The Living Guidelines: STEMI Anticoagulants as Ancillary Therapy Polling Results for 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)

 AHA / ACC 2007 STEMI Guidelines for Anticoagulants as Ancillary Therapy Class I Recommendation 1 should be CLASS I CLASS IIa CLASS IIb CLASS III

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)

 AHA / ACC 2007 STEMI Guidelines for Anticoagulants as Ancillary Therapy Class I Recommendation 1a for UFH should be CLASS I CLASS IIa CLASS IIb CLASS III

(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)

 AHA / ACC 2007 STEMI Guidelines for Anticoagulants as Ancillary Therapy Class I Recommendation 1b for enoxaparin should be CLASS I CLASS IIa CLASS IIb CLASS III

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)

 AHA / ACC 2007 STEMI Guidelines for Anticoagulants as Ancillary Therapy for Fondaparinux Class I Recommendation 1c for fondaparinux should be CLASS I CLASS IIa CLASS IIb CLASS III

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)

 AHA / ACC 2007 STEMI Guidelines for Anticoagulants as Ancillary Therapy for UFH Class I Recommendation 2a for UFH should be CLASS I CLASS IIa CLASS IIb CLASS III

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

 AHA / ACC 2007 STEMI Guidelines for Anticoagulants as Ancillary Therapy Class I Recommendation 2a for bivaluridin should be CLASS I CLASS IIa CLASS IIb CLASS III

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)

 AHA / ACC 2007 STEMI Guidelines for Anticoagulants as Ancillary Therapy Class I Recommendation 2b for enoxaparin should be: CLASS I CLASS IIa CLASS IIb CLASS III

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)

 AHA / ACC 2007 STEMI Guidelines for Anticoagulants as Ancillary Therapy Class I Recommendation 2c should be: CLASS I CLASS IIa CLASS IIb CLASS III