ANTI-COAGULATION

ENOXAPARIN DOSING• Obesity (BMI >= 40 kg/m2) – may increase prophylactic dose by 30% such as in bariatric surgery

• Abdominal Surgery…. 40 mg q day with initial dose given 2 hrs prior to surgery & continue 7-10 days

• Hip Replacement…… 30 mg q 12 hrs or 40 mg q day, with initial dose 12-24 hrs after surgery, x 10 days or until risk is less or pt on warfarin for 35 days.

• Knee replacement….. 30 mg q 12 hr or 40 mg q day, with initial dose 12-24 after surgery for 10 days (some recommend 35 days)

• Mobility Restricted…. Either 30mg (crcl < 30) or 40 mg (crcl >30) q day…within 24 hrs after surgery, hx dvt, high risk

• DVT or Pulmonary embolism= 1mg/kg q 12hr or 1.6 mg/kg q day

• Pregnant women- 1mg/kg/dose q 12 hr. Stop >=24 hrs prior to induction of labor . Continue x >=6wks postpartum

• PCI – if pt has gotten enoxaparin < 8hrs ago , no additional enoxaparin needed.

• PCI- if pt has gotten enoxaparin 8-12 hrs previous.. Give single dose of 0.3 mg/kg x 1

• PCI- if pt has gotten enoxaparin > 12 hrs previous. Give full dose.

• ST- elevation MI (STEMI) – 30mg iv bolus + 1mg/kg subq every 12 hrs. (max 100mg for first 2 doses). Additionally

• All pts should receive aspirin indefinitely and clopidogrel.

ENOXAPARIN• Mechanical heart valve (aortic or mitral) to bridge therapy- 1 mg/kg q 12 hrs

• Unstable angina or non=ST elevation (NSTEMI) – 1mg/kg q 12hrs w asa for at

• Least 2 days or up to 8 days)

ATRIAL FIBRILLATION• CHAD2 = CHF=1 HTN= 1 Age>=75 =1 DM=1 Stroke or TIA= 2

• Chad 0= no therapy or aspirin 81-325 mg / day

• CHAD1= OAC or aspirin 81-325 mg/day (ACCP= prefers dabigatran over VKA)

• CHAD2= OAC (for high risk pts not considered candidates for OAC= aspirin+Clopido)

ACTIVASE - EXCLUSIONS• Surgery within past 3 months

• HTN > 160/90

• Outside 3-4.5 hr therapeutic window

• On an anticoagulant

• Age > 80 YO

• HX Stroke & DM.

CARDIO-CONVERSION IN AF• Thrombi present plus cardioversion = 91% stroke rate.

• AF for greater than 48 hours = 15% rate of atrial thrombus

• AF for greater than 72 hours= 30% rate of thrombus.

• Anticoagulant 3-4 weeks prior to conversion

• Anticoagulant for at least 4 weeks after conversion.

STROKE- TREATMENT WITH ACTIVASE• Within 4.5 hours of symptom onset

• Dose 0.9 mg/kg IV, 90mg max, then 10% of it as bolus, rest given over 1 hour

• Improvement of symptoms

• Intracranial or subarachnoid bleed

• Other active bleed, intracranial surgery with past 3 months

• Major surgery in past 2 weeks, age > 80

• GI or UT bleed in past 3 weeks, previous stroke combined with DM

• BP >185/110 or aggressive tx to lower bp

• Pregnancy, seizure, neoplasm, taking nother anticoagulant, Plts < 100k

STROKE-SECONDARY PREVENTION• American Stroke Association recommends aspirin-dipyridamole or aspirin, or clopidogrel.

• (initiate aspirin 160-325 mg after initial dose with 50-100mg q day within 48 hrs of stroke

• Use warfarin if Afib is associate with prosthetic heart valves.

STEMI (MI) TREATMENT• (M) orphine 2-4 mg q 5-15 min prn

• (O) oxygen---- if O2 sats < 90%

• (N) itroglycerin

• (A) spirin chew and swallow 62-325mg

• Beta-blocker-start within 24 hrs

• Ace-inhibitor- start within 24 hrs

• Aldosterone antagonist

• Statin, nitrates, ccb

NSTEMI - TREATMENT• Antiplatelet plus P2Y12 plus ASA

• PCI- balloon, stent implantation