ASPIRIN↓

Cox inhibition ↓

(PROSTACYCLIN) PGI 2 & TXA 2 (THROMBOXANE)

LOW DOSE ASPIRIN

1)PREVENT ARTERIAL THROMBOSIS IHD, STROKE

2) UNSTABLE ANGINA

3) RECENT MI

4) TIA

5) ARIFICIAL VALVES

6) PTCA

7) PERIPHERAL ARTERIAL OCCLUSIVE DISEASE

8) CHRONIC LIMB ISCHEMIA

Aspirin ADR

DIPYRIDAMOLE

- VASODILATOR

- THALLIUM IMAGING

- INHIBIT PLATELET ADHESION TO VESSEL

WALL

↑ cAMP

↓ PLATELET CALCIUM

INHIBIT AGGREGATION

+ ASPIRIN – STROKE, TIA

? SUPERIOR

CLOPIDOGREL & TICLOPIDINE

INHIBIT ADP – INDUCED EXPRESSION OF PLATELET GP RECEPTORS

↓ DECREASE FIBRINOGEN BINDING

↓

DECREASE PLATELET AGGREGATION

CLOPIDOGREL → PRODRUG,

TICLOPIDINE → NEUTROPENIA

↓ CBC – 2 WEEKS UPTO 3 MONTHS

THROMBOTIC STROKE

SICKLE CELL ANEMIA

ACS

INTERMITTENT CLAUDICATION

PCI

CHRONIC ARTERIAL OCCLUSION

OPEN HEART SURGERY

AV SHUNT

ABCIXIMAB

- PCI + Aspirin & Heparin

- in MI

- Bleeding, thrombocytopenia, hypotension, Brady cardia

TIROFIBAN & EPTIFIBATIDE

- Competitive, reversible inhibitors of fibrinogen binding to GPII b / III a

- ACS – unstable angina, NSTEMI

- Angioplasty & stenting

- Bleeding

FIBRINOLYTICS:

• Streptokinase Alteplase

• Urokinase Reteplase

• Anistreplase Tenecteplase

Streptokinase 1.5 million units over 60 min

Alteplase 15mg bolus

0.75mg/1kg – 30 min

0.5mg/kg- 60 min

Reteplase – 10mg bolus

10mg after 30min

Tenecteplase – IV bolus 0.5 mg /kg

Coagulation factor concentrates

Desmopressin

HEMOSTATIC AGENTS:ε - Aminocaproic acid Aprotinin

TOPICAL ABSORBABLE: Thrombin

Microfibrillar collagen hemostat

Absorbable gelatin

Oxidized cellulose

THROMBOLYTIC THERAPY

ADV- Availability, rapid administration

DISADV – Intracranial hemorrhage

- Uncertainty of whether normal coronary flow has been restored

- Reocclusion

-Most effective within 12 hour (relative mortality decreased by 18%)

- Little benefit beyond 12 hour

Not for resolved chest pain,

ST segment depression

Fibrin selective agents should be used with

anticoagulants – UFH, LMWH,

fondraparinux & bivalirudin

Monitoring of thrombolytic therapy!

Patency is 30%

PCI patency 95% (TIMI 3)

Persistent angina

Persistent ischemic changes on ECG

<50% Reduction in ST elevation 60-90 min

after initiation of thrombolysis ---rescue PCI.

Routine coronary angiography & PCI within

24h of thrombolysis

Complications:

Intracranial bleeding 0.7 – 0.9%

Major bleeding requiring treatment 10%

Venipuncture & arterial puncture.

Diagnosis of coagulation defects

Prolonged APTT Defective Intrinsic PathwayNo change in PT

No change in APTT Defective Extrinsic PathwayProlonged PT

Prolonged APTT Defective in Common pathwayProlonged PT

Absolute C/I:1) H/o intracranial hemorrhagic / hemorrhagic stroke 2) Ischemic stroke within 3mo3) AVMs, aneurysms, tumor4) Closed head injury within 3 mo5) Aortic dissection6) severe uncontrolled HT – SBP > 180, DBP > 1107) Active bleeding / bleeding diathesis

8) Acute pericarditis.

Blood Vessel Injury

IX IXa

XI XIa

X Xa

XII XIIa

Tissue Injury

Tissue Factor

Thromboplastin

VIIa VII

X

Prothrombin Thrombin

Fibrinogen Fribrin monomer

Fibrin polymerXIII

Intrinsic Pathway Extrinsic Pathway

Factors affectedBy Heparin

Vit. K dependent FactorsAffected by Oral Anticoagulants

Thrombosis

Arterial Thrombosis : Adherence of platelets to arterial walls - White in

color - Often associated with MI, stroke and ischemia

Venous Thrombosis : Develops in areas of stagnated blood flow (deep

vein thrombosis), Red in color- Associated with Congestive Heart Failure, Cancer, Surgery.