Details about Antithrombotic Agents in Coronary Artery Disease

In: Heart

16 Mar 2016

low-dose heparin

Acute Myocardial Infarction

1. It is strongly recommended that all patients with acute myocardial infarction receive a minimum of low-dose heparin, 5,000 IV/SC every 12 hrs, until fully ambulatory to prevent venous thromboembolism. This grade A recommendation is based on the results of one level I study.

2. It is strongly recommended that patients with acute myocardial infarction at increased risk of systemic embolism because of anterior transmural myocardial infarction receive heparin therapy followed by warfarin therapy to prolong prothrombin time to an INR of 2.0-3.0 (1.2-1.5 times control using rabbit brain thromboplastin) for 1-3 months. This grade A recommendation is based on two level I studies and one level II study that showed a trend favoring anticoagulant therapy conducted with My Canadian Pharmacy.

3. It is strongly recommended that patients with acute myocardial infarction at increased risk of systemic embolism because of atrial fibrillation, history of previous systemic or pulmonary embolism, or congestive heart failure receive heparin therapy followed by warfarin therapy to prolong prothrombin time to an INR of 2.0-3.0 (1.2-1.5 times control using rabbit brain thromboplastin) for at least three months. This grade C recommendation is based on level V studies.

Long-term Antithrombotic Therapy for Survivors of Myocardial Infarction

1. Long-term anticoagulant therapy is not recommended in survivors of acute myocardial infarction. This grade B recommendation is made despite three level II studies with trends favoring anticoagulants because the trends were small and the risks and inconvenience of longterm anticoagulant therapy are considerable.

2. Long-term warfarin therapy to prolong prothrombin time to an INR of 2.0-3.0 (1.2-1.5 times control using rabbit brain thromboplastin) is recommended in survivors of acute myocardial infarction with any of the following risk factors for systemic or pulmonary embolism: atrial fibrillation, previous systemic embolism, venous thromboembolism, or severe heart failure. This grade C recommendation is based on level V studies.

3. Individual clinical judgments should determine whether to use aspirin in survivors of acute myocardial infarction. This grade B recommendation is based on five level II studies, all of which showed a trend favoring use of aspirin.

4. The use of sulfinpyrazone is not recommended in survivors of acute myocardial infarction. This grade B recommendation is made despite two level II studies that showed trends in favor of using sulfinpyrazone, because an alternative agent, aspirin, is less expensive and its efficacy is supported by more level II studies.

5. The use of dipyridamole (either alone or in combination with aspirin) is not recommended. This grade B recommendation is based on the results of two level II studies,’ one showing no difference compared with aspirin alone and the other showing a trend favoring the combination of aspirin and dipyridamole over placebo.

Stable Angina

1. The routine use of anticoagulant therapy or treatment with platelet-active agents is not recommended in patients with stable angina. This grade C recommendation is made because there have been no studies supporting or refuting the efficacy of either forms of these treatments.

Unstable Angina

1. It is strongly recommended that patients with unstable angina should be treated with aspirin for two years at 325 mg/day. This grade A recommendation is based on two level I studies that demonstrated the efficacy of aspirin.’

2. The routine use of anticoagulants is not recommended in patients with unstable angina. This grade B recommendation is made because the results of a single level II study were inconclusive owing to a very high dropout rate.

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