acute coronary syndrome. J Pharm Pract 2011; 23:324-34. [PMID: 21507832 DOI: 10.1177/0897190010366931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
There are currently over 1 million patients admitted to hospitals in the United States with the diagnosis of non-ST-segment elevation acute coronary syndrome (NSTE ACS). Due to the significant morbidity and mortality associated with NSTE ACS, appropriate use of the numerous medications employed is critical in ensuring optimal outcomes. Because atherosclerotic plaque rupture and thrombus formation are the central pathophysiologic process in patients with NSTE ACS, it is important to utilize effective and safe combinations of antiplatelet and anticoagulant drug therapy. There are a number of different anticoagulant agents available for use in patients with NSTE ACS, but it is essential to have an in-depth knowledge of the setting in which these agents have been investigated, what current consensus guidelines recommend, as well as an appreciation for the treatment approach and philosophy of the institution for management of patients with NSTE ACS. In this review manuscript, the reader will find an evaluation of the current guidelines concerning the use of anticoagulant therapy in patients with NSTE ACS, as well as a detailed examination of the literature with critical analysis on issues that should be considered when deciding on the appropriate implementation of anticoagulant therapy in protocols for NSTE ACS patients.
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Affiliation(s)
- Paul P Dobesh
- College of Pharmacy, University of Nebraska, Omaha, NE 68198, USA.
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Bertel O, Ramsay D, Wettstein T, Kurz DJ, Stettler I, Straumann E, Frielingsdorf J, Maurer D, Naegeli B. Intravenous enoxaparin versus unfractionated heparin in unselected patients undergoing percutaneous coronary interventions: the Zurich enoxaparin versus unfractionated heparin in PCI study (ZEUS). EUROINTERVENTION 2011; 6:407-12. [PMID: 20884422 DOI: 10.4244/eijv6i3a67] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS To evaluate the efficacy and safety of intravenous enoxaparin as an alternative to unfractionated heparin (UFH) as antithrombotic therapy in unselected patients undergoing percutaneous coronary intervention (PCI). METHODS AND RESULTS Eight hundred and seventy-six (876) consecutive eligible patients undergoing PCI were prospectively randomised to either intravenous enoxaparin 0.75 mg/kg or dose-adjusted UFH in this open-label study that was prematurely stopped due to slow recruitment. Randomisation was stratified on elective PCI or PCI for acute coronary syndrome (ACS). The primary endpoint was a combination of death, myocardial infarction, unplanned target vessel revascularisation and major bleeding at 30 days. Secondary endpoint was a composite of major and minor bleeding and thrombocytopenia < 50x109. The primary endpoint of intravenous enoxaparin did not differ from those of UFH (5.5% vs. 7.0%, p=ns) whereas safety endpoints were reduced with enoxaparin compared to UFH (9.9% vs. 20.0%, p<0.001). Among 229 (26%) patients presenting with ACS, the incidence of both, the primary and secondary endpoints, was lower with enoxaparin as compared to UFH (1.8% vs. 12.9% and 14.2% vs. 31%, p<0.001 and p=0.003, respectively). CONCLUSIONS Due to the premature halting of the study and the low event rate, these data are observational only, and no definite conclusion could be made concerning efficacy and safety of intravenous enoxaparin as an alternative to UFH in unselected patients undergoing PCI.
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Affiliation(s)
- Osmund Bertel
- HerzGefässZentrum Zurich, Klinik Im Park, Switzerland.
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Non-therapeutic anti-FXa levels are common among medical ward patients treated with enoxaparin. Ann Hematol 2011; 90:1345-51. [DOI: 10.1007/s00277-011-1208-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2010] [Accepted: 02/24/2011] [Indexed: 11/26/2022]
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Bossaert L, O'Connor RE, Arntz HR, Brooks SC, Diercks D, Feitosa-Filho G, Nolan JP, Hoek TLV, Walters DL, Wong A, Welsford M, Woolfrey K. Part 9: Acute coronary syndromes: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2011; 81 Suppl 1:e175-212. [PMID: 20959169 DOI: 10.1016/j.resuscitation.2010.09.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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A randomized, partially blinded, multicenter, active-controlled, dose-ranging study assessing the safety, efficacy, and pharmacodynamics of the REG1 anticoagulation system in patients with acute coronary syndromes: design and rationale of the RADAR Phase IIb trial. Am Heart J 2011; 161:261-268.e1-2. [PMID: 21315207 DOI: 10.1016/j.ahj.2010.10.022] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2010] [Accepted: 10/15/2010] [Indexed: 11/23/2022]
Abstract
Anticoagulants are the cornerstone of current acute coronary syndrome (ACS) therapy; however, anticoagulation regimens that aggressively reduce ischemic events are almost uniformly associated with more bleeding. REG1, an anticoagulation system, consists of RB006 (pegnivacogin), an RNA oligonucleotide factor IXa inhibitor, and RB007 (anivamersen), its complementary controlling agent. Phase I and IIa studies defined predictable relationships between doses of RB006, RB007, and degree of antifactor IX activity. The efficacy and safety of REG1 for the treatment of patients with ACS managed invasively and the safety of reversing RB006 with RB007 after cardiac catheterization are unknown. Randomized, partially-blinded, multicenter, active-controlled, dose-ranging study assessing the safety, efficacy, and pharmacodynamics of the REG1 anticoagulation system compared to unfractionated heparin or low molecular heparin in subjects with acute coronary syndrome (RADAR) is designed to assess both the efficacy of the anticoagulant RB006 and the safety of a range of levels of RB006 reversal with RB007. The objectives of RADAR are (1) to determine the safety of a range of levels of RB006 reversal with RB007 after catheterization, (2) to confirm whether a dose of 1 mg/kg RB006 results in near-complete inhibition of factor IXa in patients with ACS, and (3) to assess the efficacy of RB006 as an anticoagulant in patients with ACS undergoing percutaneous coronary intervention.
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Cohen M, Levine GN, Pieper KS, Lan L, Antman EM, Aylward PE, White HD, Kleiman NS, Califf RM, Mahaffey KW. Enoxaparin 0.3 mg/kg IV supplement for patients transitioning to PCI after subcutaneous enoxaparin therapy for NSTE ACS: a subgroup analysis from the SYNERGY trial. Catheter Cardiovasc Interv 2010; 75:928-35. [PMID: 20432399 DOI: 10.1002/ccd.22340] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To explore clinical and bleeding outcomes in patients enrolled in the SYNERGY trial who had percutaneous coronary intervention (PCI) based on adherence to the dosing regimens of enoxaparin mandated by the protocol. BACKGROUND In SYNERGY, 4,687 patients underwent PCI during index hospitalization. Patients in the subcutaneous (sc) enoxaparin group were to be given an 0.3 mg/kg IV bolus immediately before PCI if balloon inflation occurred > or = 8 hr after their last sc dose of enoxaparin. METHODS The incidence of the 1 degrees efficacy end point (death/myocardial infarction [MI] post PCI and through 30 days), and the rates of post-PCI in-hospital TIMI major and GUSTO severe bleeding were compared between patients randomized to unfractionated heparin (UFH) and those randomized to sc enoxaparin who did or did not receive a supplemental IV bolus of enoxaparin in accord with protocol-mandates. RESULTS A total of 4,687 patients had PCI; 2,323 were assigned sc enoxaparin and 1,332 received protocol-mandated IV enoxaparin bolus, while 215 enoxaparin patients received inappropriate IV therapy (either receiving IV enoxaparin before the 8-hr protocol time or not receiving the IV enoxaparin as directed after 8 hr). Death or MI occurring post PCI through 30-day follow-up tended to be lower in the enoxaparin patients who were treated according to protocol than in those who were not (12.3% vs. 14.4%; adjusted P = 0.25), as was TIMI major bleeding (3.0% vs. 4.7%, adjusted P = 0.08). CONCLUSION These exploratory analyses show that patients in SYNERGY who received the protocol-mandated supplemental IV bolus of 0.3 mg/kg enoxaparin before PCI performed 8-12 hr after their last sc enoxaparin dose tended to have improved outcomes compared with those who did not. Strategies to ensure adherence to dosing guidelines of enoxaparin during PCI should be considered.
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Affiliation(s)
- Marc Cohen
- Division of Cardiology, Cardiac Cath Lab, Newark Beth Israel Medical Center, Newark, New Jersey 07112, USA.
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Hermanides R, Ottervanger JP, Dambrink JH, de Boer MJ, Hoorntje J, Gosselink A, Suryapranata H, van ‘t Hof A. Incidence, predictors and prognostic importance of bleeding after primary PCI for ST-elevation myocardial infarction. EUROINTERVENTION 2010. [DOI: 10.4244/eijv6i1a16] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Thomas D, Giugliano RP. Day 1 care in patients with non-ST-segment elevation myocardial infarction. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2010; 11:41-51. [PMID: 20129360 DOI: 10.1016/j.carrev.2009.07.005] [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] [Received: 05/15/2009] [Revised: 07/13/2009] [Accepted: 07/13/2009] [Indexed: 11/19/2022]
Abstract
In 2007, the American College of Cardiology/American Heart Association and the European Society of Cardiology updated their guidelines for the management of patients with non-ST-segment elevation myocardial infarction (NSTEMI). Based on evidence from recent clinical studies, both 2007 guidelines recommend early risk stratification, administration of appropriate pharmacologic therapy, and selective use of percutaneous coronary intervention in order to reduce morbidity and mortality in these patients. In this article, we focus on management of patients with NSTEMI during the first 24 h of presentation and present a clinical scenario to illustrate the current guidelines-based management strategy.
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Affiliation(s)
- Deepak Thomas
- Brigham and Women's Hospital, Nuclear Cardiology, Boston, MA, USA
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Silvain J, Beygui F, Ankri A, Bellemain-Appaix A, Pena A, Barthelemy O, Cayla G, Gallois V, Galier S, Costagliola D, Collet JP, Montalescot G. Enoxaparin Anticoagulation Monitoring in the Catheterization Laboratory Using a New Bedside Test. J Am Coll Cardiol 2010; 55:617-25. [DOI: 10.1016/j.jacc.2009.08.077] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2009] [Revised: 08/27/2009] [Accepted: 08/30/2009] [Indexed: 10/19/2022]
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Van De Wiele C, Hogan D, Green H, Sederquist K. Antithrombotic Effect of Enoxaparin in Clinically Healthy Cats: A Venous Stasis Model. J Vet Intern Med 2010; 24:185-91. [DOI: 10.1111/j.1939-1676.2009.0412.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Parikh SV, Keeley EC. Selecting the optimal antithrombotic regimen for patients with acute coronary syndromes undergoing percutaneous coronary intervention. Vasc Health Risk Manag 2009; 5:677-91. [PMID: 19707287 PMCID: PMC2731066 DOI: 10.2147/vhrm.s4828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2009] [Indexed: 11/25/2022] Open
Abstract
The wide variety of anticoagulant and antiplatelet agents available for clinical use has made choosing the optimal antithrombotic regimen for patients with acute coronary syndromes undergoing percutaneous coronary intervention a complex task. While there is no single best regimen, from a risk-benefit ratio standpoint, particular regimens may be considered optimal for different patients. We review the mechanisms of action for the commonly prescribed antithrombotic medications, summarize pertinent data from randomized trials on their use in acute coronary syndromes, and provide an algorithm (incorporating data from these trials as well as risk assessment instruments) that will help guide the decision-making process.
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Affiliation(s)
- Shailja V Parikh
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Adding intravenous unfractionated heparin to standard enoxaparin causes excessive anticoagulation not detected by activated clotting time: results of the STACK-on to ENOXaparin (STACKENOX) study. Am Heart J 2009; 158:177-84. [PMID: 19619692 DOI: 10.1016/j.ahj.2009.05.022] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2009] [Accepted: 05/18/2009] [Indexed: 11/20/2022]
Abstract
BACKGROUND The STACKENOX study assessed the cumulative anticoagulation effect of administering stack-on intravenous unfractionated heparin (UFH) to subjects already receiving enoxaparin. METHODS Seventy-two healthy subjects aged 40 to 60 years received subcutaneous enoxaparin (1 mg/kg every 12 hours) for 2.5 days (steady state) and were randomized to receive a 70 IU/kg intravenous UFH bolus 4, 6, or 10 hours after the final enoxaparin dose. Anticoagulation levels were assessed in subjects receiving enoxaparin alone and after the UFH bolus by monitoring activated clotting time (ACT), anti-Xa and anti-IIa activities, and thrombin generation (endogenous thrombin potential [ETP]). RESULTS After the final enoxaparin dose, ETP levels decreased by 40%; anti-Xa and anti-IIa activities increased, as expected; and ACT levels did not indicate any anticoagulation effect. Stack-on UFH at 4, 6, or 10 hours after the last enoxaparin dose significantly increased anti-Xa and anti-IIa activities (P < .0001) to well above accepted therapeutic levels and resulted in total inhibition of thrombin generation for > or =2 hours; ACT levels remained within the range commonly observed in subjects receiving UFH. CONCLUSIONS The administration of stack-on UFH to subjects already receiving recommended enoxaparin dosing may result in over-anticoagulation, and should be avoided. Activated clotting time assessment did not detect the over-anticoagulation resulting from co-administration of enoxaparin and UFH.
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Wahlin M, Albertsson P, Karlsson T, Matejka G, Odell A, Tahmasebiepour F, Wolmeryd C, Grip L. Switch from abciximab to eptifibatide during percutaneous coronary intervention. Int J Cardiol 2009; 134:393-400. [PMID: 18620765 DOI: 10.1016/j.ijcard.2008.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2007] [Revised: 02/20/2008] [Accepted: 03/01/2008] [Indexed: 02/02/2023]
Abstract
BACKGROUND Treatment with glycoprotein (GP) IIb/IIIa inhibitors during percutaneous coronary intervention (PCI) reduce ischemic complications and improve outcome. Of the GPIIb/IIIa inhibitors abciximab is better documented than eptifibatide, but the former is more expensive. The aim of this study was to monitor a switch from abciximab to eptifibatide with respect to clinical outcome up to six months after PCI. METHODS All consecutive patients that six months before and six months after a switch from abciximab to eptifibatide received GPIIb/IIIa inhibitors during and after de novo PCIs were followed for six months with respect to clinical outcome. RESULTS 310 patients received abciximab and 350 eptifibatide. Baseline characteristics were similar in the two groups. 55% of the patients underwent PCI for acute ST-elevation myocardial infarction and 41% for unstable coronary artery disease. There were trends for lower mortality among abciximab-treated than among the eptifibatide-treated patients during in-hospital stay (0.6% vs 2.0%:NS) as well as during the six month follow up (2.3% vs 3.7%:NS). The combined endpoint of death, myocardial infarction, stroke, repeated revascularisation and serious bleeding occurred in 14.9% in the abciximab group vs 16.8% in the eptifibatide group (NS). CONCLUSION The study could not demonstrate any significant deterioration of clinical results after a switch from abciximab to eptifibatide as routine GPIIb/IIIa inhibition during PCI. With respect to the limited number of patients a clinical significant difference between the two GPIIb/IIIa inhibitors cannot, however, be excluded.
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Affiliation(s)
- Magnus Wahlin
- The Department of Molecular and Clinical Medicine/Cardiology, Sahlgrenska University Hospital and Gothenburg University, Sweden
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Schwarz AK, Zeymer U. Enoxaparin in patients with primary percutaneous coronary intervention for acute ST segment elevation myocardial infarction. Future Cardiol 2009; 5:43-9. [PMID: 19371202 DOI: 10.2217/14796678.5.1.43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The inhibition of thrombin plays a key role as adjunct therapy in the management of patients with primary percutaneous coronary intervention for ST elevation myocardial infarction. Enoxaparin provides a more predictable and constant level of anticoagulation compared with the current standard unfractionated heparin. The available data from smaller studies and prospective registries suggest that enoxaparin is associated with a reduction in the rate of death and nonfatal reinfarction after primary percutaneous coronary intervention without an increase in bleeding complications. Thus, a large randomized trial is warranted to further evaluate the role of enoxaparin in these patients.
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The pharmacodynamics of enoxaparin in percutaneous coronary intervention with precise rapid enoxaparin loading (PEPCI-PRE study). J Thromb Thrombolysis 2009; 28:224-8. [DOI: 10.1007/s11239-009-0326-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2008] [Accepted: 02/25/2009] [Indexed: 11/27/2022]
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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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Levin A, Ben-Artzi M, Beckerman P, Haber G, Varon D, Ben-Yehuda A, Muszkat M. Factors Associated with Bleeding in Elderly Hospitalized Patients Treated with Enoxaparin Sodium. Drugs Aging 2009; 26:77-85. [DOI: 10.2165/0002512-200926010-00006] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Canales JF, Ferguson JJ. Low-molecular-weight heparins : mechanisms, trials, and role in contemporary interventional medicine. Am J Cardiovasc Drugs 2008; 8:15-25. [PMID: 18303934 DOI: 10.2165/00129784-200808010-00003] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The clinical spectrum of acute coronary syndromes (ACS) encompasses unstable angina, non-ST-elevation, and ST-elevation myocardial infarction (STEMI). Within an atherosclerotic plaque, disruption of the endothelium can lead to exposure of tissue factor, with platelet adhesion, activation and aggregation, along with activation of the coagulation cascade, culminating in thrombin formation and the development of a cross-linked fibrin clot at the site of injury. Therapy aimed at blocking thrombin formation is now an integral part of the current cardiovascular guidelines in the treatment of ACS. Although unfractionated heparin (UFH) has been the mainstay of antithrombin therapy in the past, it has numerous clinical and biochemical limitations, including substantial protein binding (leading to inconsistent bioavailability), a need for frequent monitoring and adjustment, unreliable and variable degrees of anticoagulation, significant platelet activation, risk of heparin-induced thrombocytopenia, and the inability to block clot bound thrombin. With all of these limitations of UFH, low-molecular-weight heparins (LMWHs) have emerged as attractive alternatives. This review discusses the mechanism of action of LMWHs, and summarizes available literature concerning the use of LMWHs in a variety of clinical settings. Included in this review is an analysis of both current and prior data showing LMWH is as effective as UFH in the conservative and invasive management of patients with ACS. As well, very recent data are evaluated showing the safety and efficacy of LMWHs used in patients transitioning to the cardiac catheterization laboratory, and in those patients undergoing elective or urgent percutaneous coronary intervention (PCI). We also appraise the literature, along with the very recent studies investigating the use of LMWHs as adjunctive therapy to fibrinolytics in patients with STEMI. Finally, we set forth real-world conclusions concerning the use of LMWHs in contemporary interventional practice, including elective PCI and the treatment of ischemic coronary artery disease in the context of rapid invasive management of ACS.
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Affiliation(s)
- John F Canales
- Department of Cardiology Research, Texas Heart Institute at St Luke's Episcopal Hospital, Baylor College of Medicine, The University of Texas Health Science Center at Houston, Houston, Texas 77225-0269, USA
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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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Tebbe U, Oeckinghaus R, Appel KF, Heuer H, Haake H, Eggers E, Seidel K, Adams J, Harenberg J. AFFECT: a prospective, open-label, multicenter trial to evaluate the feasibility and safety of a short-term treatment with subcutaneous certoparin in patients with persistent non-valvular atrial fibrillation. Clin Res Cardiol 2008; 97:389-96. [PMID: 18322636 DOI: 10.1007/s00392-008-0644-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2007] [Accepted: 12/21/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Patients with persistent atrial fibrillation (AF) scheduled for electrical cardioversion need immediate anticoagulation. Unfractionated heparin (UFH) is often used for early anticoagulation in these patients before oral anticoagulation becomes effective. However, dose adjustment is required to achieve a two- to three-fold prolongation of the activated partial thromboplastin. Low molecular weight heparins, given in body weight-adjusted or independent fixed dosage, require less laboratory monitoring and are also effective within hours of first dosing. They seem to be an attractive alternative to UFH. Previous evidence has shown that these drugs are safe and effective in this indication. PATIENTS AND METHODS In this prospective, open-label, multicenter pilot study, 203 patients were enrolled with persistent non-valvular AF scheduled for electrical cardioversion. Patients received a fixed dose of 8000 U anti-Xa certoparin twice daily starting immediately after enrolment and before cardioversion was performed. Patients with AF > 48 h underwent transoesophageal echocardiography (TEE) before cardioversion to exclude intra-atrial thrombi. After cardioversion, overlapping oral anticoagulation was started. Treatment with certoparin was stopped only after two consecutive days with INR values >2. OBJECTIVES The objective was to document the feasibility and safety of a short-term treatment with a fixed, body weight-independent certoparin regimen (2 x 8000 U anti-Xa). RESULTS Out of 203 patients enrolled, 200 received at least one dose of certoparin and were included in the analysis (safety population). Median treatment duration with certoparin was 7 days. Bleedings were observed in 8 patients (4.0%) and were classified as major (1.5%) or minor (2.5%). Cerebral ischemia was reported for 1 patient (0.5%). One patient showed mild thrombocytopenia (0.5%). There were no reports of venous thromboembolism or death during the treatment period. CONCLUSION Certoparin administered at 8000 U anti-Xa twice daily independent of body weight was safe and appeared to be effective in patients with non-valvular AF undergoing electrical cardioversion. Its ease of use and the possibility of treatment on an outpatient basis make it an attractive option for early anticoagulation in AF.
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Affiliation(s)
- Ulrich Tebbe
- Klinikum Lippe GmbH, Fachbereich Herz-Kreislauf, Röntgenstrasse 18, 32756 Detmold, Germany.
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Contemporary Approach to the Diagnosis and Management of Non–ST-Segment Elevation Acute Coronary Syndromes. Prog Cardiovasc Dis 2008; 50:311-51. [DOI: 10.1016/j.pcad.2007.11.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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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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Albert N. Non?ST segment elevation acute coronary syndromes: Treatment guidelines for the nurse practitioner. ACTA ACUST UNITED AC 2007; 19:277-89. [PMID: 17535337 DOI: 10.1111/j.1745-7599.2007.00227.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE To increase awareness among nurse practitioners (NPs) of the American College of Cardiology (ACC)/American Heart Association (AHA) 2002 guideline update for the diagnosis and treatment of acute coronary syndrome, and for secondary prevention in patients with unstable angina (UA) and non-ST segment elevation myocardial infarction (NSTEMI). DATA SOURCES ACC/AHA 2002 guideline update for the management of patients with UA and NSTEMI, ACC/AHA guidelines for patients with coronary and other atherosclerotic vascular disease, 2006 update, selected research and clinical articles. CONCLUSIONS Recent research has shown that patients with UA/NSTEMI benefit from the routine, long-term use of dual antiplatelet therapy with aspirin and clopidogrel. In suitable patients, outcome is also improved by adoption of an early invasive strategy combined with aggressive medical therapy. IMPLICATIONS FOR PRACTICE Familiarity with the patient as well as current management recommendations can improve clinical outcomes for patients with UA/NSTEMI. Thus, NPs can play a pivotal role in the management of coronary disease, both during and following an acute ischemic event.
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Affiliation(s)
- Nancy Albert
- Division of Nursing and CNS, Kaufman Center for Heart Failure, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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Lucking AJ, Newby DE. Pharmacological antithrombotic adjuncts to percutaneous coronary intervention. Expert Opin Pharmacother 2007; 8:759-76. [PMID: 17425472 DOI: 10.1517/14656566.8.6.759] [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: 02/02/2023]
Abstract
Stent thrombosis is the major cause of early adverse events during percutaneous coronary intervention. Its incidence has fallen considerably in recent years, principally due to the introduction of effective antithrombotic therapies. The selection of an appropriate antithrombotic regimen is critical in achieving a balance between reducing ischaemic events and minimising bleeding complications in patients undergoing percutaneous coronary intervention. In this article, evidence for the role of antiplatelet and anticoagulant therapies is discussed, including the thienopyridines, glycoprotein IIb/IIIa receptor antagonists, direct thrombin inhibitors and pentasaccharides.
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Affiliation(s)
- Andrew J Lucking
- The University of Edinburgh, Room SU.305, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SU, Scotland.
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Feng Y, Green B, Duffull SB, Kane-Gill SL, Bobek MB, Bies RR. Development of a dosage strategy in patients receiving enoxaparin by continuous intravenous infusion using modelling and simulation. Br J Clin Pharmacol 2007; 62:165-76. [PMID: 16842391 PMCID: PMC1885085 DOI: 10.1111/j.1365-2125.2006.02650.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
AIM To develop an appropriate dosing strategy for continuous intravenous infusions (CII) of enoxaparin by minimizing the percentage of steady-state anti-Xa concentration (C(ss)) outside the therapeutic range of 0.5-1.2 IU ml(-1). METHODS A nonlinear mixed effects model was developed with NONMEM for 48 adult patients who received CII of enoxaparin with infusion durations that ranged from 8 to 894 h at rates between 100 and 1600 IU h(-1). Three hundred and sixty-three anti-Xa concentration measurements were available from patients who received CII. These were combined with 309 anti-Xa concentrations from 35 patients who received subcutaneous enoxaparin. The effects of age, body size, height, sex, creatinine clearance (CrCL) and patient location [intensive care unit (ICU) or general medical unit] on pharmacokinetic (PK) parameters were evaluated. Monte Carlo simulations were used to (i) evaluate covariate effects on C(ss) and (ii) compare the impact of different infusion rates on predicted C(ss). The best dose was selected based on the highest probability that the C(ss) achieved would lie within the therapeutic range. RESULTS A two-compartment linear model with additive and proportional residual error for general medical unit patients and only a proportional error for patients in ICU provided the best description of the data. Both CrCL and weight were found to affect significantly clearance and volume of distribution of the central compartment, respectively. Simulations suggested that the best doses for patients in the ICU setting were 50 IU kg(-1) per 12 h (4.2 IU kg(-1) h(-1)) if CrCL < 30 ml min(-1); 60 IU kg(-1) per 12 h (5.0 IU kg(-1) h(-1)) if CrCL was 30-50 ml min(-1); and 70 IU kg(-1) per 12 h (5.8 IU kg(-1) h(-1)) if CrCL > 50 ml min(-1). The best doses for patients in the general medical unit were 60 IU kg(-1) per 12 h (5.0 IU kg(-1) h(-1)) if CrCL < 30 ml min(-1); 70 IU kg(-1) per 12 h (5.8 IU kg(-1) h(-1)) if CrCL was 30-50 ml min(-1); and 100 IU kg(-1) per 12 h (8.3 IU kg(-1) h(-1)) if CrCL > 50 ml min(-1). These best doses were selected based on providing the lowest equal probability of either being above or below the therapeutic range and the highest probability that the C(ss) achieved would lie within the therapeutic range. CONCLUSIONS The dose of enoxaparin should be individualized to the patients' renal function and weight. There is some evidence to support slightly lower doses of CII enoxaparin in patients in the ICU setting.
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Affiliation(s)
- Yan Feng
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, PA 15261, USA
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