ST elevation myocardial infarction deep vein thrombosis prophylaxis and anticoagulation

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

Overview

Deep venous thromboembolism (DVT) prophylaxis and embolic prophylaxis should be considered in the management of the STEMI patient.

DVT Prophylaxis

Antithrombotic regimens to prevent venous thrombo embolism in the medically ill patient include all the following:

1. Unfractionated heparin 5000 units subcutaneously every 12 hours.

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

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

The duration of prophylactic therapy depends upon the patient risk. Intermittent pneumatic leg compression are alternatives in patients with contraindications to anticoagulants.

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 or dyskinesis.(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