Comparison of Two Nomograms of Unfractionated Heparin in Patients with Acute Coronary Syndrome
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Abstract
Heparin has an unpredictable pharmacokinetics and the responses of individuals may vary distinctly. Therefore, different dosing nomograms have been proposed. The aim of this study was to compare two prevalent nomograms to adjust heparin doses in hospitalized patients with acute coronary syndrome. One hundred and forty patients received heparin infusions based on one of two nomograms. Group 1 received a bolus of 80 U/Kg/h and an initial infusion rate of 17 U/Kg/h. In the second group, a bolus of 60 U/Kg (maximum of 4000 U) and an initial infusion rate of 12 U/Kg/h (maximum of 900U/h) was given. Activated partial thromboplastin time (aPTT) was measured at the beginning and every 6 h for 48 hours. The rate of heparin was changed according to each nomogram in order to maintain aPTT in the therapeutic level of 46-70 s. The time to pass threshold was on average 7.63±3.95 h for nomogram 1 and 11.05±4.41 h for the second nomogram (P<0.001). At 48 hours, the proportion of patients in the therapeutic range in group 1 was higher (72.86% vs 45.71%). The time patients stayed at the desired levels was significantly higher in nomogram 1 and they also required fewer heparin rate adjustments (3.41±1.55 vs 4.53±1.63). This study indicated that using nomogram 1 facilitated a more rapid achievement of the therapeutic threshold, higher proportion of patients in the therapeutic range for a longer time, and fewer changes of in the heparin rate.
Carson JL Subcutaneous Unfractionated Heparin vs. Low- Molecular-Weight Heparin for Acute Thromboembolic Disease. JAMA 2006; 296(8):991-3.
Lee MS, Menon V, Schappert J, Wilentz JR, Singh V, Hochman JS. Establishing a new target range forunfractionated.heparin for acute coronary syndromes. JThromb Thrombolysis 2004; 17(2):121–6.
Bernardi E, Piccioli A, Oliboni G, Zuin R, Girolami A, Prandoni P. Nomograms for the administration of unfractionated heparin in the initial treatment of acute thromboembolism--an overview. Thromb Haemost 2000; 84(1):22-6.
Hirsh J, Raschke R. Heparin and low-molecular-weight heparin: The Seventh ACCP Conference onAntithrombotic and Thrombolytic Therapy. Chest 2004; 126(3 Suppl):188-203S.
Haines ST, Zeolla M, Witt DM. Venous Thromboembolism. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM. Pharmacotherapy: A Pathophysiological Approach. 6th ed. New York: McGraw-Hill Companies,Inc.; 2005:373-413.
Prandoni P, Carnovali M, Marchiori A; GalileiInvestigators. Prandoni P, Carnovali M, Marchiori A;Galilei Investigators. Subcutaneous adjusted-dose unfractionated heparin vs fixed-dose low-molecular-weight heparin in the initial treatment of venous thromboembolism. Arch Intern Med 2004; 164(10):1077-83.
Gilchrist IC, Berkowitz IC, Thompson TD, Califf RM, Granger CB. Heparin dosing and outcome in acute coronary syndromes: The GUSTO-IIb Experience. Am Heart J 2002; 144(1):73-80.
. Lee MS, Wali AU, Menon V, Berkowitz SD, Thompson TD, Califf RM, Topol EJ, Granger CB, Hochman JS. Thedeterminants of activated partial thromboplastin time, relation of activated partial thromboplastin time to clinical outcomes, and optimal dosing regimens for heparin treated patients with acute coronary syndromes: a review of GUSTO-IIb. J Thromb Thrombolysis 2002; 14(2):91-101.
Raschke RA, Reilly BM, Guidry JR, Fontana JR, Srinivas S. The weight-based heparin dosing nomogram compared with a "standard care" nomogram. Ann Intern Med 1993; 119(9):874-81.
Hochman JS, Wali AU, Gavrila D, Sim MJ, Malhotra S, Palazzo AM, De La Fuente B. A new regimen for heparinuse in acute coronary syndromes. Am Heart J . 1999; 138(2):313-8.
Cheng S, Morrow DA Sloan S, Antman EM, Sabatine MS. Predictors of initial nontherapeutic anticoagulation withunfractionated heparin in ST-Segment elevation myocardial infarction. Circulation 2009; 119(9):1195-202.
Anand SS, Yusuf S, Pogue J, Ginsberg JS, Hirsh J;Organization to Assess Strategies for Ischemic Syndromes Investigators. Relationship of activated partial thromboplastin time to coronary events and bleeding in patients with acute coronary syndromes who receive heparin. Circulation 2003; 107(23):2884-8.
Folstad J, Caron MF, Nguyen I, White CM. Assessment of weight-based versus standard dosing of heparin in patients with unstable angina. J Clin Pharm Ther 2001; 26(4):283-6.
Gunnarsson PS, Sawyer WT, Montague D, Williams ML, Dupuis RE, Caiola SM. Appropriate use of heparin. Empiric vs nomogram-based dosing. Arch Intern Med 1995; 155(5):526-32.
Toth C, Voll C. Validation of a weight-based nomogramfor the use of intravenous heparin in transient ischemic attack or stroke. Stroke. 2002;33(3):670-4.
de Groot MR, Buller HR, ten Cate JW, van Marwijk Kooy M. Use of a heparin nomogram for treatment of patients with venous thromboembolism in a community hospital. Thromb Haemost 1998; 80(1):70-3.
Mitrovska S, Jovanova S. Correlation between the aPTT and clinical events in acute coronary syndromes treated with unfractionated heparin. Bratisl Lek Listy 2006; 107(11-12):422-5.
18 Krulder JW, van der Meer FJ, Briet E, Meinders AE. Monitoring heparin treatment with the APTT: the effect of methodological changes on the APTT. Neth J Med 1996; 49(1):13-8.
Smith ML, Vheeler KE. Weight-based heparin protocol using antifactor Xa monitoring. Am J Health-Syst Pharm 2010; 67(5):371-4.
Davydov, L, Dietz PA, Lewis P, Twichell ML, Bertino JS. Outcomes of Weight-Based Heparin Dosing Based on Literature Guidelines and Institution Individualization.Pharmacotherapy 2000; 20(10):1179-83.
Lee CH, Tan E, Wong HB, Tay E, Tan HC. Impact of different Asian ethnic groups on correlation between heparin dose, activated clotting time and complications in percutaneous coronary intervention. Int J Cardio 2008; 130(3):500-2.
Becker RC, Ball SP, Eisenberg P, Borzak S, Held AC, Spencer F, Voyce SJ, Jesse R, Hendel R, Ma Y, Hurley T, Hebert J. A randomized multicenter trial of weighadjusted intravenous heparin dose titration and point of care coagulation monitoring in hospitalized patients with active thromboembolic disease. Am Heart J 1999; 137:59-71.
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| Issue | Vol 51, No 2 (2013) | |
| Section | Articles | |
| Keywords | ||
| Acute coronary syndrome Nomogram Unfractionated heparin | ||
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