Summary: <a href="http://journal.publications.chestnet.org/issue.aspx?journalid=99&issueid=23443&direction=P"></a><br> From American College of Chest Physicians<br> <a href="http://journal.publications.chestnet.org/issue.aspx?journalid=99&issueid=23443&direction=P">Antithrombotic Therapy and Prevention of Thrombosis</a>, 9th ed Guidelines<br> <br> <a href="http://journal.publications.chestnet.org/article.aspx?articleid=1159399">Chest 2012;141:7S-47S</a> (Executive Summary)<br> <br> For outpatient treatment, start 10 mg daily for the first 2 days followed by INR measurements<br> <br> Give 1 day of LMWH or UFH before initiation, if treating VTE<br> <br> If the patient is on VKAs, avoid NSAIDs and certain ABX (table 8 from full guidelines)<br> <br> <br> <br> Avoid anti-plt agents unless clinical condition warrants<br> <br> Normal goal is 2-3, including antiphospholipid<br> <br> No need to taper when d/cing<br> <br> Heparin – 80/18 for VTE, 70/15 for cardiac or stroke patients<br> <br> For outpatients with VTE treated with SC UFH, they suggest weight-adjusted dosing (first dose 333 units/kg, then 250 units/kg) without monitoring rather than fixed or weight-adjusted dosing with monitoring<br> High INRs<br> 4.5-10, no bleeding: no vitamin K necessary<br> <br> > 10, no bleeding: Oral Vitamin K<br> <br> If anticoagulant related major bleeding: 4-factor PCC and Vitamin K Slow IV Injection<br> <br> See Michelle Lin’s Paucis Verbis on the same<br> Critically Ill Patients<br> Recommend against routine screening<br> <br> Use LMWH or LDUH in all patients unless contra-indicated<br> <br> For travelers at risk of VTE, use graded compression stockings; do not prescribe aspirin or anticoagulants<br> Diagnosis of DVT<br> Low Risk<br> moderate sens d-dimer, high sens d-dimer, or CUS of proximal veins only. D-dimers are preferred<br> <br> If d-dimer is positive, get Compression Ultrasound (CUS) of proximal veins<br> Moderate Risk<br> Use High sens d-dimer, CUS of prox, or CUS of whole leg<br> <br> Can stop if high-sens D-dimer is negative<br> <br> If no d-dimer or d-dimer postive, need a second CUS 1 week later if only prox CUS done<br> <br> If whole leg CUS is negative, you are done<br> High Risk<br> Prox CUS or Whole Leg CUS<br> <br> If prox CUS and d-dimer negative as well, done<br> <br> If d-dimer positive or only prox CUS, get 1 week f/u CUS<br> <br> If whole leg CUS is negative, you are done<br> Recurrent<br> In patients with past DVT, recommend high-sens d-dimer, if positive get Prox CUS and 1 week Prox CUS<br> <br> If negative, get just one Prox CUS<br> <br> If the old CUS is not available, confirm with venography if positive CUS<br> Upper Ext<br> Go right to Doppler CUS for upper extremity dvt suspicion<br> Treatment of DVT<br> Start with IV or SQ UFH, LMWH, or fondaparinux (Latter two preferred)<br> <br> If high pretest, start heparin immediately; If moderate, start heparin only if diagnostic tests are expected to be > 4 hours delayed<br> <br> Isolated distal DVT-serial CUS rather than treatment unless severe symptoms or risk factors for extension (see full text)<br> <br> Ambulate DVTs, no bed rest<br> <br> In patients with hypotension (SBP) < 90 and PE, give systemic thrombolytics (through peripheral, rather than PA cath)<br> Atrial Fib<br> Chads 0 – nothing<br> <br> Chads 1/2 – VKA/oral anti-coag; Dabi is preferred<br> <br> If a-fib > 48 hours; give 3 weeks of VKA/dabi before cardioversion. Or get TEE with LMWH. Follow with 1 month of Vka/oral anti-coag<br> <br> If a-fib < 48 hours; Start LMWH and then VKA for 4 weeks<br> <br> If hemodynamically unstable, treat with anticoagulation ASAP preferably before cardioversion and then continue for 4 weeks<br> <br> Treat a-flutter like a-fib for all of the above<br> Stroke<br> If hemorrhagic,
