View source for ST elevation myocardial infarction deep vein thrombosis prophylaxis and anticoagulation

__NOTOC__
{{ST elevation myocardial infarction}}
'''Editors-In-Chief:'''  [[C. Michael Gibson| C. Michael Gibson, M.S., M.D.]]

==Overview==
[[DVT|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<ref name="pmid15222649">{{cite journal |author=Ramzi DW, Leeper KV |title=DVT and pulmonary embolism: Part II. Treatment and prevention |journal=Am Fam Physician |volume=69 |issue=12 |pages=2841–8 |year=2004 |month=June |pmid=15222649 |doi= |url=}}</ref>:

1. [[Unfractionated heparin]] 5000 units subcutaneously every 12 hours.

2. [[Low molecular weight heparin]]s have been show to be as effective as unfractionated heparin.

{| border="1"
|-
| [[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 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: Executive Summary(DO NOT EDIT)<ref name="pmid23256913">{{cite journal| author=American College of Emergency Physicians. Society for Cardiovascular Angiography and Interventions. O'Gara PT, Kushner FG, Ascheim DD, Casey DE et al.| title=2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=J Am Coll Cardiol | year= 2013 | volume= 61 | issue= 4 | pages= 485-510 | pmid=23256913 | doi=10.1016/j.jacc.2012.11.018 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23256913  }} </ref>==

===Anticoagulation After STEMI (DO NOT EDIT)<nowiki>¶</nowiki><ref name="pmid23256913">{{cite journal| author=American College of Emergency Physicians. Society for Cardiovascular Angiography and Interventions. O'Gara PT, Kushner FG, Ascheim DD, Casey DE et al.| title=2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=J Am Coll Cardiol | year= 2013 | volume= 61 | issue= 4 | pages= 485-510 | pmid=23256913 | doi=10.1016/j.jacc.2012.11.018 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23256913  }} </ref>===

{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Anticoagulant therapy with a [[vitamin K antagonist]] should be provided to patients with [[STEMI]] and [[atrial fibrillation]] with CHADS2<nowiki>*</nowiki> score greater than or equal to 2, [[mechanical heart valve]]s, [[venous thromboembolism]], or hypercoagulable disorder.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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]].<nowiki>**</nowiki>''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
|}

{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[Anticoagulant]] therapy with a vitamin K antagonist is reasonable for patients with STEMI and asymptomatic LV mural thrombi.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Anticoagulant therapy may be considered for patients with STEMI and anterior apical [[akinesis]] or [[dyskinesis]].''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

==2013 Revised ACCF/AHA Guidelines for the Management of ST-Elevation Myocardial Infarction (DO NOT EDIT)<ref name="pmid23247303">{{cite journal |author=O'Gara PT, Kushner FG, Ascheim DD, ''et al.'' |title=2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines |journal=Circulation |volume= |issue= |pages= |year=2012 |month=December |pmid=23247303 |doi=10.1161/CIR.0b013e3182742c84|url=}}</ref>==

===Anticoagulation After STEMI (DO NOT EDIT)<nowiki>¶</nowiki><ref name="pmid23247303">{{cite journal |author=O'Gara PT, Kushner FG, Ascheim DD, ''et al.'' |title=2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines |journal=Circulation |volume= |issue= |pages= |year=2012 |month=December |pmid=23247303 |doi=10.1161/CIR.0b013e3182742c84|url=}}</ref>===

{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Anticoagulant therapy with a [[vitamin K antagonist]] should be provided to patients with [[STEMI]] and [[atrial fibrillation]] with CHADS2<nowiki>*</nowiki> score greater than or equal to 2, [[mechanical heart valve]]s, [[venous thromboembolism]], or hypercoagulable disorder.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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]].<nowiki>**</nowiki>''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-

| bgcolor="LightGreen"|<nowiki>"</nowiki><nowiki>*</nowiki> [[CHADS2]] ([[Congestive heart failure]], [[Hypertension]], Age >75 years, [[Diabetes mellitus]], previous [[Stroke]]/[[Transient ischemic attack]] [doubled risk weight]) score.
|-

| bgcolor="LightGreen"|<nowiki>"</nowiki><nowiki>**</nowiki> 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.<ref name="pmid22315271">{{cite journal |author=You JJ, Singer DE, Howard PA, ''et al.'' |title=Antithrombotic therapy for atrial fibrillation: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines |journal=Chest |volume=141 |issue=2 Suppl |pages=e531S–75S |year=2012 |month=February |pmid=22315271 |doi=10.1378/chest.11-2304 |url=}}</ref><ref name="pmid22315274">{{cite journal |author=Vandvik PO, Lincoff AM, Gore JM, ''et al.'' |title=Primary and secondary prevention of cardiovascular disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines |journal=Chest |volume=141 |issue=2 Suppl |pages=e637S–68S |year=2012 |month=February |pmid=22315274 |doi=10.1378/chest.11-2306 |url=}}</ref><ref name="pmid20447945">{{cite journal |author=Lip GY, Huber K, Andreotti F, ''et al.'' |title=Antithrombotic management of atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing coronary stenting: executive summary--a Consensus Document of the European Society of Cardiology Working Group on Thrombosis, endorsed by the European Heart Rhythm Association (EHRA) and the European Association of Percutaneous Cardiovascular Interventions (EAPCI) |journal=Eur. Heart J. |volume=31 |issue=11 |pages=1311–8 |year=2010 |month=June |pmid=20447945 |doi=10.1093/eurheartj/ehq117 |url=}}</ref><ref name="pmid21785808">{{cite journal |author=Faxon DP, Eikelboom JW, Berger PB, ''et al.'' |title=Consensus document: antithrombotic therapy in patients with atrial fibrillation undergoing coronary stenting. A North-American perspective |journal=Thromb. Haemost. |volume=106 |issue=4 |pages=572–84 |year=2011 |month=October |pmid=21785808 |doi=10.1160/TH11-04-0262 |url=}}</ref>
|}

{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[Anticoagulant]] therapy with a vitamin K antagonist is reasonable for patients with STEMI and asymptomatic LV mural thrombi.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Anticoagulant therapy may be considered for patients with STEMI and anterior apical [[akinesis]] or [[dyskinesis]].''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

* <nowiki>¶</nowiki> = 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.<ref name="pmid16143706">{{cite journal |author=Andreotti F, Testa L, Biondi-Zoccai GG, Crea F |title=Aspirin plus warfarin compared to aspirin alone after acute coronary syndromes: an updated and comprehensive meta-analysis of 25,307 patients |journal=Eur. Heart J. |volume=27 |issue=5 |pages=519–26 |year=2006 |month=March |pmid=16143706 |doi=10.1093/eurheartj/ehi485 |url=}}</ref>

==Sources==
* 2013 Revised ACCF/AHA Guidelines for the Management of ST-Elevation Myocardial Infarction<ref name="pmid23247303">{{cite journal |author=O'Gara PT, Kushner FG, Ascheim DD, ''et al.'' |title=2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines |journal=Circulation |volume= |issue= |pages=|year=2012 |month=December |pmid=23247303 |doi=10.1161/CIR.0b013e3182742c84|url=}}</ref>

==References==
{{reflist|2}}

[[Category:Disease]]
[[Category:Cardiology]]
[[Category:Ischemic heart diseases]]
[[Category:Intensive care medicine]]
[[Category:Emergency medicine]]
[[Category:Mature chapter]]

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