Anticoagulants for in-hospital management: considerations

How long should anticoagulant therapy be given for in-hospital management of ACS?

For the duration of the patient’s hospitalization — no longer!!!

What anticoagulant agent is first-line in all management scenarios?

UFH

Which anticoagulant agent does not require renal dose adjustment?

UFH

• Enoxaparin and bivalirudin need renal dose adjustment at CrCl <30; fondaparinux should be avoided (contraindication) at CrCl <30

What situation is enoxaparin used as an alternative anticoagulant therapy?

When patient went with or without PCI — both are fine

What situation is fondaparinux used as an alternative anticoagulant therapy?

Only when patient went without PCI

What situation is bivalirudin used as an alternative anticoagulant therapy?

Only when patient went with PCI

NSTE-ACS selective or noninvasive strategy first-line anticoagulant?

UFH

NSTE-ACS selective or noninvasive strategy alternative anticoagulant?

Enoxaparin, fondaparinux

ACS with PCI first-line anticoagulant?

UFH

ACS with PCI alternative anticoagulant?

Bivalirudin, enoxaparin

STEMI with fibrinolytics first-line anticoagulant?

UFH or enoxaparin

First-line anticoagulant in patients with a history of HIT?

Bivalirudin

• Remember: still can only be used if patient is undergoing a PCI

STEMI with fibrinolytics alternative anticoagulant?

Fondaparinux

What is contraindicated with all anticoagulant agents?

Severe bleeding risk

Which safety monitoring parameter is shared with all anticoagulant agents?

S/S of bleeding

History of HIT — contraindicated in which anticoagulants?

UFH, enoxaparin

UFH requires what monitoring every 1-2 days?

Platelets every 1-2 days — for signs of HIT development

Enoxaparin requires what monitoring every 1-2 days?

Platelets every 1-2 days — for signs of HIT development

Shared safety monitoring parameter for UFH and enoxaparin?

Platelets every 1-2 days for development of HIT

UFH — what objective parameter should be monitored to assess anticoagulation effect?

aPTT or heparin anti-Xa levels

UFH — duration

• With PCI: d/c after PCI

• Without PCI (noninvasive, fibrinolytics): ≤48 hours, or hospital discharge

Enoxaparin — what objective parameter should be monitored to assess anticoagulation effect?

Typically not warranted in ACS

Enoxaparin — duration

• With PCI: d/c after PCI

• Without PCI (noninvasive, fibrinolytics): ≤8 days, or hospital discharge

Which anticoagulant requires a dose reduction for CrCl <30 mL/min?

Enoxaparin

• Reduce frequency from q12h to daily

Why can fondaparinux not be used as anticoagulation for a PCI?

Risk of catheter thrombosis

Fondaparinux — what objective parameter should be monitored to assess anticoagulation effect?

Not needed

Fondaparinux — duration

≤8 days, or hospital discharge

• Remember fondaparinux is only used for non-PCI situations

What is fondaparinux’s unique contraindication?

CrCl <30 mL/min

Bivalirudin — what objective parameter should be monitored to assess anticoagulation effect?

Activated clotting time (ACT) during PCI

Bivalirudin — duration

D/c after PCI