“Parenteral anticoagulation, in addition to antiplatelet therapy, is recommended for all patients with NSTE-ACS regardless of initial treatment strategy.” AAFP 2017
[Will start heparin (preferably) or Lovenox treatment dose if the patient starts having one of the following: 1) Active chest pain, 2) Significantly elevated Troponins (e.g. above 0.50), 3) ST depressions or T wave changes, 4) STEMI (which will go to cath lab immediately). Heparin is easily reversible if needed.]
- Heparin 60 U/kg IVB (max 4000 U); 12 U/kg/hr (max 1000 U/hr initially).
- Enoxaparin 1mg/kg SC BID for > 2d until patient stabilized. D/C if Plt <100,000
- Bivalirudin is an option for patients with HIT.
- Fondaparinux is also an option.
Target aPTT for ACS patients on heparin.
*** Cardiologist Dr. Bernstein says that aPTT has to be > 50 to be therapeutic for patients on heparin drip for ACS. This NIH article corroborates that, “The target activated partial thromboplastin time (aPTT) range of 1.5 to 2.5 times the control value or 45 to 75 seconds recommended by the ACC/AHA for patients receiving unfractionated heparin (UFH) for acute coronary syndromes (ACS) is vulnerable to variation in test reagents.”
*** “LMWH does not prolong the aPTT in a predictable fashion. However, LMWH have a number of advantages over UFH, including a more predictable anticoagulant effect and a reduced likelihood of inducing immune-mediated thrombocytopenia.”
Reference
Am Fam Physician. 2017 Feb 15;95(4):232-240. http://www.aafp.org/afp/2017/0215/p232.html
https://www.ncbi.nlm.nih.gov/pubmed/15306747