Unstable angina non ST elevation myocardial infarction anticoagulant therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-in-Chief: Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.; Smita Kohli, M.D.

Overview

Anticoagulation, traditionally with unfractionated heparin (UFH), is a cornerstone of therapy for patients with unstable angina]]/[[NSTEMI. Some of the agents available in this category include unfractionated heparin, low molecular weight heparin, direct thrombin inhibitors (e.g., bivalirudin) factor Xa Inhibitors (e.g., fondaparinux), and warfarin. These agents are also sometimes referred to as antithrombins, although, it should be noted that they often inhibit one or more proteins in the coagulation cascade before thrombin.

Anticoagulant Therapy in UA/NSTEMI

You can read in greater detail about each of the therapies specifically in relation to unstable angina and NSTEMI, by clicking on the link for that therapy:

• Unfractionated heparin
• Low molecular weight heparin
• Direct thrombin inhibitors
• Factor Xa inhibitors
• Long-term anticoagulation

2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes (DO NOT EDIT)

Class I

"1.In patients with NSTE-ACS, anticoagulation, in addition to antiplatelet therapy, is recommended for all patients irrespective of initial treatment strategy. Treatment options include: Enoxaparin: 1 mg/kg subcutaneous (SC) every 12 hours (reduce dose to 1 mg/kg SC once daily in patients with creatinine clearance [CrCl] <30 mL/min), continued for the duration of hospitalization or until PCI is performed. An initial intravenous loading dose is 30 mg. (Level of Evidence: A) Bivalirudin: 0.10 mg/kg loading dose followed by 0.25 mg/kg per hour (only in patients managed with an early invasive strategy), continued until diagnostic angiography or PCI, with only provisional use of GP IIb/IIIa inhibitor, provided the patient is also treated with DAPT. (Level of Evidence: B) Fondaparinux: 2.5 mg SC daily, continued for the duration of hospitalization or until PCI is performed. (Level of Evidence: B) If PCI is performed while the patient is on fondaparinux, an additional anticoagulant with anti-IIa activity (either UFH or bivalirudin) should be administered because of the risk of catheter thrombosis. (Level of Evidence: B) UFH IV: initial loading dose of 60 IU/kg (maximum 4,000 IU) with initial infusion of 12 IU/kg per hour (maximum 1,000 IU/h) adjusted per activated partial thromboplastin time to maintain therapeutic anticoagulation according to the specific hospital protocol, continued for 48 hours or until PCI is performed. (Level of Evidence: B) "

2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non -ST-Elevation Myocardial Infarction (DO NOT EDIT)

Anticoagulant Therapy (DO NOT EDIT)

Class I

"1. Anticoagulant therapy should be added to antiplatelet therapy in UA / NSTEMI patients as soon as possible after presentation.

a) For patients in whom an invasive strategy is selected, regimens with established efficacy at a (Level of Evidence: A) include enoxaparin and UFH, and those with established efficacy at a (Level of Evidence: B) include bivalirudin and fondaparinux.

b) For patients in whom a conservative strategy is selected, regimens using either enoxaparin‡ or UFH (Level of Evidence: A) or fondaparinux (Level of Evidence: B) have established efficacy. See also Class IIa recommendation below.

c) In patients in whom a conservative strategy is selected and who have an increased risk of bleeding, fondaparinux is preferable. (Level of Evidence: B)"

Class IIa

"1. For UA / NSTEMI patients in whom an initial conservative strategy is selected, enoxaparin‡ or fondaparinux is preferable to UFH as anticoagulant therapy, unless CABG is planned within 24 h. (Level of Evidence: B)"

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‡ Limited data are available for the use of other LMWHs (e.g., dalteparin) in UA/NSTEMI.

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