The Living Guidelines: STEMI Anticoagulants as Ancillary Therapy Suggest Revisions to the CLASS I Guidelines

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Class I Guidelines
1- Patients undergoing reperfusion with fibrinolytics should receive anticoagulant therapy for a minimum of 48 h (Class I, Level of Evidence: C) and preferably for the duration of the index hospitalization, up to 8 days (regimens other than UFH are recommended if anticoagulant therapy is given for >48 h because of the risk of heparin induced thrombocytopenia with prolonged UFH treatment). (Class I, Level of Evidence: A)

Anticoagulant regimens with established efficacy include

a. UFH (initial intravenous bolus 60 U per kg [maximum 4000 U]) followed by an intravenous infusion of 12 U / kg per hour (maximum 1000 U / h) initially, adjusted to maintain the activated partial thromboplastin time at 1.5 to 2.0 times control (approximately 50 to 70 sec) (Class I, Level of Evidence: C)

(Note: the available data do not suggest a benefit of prolonging the duration of the infusion of UFH beyond 48 h in the absence of ongoing indications for anticoagulation; more prolonged infusions of UFH increase the risk of development of heparin-induced thrombocytopenia)

b. Enoxaparin (provided the serum creatinine is less than 2.5 mg / dL in men and 2.0 mg / dL in women): for patients <75 years of age, an initial 30 mg intravenous bolus is given, followed 15 min later by subcutaneous injections of 1.0 mg / kg every 12 h; for patients at least 75 years of age, the initial intravenous bolus is eliminated and the subcutaneous dose is reduced to 0.75 mg / kg every 12 h. Regardless of age, if the creatinine clearance (using the Cockroft - Gault formula) during the course of treatment is estimated to be <30 mL / min, the subcutaneous regimen is 1.0 mg / kg every 24 h. Maintenance dosing with enoxaparin should be continued for the duration of the index hospitalization, up to 8 days. (Class I, Level of Evidence: A)

c. Fondaparinux (provided the serum creatinine is < 3.0 mg / dL): initial dose 2.5 mg intravenously; subsequently subcutaneous injections of 2.5 mg once daily. Maintenance dosing with fondaparinux should be continued for the duration of the index hospitalization, up to 8 days. (Class I, Level of Evidence: B)

2- For patients undergoing PCI after having received an anticoagulant regimen, the following dosing recommendations should be followed

a. For prior treatment with UFH, administer additional boluses of UFH as needed to support the procedure, taking into account whether GP IIb/IIIa receptor antagonists have been administered. (Class I, Level of Evidence: C)

Bivalirudin may also be used in patients treated previously with UFH. (Class I, Level of Evidence: C)

b. For prior treatment with enoxaparin, if the last subcutaneous dose was administered within the prior 8 h, no additional enoxaparin should be given; if the last subcutaneous dose was administered at least 8 to 12 h earlier, an intravenous dose of 0.3 mg / kg of enoxaparin should be given. (Class I, Level of Evidence: B)

c. For prior treatment with fondaparinux, administer additional intravenous treatment with an anticoagulant possessing anti-IIa activity taking into account whether GP IIb/IIIa receptor antagonists have been administered. (Class I, Level of Evidence: C)