ST elevation myocardial infarction deep vein thrombosis prophylaxis and anticoagulation

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Editors-In-Chief: Alexandra Lansky, M.D. and C. Michael Gibson, M.S., M.D.

Overview

Deep venous thromboembolism and embolic prophylaxis are key considerations in determining the appropriate care for a STEMI patient. A number of guidelines, recommendations and current practice patterns exist to allow physicians to weigh various considerations and ensure proper delivery of care.

I.Recommendations for Long-Term Oral Anticoagulation Following AMI

1. In most health-care settings, for moderate- and low-risk patients with an MI, we recommend aspirin alone over oral vitamin K antagonists (VKAs) plus aspirin (Grade 2B).

Underlying values and preferences: This recommendation places a relatively low value on prevention of thromboembolism, and a relatively high value on avoiding the inconvenience, expense, and bleeding associated with VKA therapy.

2. In health-care settings in which meticulous INR monitoring is standard and routinely accessible, for both high- and low-risk patients after MI, we recommend long-term (up to 4 years) high-intensity oral VKA (target INR, 3.5; range, 3.0 to 4.0) without concomitant aspirin, or moderate-intensity oral VKA (target INR, 2.5; range, 2.0 to 3.0) with aspirin (both Grade 2B).

3. For high-risk patients with MI, including those with a large anterior MI, those with significant heart failure, those with intracardiac thrombus visible on echocardiography, and those with a history of a thromboembolic event, we suggest the combined use of moderate-intensity (INR, 2.0 to 3.0) oral VKA plus low-dose aspirin, ≤ 100 mg/d, for 3 months after the MI (Grade 2A).

Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients’ values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S–187S).

II. Recommendation for Adjunctive treatment with UFH or LMWH following AMI (ACC/AHA Guidelines and ESC Guidelines)

There are no specific guideline recommendations for the use of UFH or LMWH following PCI for STEMI.

III. Recommendations for Venous Thromboemolic phrophylaxis in the Medical Patient

III.a Medical Conditions

1. For acutely ill medical patients admitted to hospital with congestive heart failure or severe respiratory disease, or who are confined to bed and have one or more additional risk factors, including active cancer, previous VTE, sepsis, acute neurologic disease, or inflammatory bowel disease, we recommend thromboprophylaxis with LMWH (Grade 1A), LDUH (Grade 1A), or fondaparinux (Grade 1A).

2. For medical patients with risk factors for VTE, and for whom there is a contraindication to anticoagulant thromboprophylaxis, we recommend the optimal use of mechanical thromboprophylaxis with GCS or IPC (Grade 1A).

III.b Critical Care

1. For patients admitted to a critical care unit, we recommend routine assessment for VTE risk and routine thromboprophylaxis in most (Grade 1A).

2. For critical care patients who are at moderate risk for VTE (eg, medically ill or postoperative general surgery patients), we recommend using LMWH or LDUH thromboprophylaxis (Grade 1A).

3. For critical care patients who are at higher risk (eg, following major trauma or orthopedic surgery), we recommend LMWH thromboprophylaxis (Grade 1A).

4. For critical care patients who are at high risk for bleeding, we recommend the optimal use of mechanical thromboprophylaxis with GCS and/or IPC at least until the bleeding risk decreases (Grade 1A). When the high bleeding risk decreases, we recommend that pharmacologic thromboprophylaxis be substituted for or added to the mechanical thromboprophylaxis (Grade 1C).

IV. Antithrombin Selection and Dosing Recommendations

Medical prevention of thromboembolic disease in the medical patient include all the following:

1. Unfractionated heparin 5000 units subcutaneously every 12 hours.

Low molecular heparin have been show to be as effective as unfractionated heparin.

Enoxaparin	40mg SC daily
Dalteparin	2500 units SC daily
Nadroparin	2850 units SC daily

Duration of therapy depends on patient risk Intermittent pneumatic leg compression are alternatives in patients with contraindications to anticoagulants

V. Regional Differences in Prophylaxis Practices

The ACCP consensus group guidelines recommend appropriate prophylaxis in high risk medically treated patient groups. An analysis of DVT prophylaxis in subsets of the IMPROVE study patients who met the ACCP guideline criteria for prophylaxis, provide a benchmark comparison for the real-world practices observed in the entire IMPROVE study population (N=15,156). These subsets of patients are those in whom pharmacologic prophylaxis has been shown to be effective, and our observed prophylaxis rates highlight an underuse of prophylaxis in these populations of patients.

IMPROVE is an ongoing, multinational, observational study of DVT prophylaxis practices. From July 2002 to September 30, 2006, 15,156 patients were enrolled from 52 hospitals in 12 countries, of whom 50% received in-hospital pharmacologic and/or mechanical VTE prophylaxis. In the United States and other participating countries, 52% and 43% of patients, respectively, should have received prophylaxis according to guideline recommendations from the American College of Chest Physicians (ACCP). Only approximately 60% of patients who either met the ACCP criteria for requiring prophylaxis or were eligible for enrollment in randomized clinical trials that have shown the benefits of pharmacologic prophylaxis actually received prophylaxis. Practices varied considerably. Intermittent pneumatic compression was the most common form of medical prophylaxis utilized in the United States, although it was used very rarely in other countries (22% vs 0.2%, respectively). Unfractionated heparin was the most frequent pharmacologic approach used in the United States (21% of patients), with low-molecular-weight heparin used most frequently in other participating countries (40%). There was also variable use of elastic stockings in the United States and other participating countries (3% vs 7%, respectively).

2013 Revised ACCF/AHA Guidelines for the Management of ST-Elevation Myocardial Infarction (DO NOT EDIT)

Anticoagulation After STEMI (DO NOT EDIT)¶

Class I

"1. Anticoagulant therapy with a vitamin K antagonist should be provided to patients with STEMI and atrial fibrillation with CHADS2* score greater than or equal to 2, mechanical heart valves, venous thromboembolism, or hypercoagulable disorder.(Level of Evidence: C)"

"2. The duration of triple-antithrombotic therapy with a vitamin K antagonist, aspirin, and a P2Y12 receptor inhibitor should be minimized to the extent possible to limit the risk of bleeding.**(Level of Evidence: C)"

"* CHADS2 (Congestive heart failure, Hypertension, Age >75 years, Diabetes mellitus, previous Stroke/transient ischemic attack [doubled risk weight]) score.

"** Individual circumstances will vary and depend on the indications for triple therapy and the type of stent placed during PCI. After this initial treatment period, consider therapy with a vitamin K antagonist plus a single antiplatelet agent. For patients treated with fibrinolysis, consider triple therapy for 14 days, followed by a vitamin K antagonist plus a single antiplatelet agent.

Class IIa

"1. Anticoagulant therapy with a vitamin K antagonist is reasonable for patients with STEMI and asymptomatic LV mural thrombi.(Level of Evidence: C)"

Class IIb

"1. Anticoagulant therapy may be considered for patients with STEMI and anterior apical akinesis ordyskinesis.(Level of Evidence: C)"

"2. Targeting vitamin K antagonist therapy to a lower international normalized ratio (eg, 2.0 to 2.5) might be considered in patients with STEMI who are receiving DAPT.(Level of Evidence: C)"

• ¶ = These recommendations apply to patients who receive intracoronary stents during PCI for STEMI. Among individuals with STEMI who do not receive an intracoronary stent, the duration of DAPT beyond 14 days has not been studied adequately for patients who undergo balloon angioplasty alone, are treated with fibrinolysis alone, or do not receive reperfusion therapy. In this subset of patients with STEMI who do not receive an intracoronary stent, the threshold for initiation of oral anticoagulation for secondary prevention, either alone or in combination with aspirin, may be lower, especially if a shorter duration (ie, 14 days) of DAPT is planned.

Sources

• 2013 Revised ACCF/AHA Guidelines for the Management of ST-Elevation Myocardial Infarction