Anticoagulation in ACS

Question 1

STEMI (PPCI) recommended anticoagulants

Answer 1

UFH, bivalirudin

Question 2

STEMI with fibrinolytic recommended anticoagulants

Answer 2

UFH, enoxaparin, fondaparinux

Question 3

NSTE-ACS, early invasive strategy recommended anticoagulants

Answer 3

Enoxaparin, bivalirudin, UFH

Question 4

NSTE-ACS, ischemia-guided strategy recommended anticoagulants

Answer 4

Enoxaparin, fondaparinux, UFH

Question 5

Bivalirudin as monotherapy

Answer 5

bleeding risk is high in NSTE-ACS early invasive it is reasonable in preference to UFH plus GP IIb/IIIa inhibitor

Question 6

UFH NSTE-ACS Dose

Answer 6

60 units/kg IVB (max 4000 units), 12 units/kg/hr IV (max 1000 units/hr) for 48 hr or until PCI; goal aPTT/anti-Xa according to hospital-specific protocol

Question 7

UFH PCI/STEMI ± primary PCI dose

Answer 7

Supplemental doses to target ACTa; if GP IIb/IIIa inhibitor, UFH 50–70 units/kg IVB; if no GP IIb/IIIa inhibitor, UFH 70–100 units/kg IVB

Question 8

Enoxaparin NSTE-ACS dosing

Answer 8

1 mg/kg SC every 12 hr for 24–48 hr or until PCI or throughout hospitalization (up to 8 days); 30 mg IVB

Question 9

Enoxaparin PCI dose

Answer 9

If last dose < 8 hr, nothing additional needed
if last dose > 8 hr, 0.3 mg/kg IVB if last dose 8–12 hr before or < 2 therapeutic doses received before PCI.
Greater than 12 hr usually treated with full-dose de novo anticoagulation with an established regimen (e.g., full-dose UFH or bivalirudin).

Question 10

Enoxaparin STEMI ± primary PCI dose (less than 75 yrs)

Answer 10

30 mg IVB, followed Immediately by 1 mg/kg SC every 12 hr; do not exceed 100 mg on first two doses;

Question 11

Enoxaparin STEMI ± primary PCI dose (greater than 75 yrs)

Answer 11

if> 75 yr, omit bolus; 0.75 mg/kg SC every 12 hr; do not exceed 75 mg on first two doses

Question 12

Fondaparinux NSTE-ACS Dose

Answer 12

2.5 mg SC daily

Question 13

Fondaparinux STEMI ± primary PCI Dose

Answer 13

2.5 mg IVB; then 2.5 mg SC daily

Question 14

Fondaparinux Contraindication

Answer 14

CrCl < 30 mL/min

Question 15

Bivalirudin NSTE-ACS Dose

Answer 15

0.1 mg/kg IVB; then 0.25 mg/kg/hr IV (only for planned invasive strategy)

Question 16

Bivalirudin PCI/STEMI ± primary PCI Dose

Answer 16

0.75 mg/kg IVB, 1.75mg/kg/hr IV d/c at end of PCI, or continue for up to 4 hr after procedure if needed; hold UFH 30 min before administration, already receiving a bivalirudin infusion, give an additional 0.5-mg/kg LD, and increase the infusion to 1.75 mg/kg/hour during PCI.

Question 17

Bivalirudin Renal Dose

Answer 17

CrCl < 30 mL/min, reduce infusion to 1 mg/kg/hr;
if on hemodialysis, reduce infusion to 0.25 mg/kg/hr

Question 18

Fondaparinux +UFH for PCI

Answer 18

additional 85 units/kg of intravenous UFH is required immediately before PCI revascularization if fondaparinux was initially chosen as the anticoagulant strategy if no GP IIb/IIIa inhibitor is used and 60 units/kg IV if a GP IIb/IIIa inhibitor is used