ST elevation myocardial infarction deep vein thrombosis prophylaxis and anticoagulation

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

Deep Venous Thomboemblism and Embolic Prophylaxis in the STEMI Patient: Current Guidelines, Recommendations, and Practice Patterns

I.Recommendations for long-term oral anticoagulation following AMI (1)
1. In most health-care settings, for moderate- and low-risk patients with an MI, we recommend aspirin alone over oral vitamin K antagonists (VKAs) plus aspirin (Grade 2B).

Underlying values and preferences: This recommendation places a relatively low value on prevention of thromboembolism, and a relatively high value on avoiding the inconvenience, expense, and bleeding associated with VKA therapy.

2. In health-care settings in which meticulous INR monitoring is standard and routinely accessible, for both high- and low-risk patients after MI, we recommend long-term (up to 4 years) high-intensity oral VKA (target INR, 3.5; range, 3.0 to 4.0) without concomitant aspirin, or moderate-intensity oral VKA (target INR, 2.5; range, 2.0 to 3.0) with aspirin (both Grade 2B).

3. For high-risk patients with MI, including those with a large anterior MI, those with significant heart failure, those with intracardiac thrombus visible on echocardiography, and those with a history of a thromboembolic event, we suggest the combined use of moderate-intensity (INR, 2.0 to 3.0) oral VKA plus low-dose aspirin, ≤ 100 mg/d, for 3 months after the MI (Grade 2A).

Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients’ values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S–187S).

II. Recommendation for Adjunctive treatment with UFH or LMWH following AMI (ACC/AHA Guidelines and ESC Guidelines) (2,3)
There are no specific guideline recommendations for the use of UFH or LMWH following PCI for STEMI.

III.a Medical Conditions
1. For acutely ill medical patients admitted to hospital with congestive heart failure or severe respiratory disease, or who are confined to bed and have one or more additional risk factors, including active cancer, previous VTE, sepsis, acute neurologic disease, or inflammatory bowel disease, we recommend thromboprophylaxis with LMWH (Grade 1A), LDUH (Grade 1A), or fondaparinux (Grade 1A).

2. For medical patients with risk factors for VTE, and for whom there is a contraindication to anticoagulant thromboprophylaxis, we recommend the optimal use of mechanical thromboprophylaxis with GCS or IPC (Grade 1A).

III.b Critical Care
1. For patients admitted to a critical care unit, we recommend routine assessment for VTE risk and routine thromboprophylaxis in most (Grade 1A).

2. For critical care patients who are at moderate risk for VTE (eg, medically ill or postoperative general surgery patients), we recommend using LMWH or LDUH thromboprophylaxis (Grade 1A).

3. For critical care patients who are at higher risk (eg, following major trauma or orthopedic surgery), we recommend LMWH thromboprophylaxis (Grade 1A).

4. For critical care patients who are at high risk for bleeding, we recommend the optimal use of mechanical thromboprophylaxis with GCS and/or IPC at least until the bleeding risk decreases (Grade 1A). When the high bleeding risk decreases, we recommend that pharmacologic thromboprophylaxis be substituted for or added to the mechanical thromboprophylaxis (Grade 1C).

IV. Antithrombin Selection and Dosing Recommendations (6)
Medical prevention of Thromboembolic Disease in the medical patient include all the following:

1. Unfractionated Heparin 5000units subcutaneously every 12 hours.

Low Molecular Heparin     have been show to be as effective as unfractionated heparin.

Enoxaparin      40mg SC daily Dalteparin:      2,500 units SC daily Nadroparin:      2850 units SC daily

Duration of therapy     depends on patient risk Intermittent pneumatic     leg compression are alternatives in patients with contraindications to      anticoagulants

V.      Regional Differences in Prophylaxis Practices (7)
The ACCP consensus group guidelines recommend appropriate prophylaxis in high risk medically treated patient groups. An analysis of DVT prophylaxis in subsets of the IMPROVE study patients who met the ACCP guideline criteria for prophylaxis, provide a benchmark comparison for the real-world practices observed in the entire IMPROVE study population (N=15,156). These subsets of patients are those in whom pharmacologic prophylaxis has been shown to be effective, and our observed prophylaxis rates highlight an underuse of prophylaxis in these populations of patients.

IMPROVE is an ongoing, multinational, observational study of DVT prophylaxis practices. From July 2002 to September 30, 2006, 15,156 patients were enrolled from 52 hospitals in 12 countries, of whom 50% received in-hospital pharmacologic and/or mechanical VTE prophylaxis. In the United States and other participating countries, 52% and 43% of patients, respectively, should have received prophylaxis according to guideline recommendations from the American College of Chest Physicians (ACCP). Only approximately 60% of patients who either met the ACCP criteria for requiring prophylaxis or were eligible for enrollment in randomized clinical trials that have shown the benefits of pharmacologic prophylaxis actually received prophylaxis. Practices varied considerably. Intermittent pneumatic compression was the most common form of medical prophylaxis utilized in the United States, although it was used very rarely in other countries (22% vs 0.2%, respectively). Unfractionated heparin was the most frequent pharmacologic approach used in the United States (21% of patients), with low-molecular-weight heparin used most frequently in other participating countries (40%). There was also variable use of elastic stockings in the United States and other participating countries (3% vs 7%, respectively).

REFERENCES

1. Antithrombotic Therapy for Coronary Artery Disease : The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy

Robert A. Harrington, Richard C. Becker, Michael Ezekowitz, Thomas W., Meade, Christopher M. O'Connor, David A. Vorchheimer and Gordon H.Guyatt. Chest 2004;126;513S-548S

2. Guidelines for Percutaneous Coronary Intervention. The Task Force of the European Society of Cardiology. Silber S et al. Eur Heart J. 26 (8): 804-847

3. Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (Updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (Updating the 2005 Guideline and 2007 Focused Update). A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Kushner F, Hand M, Smith SC et al. Circulation 2009, 120 (22); 2271

4. Thrombolysis and Adjunctive therapy in Acute Myocardial Infarction: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Venu Menon, Robert Harrington, Judith Hochman et al. Chest 2004; 126:549-575S

5. Prevention of Venous Thromboembolism. American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). William H. Geerts, MD, FCCP, David Bergqvist, MD, PhD, Graham F. Pineo, MD, John A. Heit, MD, Charles M. Samama, MD, PhD, FCCP, Michael R. Lassen, MD, and Clifford W. Colwell, MD; CHEST June 2008 vol. 133 no. 6 suppl 381S-453S

6. DVT and pulmonary embolism: Part II. Treatment and prevention. Ramzi D et al. Am Family Physician 2004;69:2841-48

7. Expand+Venous Thromboembolism Prophylaxis in Acutely Ill Hospitalized Medical Patients* Findings From the International Medical Prevention Registry on Venous Thromboembolism. Tapson VF, Decousus H, Pini M,et al. for the IMPROVE Investigators. CHEST September 2007 vol. 132 no. 3 936-945.