- Author: Vera A De Palo, MD; Chief Editor: Harris Gellman, MD more...
Anticoagulant inpatient medications should include heparin or an LMWH, followed by the initiation of an oral coumarin derivative. Heparin is administered by bolus dosing, followed by a continuous infusion. The predominant coumarin derivative in clinical use in North America is warfarin sodium.
The FDA has approved the thrombolytic agents streptokinase and recombinant tissue-type plasminogen activator (rt-PA) for thrombolytic use in PE. Because antibodies to streptokinase may develop and rt-PA has increasingly been used as the first-choice thrombolytic agent.
Anticoagulant medications prevent further clot deposition. They allow the natural fibrinolytic mechanisms to lyse the existing clot.
Heparin augments the activity of antithrombin III and prevents conversion of fibrinogen to fibrin. It does not actively lyse but is able to inhibit further thrombogenesis. The drug prevents the reaccumulation of clot after spontaneous fibrinolysis.
Warfarin interferes with the hepatic synthesis of vitamin K–dependent coagulation factors. It is used for prophylaxis and treatment of venous thrombosis, PE, and thromboembolic disorders. Tailor the dose to maintain an INR in the range of 2.0-3.0.
Enoxaparin prevents DVT, which may lead to PE in patients undergoing surgery who are at risk for thromboembolic complications. The average duration of treatment is 7-14 days. Enoxaparin enhances the inhibition of factor Xa and thrombin by increasing antithrombin III activity. In addition, it preferentially increases the inhibition of factor Xa. Enoxaparin also has been approved for the treatment of DVT and PE.
Dalteparin is indicated for the prevention of DVT, which may lead to PE. It enhances the inhibition of factor Xa and thrombin by increasing antithrombin III activity. In addition, dalteparin preferentially increases the inhibition of factor Xa. The average duration of treatment is 7-14 days.
Rivaroxaban is an oral factor Xa inhibitor that inhibits platelet activation by selectively blocking the active site of factor Xa without requiring a cofactor (eg, antithrombin III) for activity. It is indicated for treatment of DVT or PE, and to reduce risk of recurrent DVT and PE following initial treatment. It is also indicated for prophylaxis of DVT in patients undergoing knee or hip replacement surgery.
Dabigatran is a direct thrombin inhibitor. Both free and clot-bound thrombin, and thrombin-induced platelet aggregation is inhibited. It is indicated for the treatment of DVT and PE in patients who have been treated with a parenteral anticoagulant for 5-10 days. It is also indicated to reduce the risk of DVT and PE recurrence in patients who have been previously treated.
Apixaban is a Factor Xa inhibitor indicated for treatment of DVT and PE. It is also indicated to reduce the risk of recurrence of DVT and PE in patients who have been previously treated.
Edoxaban is a Factor Xa inhibitor indicated for treatment of DVT and PE in patients who have been initially treated with a parenteral anticoagulant for 5-10 days.
As advanced by the American College of Chest Physicians in the "Antithrombotic Therapy and Prevention of Thrombosis Evidence-Based Clinical Practice Guidelines, 9th ed.", thrombolytic treatment is indicated for acute, massive PE with hemodynamic instability in patients who do not seem prone to bleeding. These agents dissolve recent clots promptly by activating a plasma proenzyme, plasminogen, to its active form, plasmin. Plasmin degrades fibrin to soluble peptides.
Thrombolytic therapy speeds pulmonary tissue reperfusion and rapidly reverses right heart failure. It improves pulmonary capillary blood flow and more rapidly improves hemodynamic parameters.
Reteplase is used in the management of PE in hemodynamically unstable patients. Its safety and efficacy with concomitant administration of heparin or aspirin during first 24 hours after symptom onset have not been investigated.
Tenecteplase is a modified version of alteplase made by substituting 3 amino acids. It has a longer half-life than alteplase and thus can be given as a single bolus infused over 5 seconds (as opposed to the 90 minutes required for alteplase). It appears to cause less non–intracranial bleeding than alteplase but carries a comparable risk of intracranial bleeding and stroke.
Base the dose on the patient's weight. Initiate treatment as soon as possible after the onset of AMI symptoms. Because tenecteplase contains no antibacterial preservatives, it must be reconstituted immediately before use.
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