CLEVELAND CLINIC ANTICOAGULATION MANAGEMENT PROGRAM (C-CAMP) 1 Table of Contents I. EXECUTIVE SUMMARY ......................................................................................................................................... 6 II. VENOUS THROMBOEMBOLISM RISK ASSESSMENT AND PROPHYLAXIS ............................................. 9 III. RECOMMENDED PROPHYLAXIS OPTIONS FOR THE PREVENTION OF VENOUS THROMBOEMBOLISM. ........................................................................................................................................ 10 IIIA. RECOMMENDED PROPHYLAXIS OPTIONS FOR THE PREVENTION OF VENOUS THROMBOEMBOLISM BASED ON RISK FACTOR ASSESSMENT ............................................................. 12 A) UNFRACTIONATED HEPARIN (UFH) ................................................................................................................... 14 B) LOW MOLECULAR WEIGHT HEPARIN (LMWH) ENOXAPARIN (LOVENOX®) .............................................. 14 C) FONDAPARINUX/ (ARIXTRA®) …………………………………………………………………………..……16 D) RIVAROXABAN (XARELTO®) .......................................................................................................................... 16 E) DESIRUDIN (IPRIVASK®)………………………………………………………………………………..…….17 F) WARFARIN/COUMADIN®) ............................................................................................................................... 16 G) ASPIRIN……………………………………………………………………………………………………..……18 H) INTERMITTENT PNEUMATIC COMPRESSION DEVICES ...................................................................................... 18 I) GRADUATED COMPRESSION STOCKINGS ............................................................................................................ 18 J ) EARLY AMBULATION .......................................................................................................................................... 19 IV. DIAGNOSIS OF VENOUS THROMBOEMBOLISM .......................................................................................... 19 V. TREATMENT OF VENOUS THROMBOEMBOLISM ....................................................................................... 24 A) UNFRACTIONATED HEPARIN (UFH) ................................................................................................................ 26 B) LOW MOLECULAR WEIGHT HEPARIN (LMWH) ENOXAPARIN/ (LOVENOX®) ............................................ 30 C) FONDAPARINUX (ARIXTRA®) .......................................................................................................................... 32 D) ALTEPLASE/ACTIVASE® (RT-PA) .................................................................................................................... 33 E) RIVAROXABAN (XALERTO®)…………………………………………………………………………………..34 F) WARFARIN (COUMADIN®) ............................................................................................................................... 35 G) INFERIOR VENA CAVA FILTERS ....................................................................................................................... 37 H) COMPRESSION STOCKINGS - PREVENTION OF THE POST-THROMBOTIC SYNDROME .................................... 37 I) DIETARY ROLE IN THE MANAGEMENT OF VTE .............................................................................................. 38 VI. TREATMENT OF PATIENTS WITH ACUTE CORONARY SYNDROMES STEMI .................................... 39 VII. TREATMENT OF PATIENTS WITH ACUTE CORONARY SYNDROMES NSTEMI.................................. 41 VIII. TREATMENT OF PATIENTS UNDERGOING PERCUTANEOUS CORONARY INTERVENTION ......... 42 A) UNFRACTIONATED HEPARIN (UFH) ................................................................................................................ 44 B) LOW MOLECULAR WEIGHT HEPARIN (LMWH) ENOXAPARIN(LOVENOX®) ............................................... 48 C) BIVALIRUDIN (ANGIOMAX®) ............................................................................................................................ 50 D) TENECTEPLASE (TNKASE®) ............................................................................................................................ 51 IX. TREATMENT OF PATIENTS WITH ATRIAL FIBRILLATION ..................................................................... 52 A) UNFRACTIONATED HEPARIN ............................................................................................................................ 54 B) LOW MOLECULAR WEIGHT HEPARIN (LMWH) ENOXAPARIN (LOVENOX®) .............................................. 58 C) WARFARIN (Coumadin®)................................................................................................................................59 D) DABIGATRAN (PRADAXA®).........................................................................................................................61 E) RIVAROXABAN (XARELTO®).....................................................................................................................62 X. TREATMENT OF PATIENTS WITH PROSTHETIC HEART VALVES ......................................................... 64 A) ANTICOAGULATION POST MECHANICAL HEART VALVE REPLACEMENT SURGERY ...................................... 66 B) PREGNANCY AND MECHANICAL HEART VALVES ............................................................................................ 66 C) ANTICOAGULATION POST BIOPROSTHETIC VALVE REPLACEMENT SURGERY ............................................. 67 D) UNFRACTIONATED HEPARIN ............................................................................................................................ 67 E) LOW MOLECULAR WEIGHT HEPARIN (LMWH) ENOXAPARIN (LOVENOX®) .............................................. 70 XI. WARFARIN FOR ACS, ATRIAL FIBRILLATION, PROSTHETIC HEART VALVES ................................ 72 2 XII. TREATMENT OF ACUTE ISCHEMIC STROKE ............................................................................................... 75 XIII. COMPLICATIONS OF ANTICOAGULATION ................................................................................................... 84 A) HEPARIN INDUCED THROMBOCYTOPENIA ....................................................................................................... 87 XIV. REVERSAL GUIDELINES OF PARENTAL AND ORAL ANTICOAGULANTS A) HEPARIN…………………………………………………….………………………………………………....85 B) LOW MOLECULAR WEIGHT HEPARIN…….………………………………………………………..…..86 C) ANTI-XA INHIBITORS……………………………………………………………………………………………86 D) DIRECT THROMBIN INHIBITORS…………………………………………………………………………………87 XV. BRIDGING THERAPY ............................................................................................................................................ 89 A) LMWH AS A PERIOPERATIVE BRIDGING AGENT .............................................................................. 91 B) UNFRACTIONATED HEPARIN AS A PERIOPERATIVE BRIDGING AGENT .................................. 91 C) DABIGATRAN AS A PERIOPERATIVE BRIDGING AGENT D) XARELTO AS A PREOPERATIVE BRIDGING AGENT XVI. GENERAL INSTRUCTIONS FOR ORAL ANTICOAGULANTS: WARFARIN (COUMADIN®) DABIGATRAN ( PRADAXA®), RIVAROXABAN (XARELTO®) FOR THE PATIENT AT DISCHARGE 93 A) CONTRAINDICATIONS ....................................................................................................................................... 93 B) RISK AND BENEFITS OF WARFARIN THERAPY. ................................................................................................ 93 C) PATIENT INSTRUCTIONS FOR UNDERSTANDING WARFARIN/COUMADIN® .................................................... 93 3 List of Tables and Figures TABLE 1. AVAILABLE ANTICOAGULANTS AT CLEVELAND CLINIC HOSPITALS………………………………………….…....8 TABLE 2. SUMMARY OF VENOUS THROMBOEMBOLISM PROPHYLAXIS OPTIONS - GENERAL ................................................. 10 TABLE 3. RECOMMENDED PROPHYLAXIS OPTIONS FOR PREVENTION OF VTE BASED ON RISK FACTOR ASSESSMENT ......... 12 TABLE 4. CLINICAL DECISION RULE TO HELP DETERMINE THE PRETEST PROBABILITY FOR DVT ........................................ 20 FIGURE 1. ALGORITHM FOR DIAGNOSING DVT ...................................................................................................................... 21 TABLE 5. CLINICAL DECISION RULE TO DETERMINE THE PRETEST PROBABILITY OF PE ....................................................... 22 FIGURE 2. ALGORITHM FOR DIAGNOSING PE ......................................................................................................................... 23 TABLE 6. SUMMARY TABLE OF PHARMACEUTICAL AGENTS, DOSING GUIDELINES FOR TREATMENT OF VTE* .................... 24 TABLE 7. HEPARIN NOMOGRAM ORDERS FOR THE TREATMENT OF ACUTE VENOUS THROMBOEMBOLISM .......................... 27 TABLE 8. TARGET INR FOR THE TREATMENT OF ACUTE VTE ............................................................................................... 35 TABLE 9. SUMMARY TABLE OF PHARMACOLOGICAL AGENTS, DOSING GUIDELINES FOR ACS (STEMI) ............................. 39 TABLE 10. SUMMARY TABLE OF PHARMACOLOGICAL AGENTS, DOSING GUIDELINES FOR ACS.(NSTEMI) .......................... 41 TABLE 11. SUMMARY TABLE OF PATIENTS UNDERGOING PERCUTANEOUS CORONARY INTERVENTION ................................. 42 TABLE 12. HEPARIN NOMOGRAM PHYSICIAN’S ORDER FOR ACUTE CORONARY SYNDROME PATIENTS .................................. 45 FIGURE 3. DOSING GUIDELINES FOR TENECTEPLASE………………………………………………….………………..…......51 TABLE 13. SUMMARY OF PHARMACEUTICAL