Title: Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians EvidenceBased Clinical
1- Antithrombotic and Thrombolytic Therapy American
College of Chest Physicians Evidence-Based
Clinical Practice Guidelines (8th Edition) - An Overview Presented by Kristen Amann, MD
2- The subject matter is vast and Dr. Amann was a
real mensch for taking it on at such short
notice. (Dr. Chelminski, Special ACC Wednesday
Ambulatory Conference. July 22, 2008) - Mensch
- \'men(t)sh\ Noun. From Yiddish, from the German
mensch. - A person of integrity and honor.
- An unsuspecting bystander called out by her
attending to complete an enviable assignment.
3Warfarin History
- 1920s Cattle in US and Canada dying from
uncontrollable hemorrhage - Wisconsin Alumni Research Foundation coumARIN
- 1951 Army inductee unsuccessfully attempts
suicide - 1955 Dwight D. Eisenhower
4Warfarin Challenges
- Narrow therapeutic window
- Exhibit considerable variability in dose response
due to genetic and other factors - Subject to interactions with drugs and diet
- Laboratory control is difficult to standardize
- Maintenance of a therapeutic level requires a
good understanding of pharmacokinetics,
pharmacodynamics, and good patient communication
5VKH2
6Complications
- Major hemorrhage intracranial, retroperitoneal,
leading directly to death, resulting in
hospitalization or transfusion - Increases risk 0.3-0.5/yr
- ICH 0.2/yr
7Antithrombotic and Thrombolytic Therapy ACCP
Guidelines
- Parenteral anticoagulants
- Perioperative management of antithrombotic
therapy - Treatment and prevention of heparin-induced
thrombocytopenia - Prevention of VTE
- Antithrombotic therapy for venous thromboembolic
disease - Antithrombotic therapy in AF
- Valvular and structural heart disease
- Antithrombotic therapy and thrombolytic therapy
for ischemic stroke
- Antithrombotic therapy for non-ST-segment acute
coronary syndromes Acute ST-elevation myocardial
infarction - Primary and secondary prevention of chronic
coronary artery disease - Antithrombotic therapy in peripheral artery
occlusive disease - VTE, thrombophilia, antithrombotic therapy, and
pregnancy - Antithrombotic therapy in children and neonates
8Case 1
- 72yo WM with CAD, HTN, ischemic cardiomyopathy
(EF 20) presents from SNF with 4 days of right
leg pain at site of previous femoral venous line.
Discharged one week ago after presenting with
urosepsis. Doppler studies show a femoral DVT.
Meds Levaquin, simvastatin, metoprolol, ASA,
lisinopril, Lasix, spironolactone. - Starting dose of warfarin?
- Length of treatment?
9Case 1 Starting dose of warfarin
10Case 1 Length of treatment
11Case 1 Length of treatment
12Case 2
- 44 yo WF with fibromyalgia, depression, tobacco
abuse presents with 4 days of left upper
extremity swelling and pain. Diagnosed with
acute DVT (brachial v.) in the ED and started on
Lovenox. Presents one week later for pain
medication and help with smoking cessation. - Is anticoagulation therapy indicated?
- Duration of therapy?
13Case 2 Duration of therapy
14Case 3
- 70 yo AAM with COPD, OSA, and paroxysmal atrial
fibrillation. Rate-controlled with diltiazem, on
warfarin. Presents to clinic for routine
follow-up. BP 136/82. LV EF 50. - Aspirin or warfarin for anticoagulation?
15CHADS2 Scoring
CHADS2 stroke risk index assigns 1 point for each
of four risk factors (congestive heart failure,
hypertension, age 75 years, diabetes mellitus)
and 2 points for a previous stroke. (Adapted from
Gage et al)
16Case 3 Aspirin versus warfarin
17Case 3 Aspirin versus warfarin
18Case 3 Aspirin versus warfarin
19Valvular Disease
- Rheumatic mitral valve disease
- Mitral valve prolapse
- Mitral annular calcification
- Isolated calcific aortic valve disease
- Mechanical heart valves
20Case 4
- 68yo WF with rheumatic mitral valve disease and
atrial fibrillation follows up in the clinic
after being admitted for chest pain. Ruled out
for myocardial infarction however TTE shows new
left atrial thrombus. INR on admission was 2.6.
Told to continue current dose of warfarin and
follow-up in clinic. - Further anticoagulation?
21Case 4 Further anticoagulation
22Case 4 Rheumatic mitral valve disease
23Case 5
- 35yo Hispanic female with MVP, otherwise healthy.
Mother had MVP and recently died of an MI (82
yo). Presents to clinic asking if she should
take aspirin daily. - Anticoagulation therapy?
24Case 5 Anticoagulation therapy
25References
- Ansell J, Hirsch J, Hylek E, Jacobson A, Crowther
M, Palareti G. Pharmacology and Management of the
Vitamin K Antagonists American College of Chest
Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition). CHEST 2008 126
160-198. - Gage BF, Waterman AD, Shannon W, et al.
Validation of clinical classification schemes for
predicting stroke results from the National
Registry of Atrial Fibrillation. JAMA 2001
28528642870. - Hirsch J, Guyatt G, Albers G, Harrington R,
Schunemann H. The Eight ACCP Conference on
Antithrombotic and Thrombolytic Therapy
Evidence-Based Guidelines. CHEST 2008 133
71-109. - Hirsch J, Guyatt G, Albers G, Schunemann H. The
Seventh ACCP Conference on Antithrombotic and
Thrombolytic Therapy Evidence-Based Guidelines.
CHEST 2004 126 338-476. - Schulman S, Beyth R, Kearon C, Levine M.
Hemorrhagic Complications of Anticoagulant and
Thrombotic Treatment American College of Chest
Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition). Chest 2008 133
257-298. - www.wikipedia.com
- Thanks!