Chest
Volume 133, Issue 6, Supplement, June 2008, Pages 71S-109S
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Antithrombotic and Thrombolytic Therapy, 8th ED: ACCP Guidelines
Executive Summary: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)

https://doi.org/10.1378/chest.08-0693Get rights and content

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Monitoring Antithrombotic Effect

2.2.3. In patients treated with low-molecular-weight heparin (LMWH), we recommend against routine coagulation monitoring (Grade 1C). In pregnant women treated with therapeutic doses of LMWH, we recommend monitoring of anti-Xa levels (Grade 1C).

Dosing and Monitoring in Special Situations

2.2.4. In obese patients receiving LMWH prophylaxis or treatment, we suggest weight-based dosing (Grade 2C). In patients with severe renal insufficiency (creatinine clearance [CrCl] < 30 mL/min) who require therapeutic anticoagulation, we suggest the use

Initiation and Maintenance Dosing

2.1.1. In patients beginning VKA therapy, we recommend the initiation of oral anticoagulation with doses between 5 and 10 mg for the first 1 or 2 days for most individuals, with subsequent dosing based on the international normalized ratio (INR) response (Grade 1B). At the present time, for patients beginning VKA therapy, without evidence from randomized trials, we suggest against the use of pharmacogenetic-based initial dosing to individualize warfarin dosing (Grade 2C).

Initiation of Anticoagulation in the Elderly or Other Populations

2.2.1. In elderly

Perioperative Management of Patients Who Are Receiving VKAs

2.1. In patients who require temporary interruption of a VKA before surgery or a procedure and require normalization of the INR for the surgery or procedure, we recommend stopping VKAs approximately 5 days before surgery over stopping VKAs within a shorter time interval before surgery to allow adequate time for the INR to normalize (Grade 1B).

2.2. In patients who have had temporary interruption of a VKA before surgery or a procedure, we recommend resuming VKAs approximately 12 to 24 h (the

TREATMENT AND PREVENTION OF HEPARIN-INDUCED THROMBOCYTOPENIA

1.0 Recognition of Heparin-Induced Thrombocytopenia

Hospital Thromboprophylaxis Policy

1.2.1. For every general hospital, we recommend that a formal, active strategy that addresses the prevention of VTE be developed (Grade 1A).

1.2.2. We recommend that the local thromboprophylaxis strategy be in the form of a written, institution-wide thromboprophylaxis policy (Grade 1C).

1.2.3. We recommend the use of strategies shown to increase thromboprophylaxis adherence, including the use of computer decision support systems (Grade 1A), preprinted orders (Grade 1B), and periodic audit and

Initial Anticoagulation of Acute DVT of the Leg

1.1.1. For patients with objectively confirmed DVT, we recommend short-term treatment with SC LMWH (Grade 1A) , IV UFH (Grade 1A), monitored SC UFH (Grade 1A), fixed-dose SC UFH (Grade 1A), or SC fondaparinux (Grade 1A) rather than no such acute treatment.

1.1.2. For patients with a high clinical suspicion of DVT, we recommend treatment with anticoagulants while awaiting the outcome of diagnostic tests (Grade 1C).

1.1.3. In patients with acute DVT, we recommend initial treatment with LMWH, UFH,

AF

1.1.1. In patients with AF, including those with paroxysmal AF, who have had a prior ischemic stroke, transient ischemic attack, or systemic embolism, we recommend long-term anticoagulation with an oral VKA, such as warfarin, targeted at an INR of 2.5 (range, 2.0 to 3.0) because of the high risk of future ischemic stroke faced by this set of patients (Grade 1A). Timing of the initiation of VKA therapy after an acute ischemic stroke involves balancing the risk of hemorrhagic conversion with

VALVULAR AND STRUCTURAL HEART DISEASE

1.1.1. For patients with rheumatic mitral valve disease complicated singly or in combination by the presence of AF, previous systemic embolism, or left atrial thrombus, we recommend VKA therapy (target INR, 2.5; range, 2.0 to 3.0) [Grade 1A].

1.1.2. For patients with rheumatic mitral valve disease with AF who suffer systemic embolism or have left atrial thrombus while receiving VKAs at a therapeutic INR, we suggest the addition of low-dose aspirin (50 to 100 mg/d) therapy after consideration of

IV Tissue Plasminogen Activator for Acute Ischemic Stroke Within 3 h of Symptom Onset

1.1.1. For eligible patients (see inclusion and exclusion criteria listed below) we recommend administration of IV tissue plasminogen activator (tPA) in a dose of 0.9 mg/kg (maximum of 90 mg), with 10% of the total dose given as an initial bolus and the remainder infused over 60 min, provided that treatment is initiated within 3 h of clearly defined symptom onset (Grade 1A).

Underlying values and preferences: This recommendation places relatively more weight on overall prospects for long-term

Antiplatelet Therapies

  • 1.

    For all patients presenting with NSTE ACS, without a clear allergy to aspirin, we recommend immediate aspirin (162 to 325 mg po) and then daily oral aspirin (75 to 100 mg) [Grade 1A].

  • 2.

    For all NSTE ACS patients with an aspirin allergy, we recommend immediate treatment with clopidogrel, 300 mg po bolus, followed by 75 mg/d indefinitely (Grade 1A).

  • 3.

    For NSTE ACS patients who are at moderate or greater risk (eg, ongoing chest pain, hemodynamic instability, positive troponin, or dynamic ECG changes)

REPERFUSION THERAPY

1.0.1. For patients with ischemic symptoms characteristic of acute myocardial infarction of ≤ 12 h duration and persistent ST-segment elevation, we recommend that all undergo rapid evaluation for reperfusion (primary PCI or fibrinolytic) therapy and have a reperfusion strategy implemented promptly after contact with the health-care system (Grade 1A).

THE PRIMARY AND SECONDARY PREVENTION OF CHRONIC CORONARY ARTERY DISEASE

1.1.1. For patients with ACS with and without ST-segment elevation, we recommend aspirin given initially at a dose of 75–162 mg and then indefinitely at a dose of 75–100 mg/d (Grade 1A).

1.1.2. For patients with ST-segment elevation ACS, with or without fibrinolytic therapy, we recommend clopidogrel, administered as a 300-mg po loading dose for patients ≤ 75 years of age and 75-mg starting dose for those > 75 years of age and continued at a daily dose of 75 mg for 2–4 weeks (Grade 1A). We

CHRONIC LIMB ISCHEMIA AND INTERMITTENT CLAUDICATION

1.1.1.1. In peripheral artery occlusive disease patients with clinically manifest coronary or cerebrovascular disease, we recommend lifelong antiplatelet therapy in comparison to no antiplatelet therapy (Grade 1A).

1.1.1.2. In those without clinically manifest coronary or cerebrovascular disease, we suggest aspirin (75–100 mg/d) over clopidogrel (Grade 2B). In patients who are aspirin intolerant, we recommend clopidogrel over ticlopidine (Grade 1B).

Underlying values and preferences: This

VKA Exposure in Utero

2.1.1. For women receiving anticoagulation for the management of VTE who become pregnant, we recommend that VKAs be substituted with UFH or LMWH (Grade 1A).

2.1.2. For women with mechanical valves who become pregnant, we suggest either adjusted-dose bid LMWH or UFH throughout pregnancy or adjusted-dose bid LMWH or UFH until the thirteenth week with substitution by VKAs until LMWH or UFH are resumed close to delivery (Grade 1C). In pregnant women with high-risk mechanical valves (eg,

In Neonates With VTE (CVL and Non-CVL Related)

1.1.1. We suggest that central venous lines (CVL) or UVCs associated with confirmed thrombosis be removed, if possible, after 3 to 5 days of anticoagulation (Grade 2C).

1.1.2. We suggest either initial anticoagulation, or supportive care with radiologic monitoring (Grade 2C) ; however, we recommend subsequent anticoagulation if extension of the thrombosis occurs during supportive care (Grade 1B).

1.1.3. We suggest anticoagulation should be with either of the following: (1) LMWH given bid and

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