Clinical Guide to the Use of Antithrombotic Drugs in Coronary Artery Disease

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Date Released Mar revised Aug ; republished Jun. Full Text Guideline Antithrombotics: indications and management. Implementation of the Guideline Description of Implementation Strategy. Rating Scheme for the Strength of the Recommendations Grades of Recommendation Note : The grade of recommendation relates to the strength of the evidence on which the recommendation is based.

Qualifying Statements Qualifying Statements. This guideline is not intended to be construed or to serve as a standard of care. Standards of care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge and technology advance and patterns of care evolve. Adherence to guideline recommendations will not ensure a successful outcome in every case, nor should they be construed as including all proper methods of care or excluding other acceptable methods of care aimed at the same results.

The ultimate judgement must be made by the appropriate healthcare professional s responsible for clinical decisions regarding a particular clinical procedure or treatment plan. This judgement should only be arrived at following discussion of the options with the patient, covering the diagnostic and treatment choices available. It is, however, advised that significant departures from the national guideline or any local guidelines derived from it should be fully documented in the patient's case notes at the time the relevant decision is taken.

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Recommendations within this guideline are based on the best clinical evidence. Some recommendations may be for medicines prescribed outwith the marketing authorisation product licence. This is known as "off label" use. It is not unusual for medicines to be prescribed outwith their product licence and this can be necessary for a variety of reasons.

Medicines may be prescribed outwith their product licence in the following circumstances: For an indication not specified within the marketing authorization For administration via a different route For administration of a different dose Prescribing medicines outside the recommendations of their marketing authorisation alters and probably increases the prescribers' professional responsibility and potential liability.

Literature Search for Patient Issues At the start of the guideline development process, a SIGN Information Officer conducted a literature search for qualitative and quantitative studies that addressed patient issues of relevance to early management of patients with a head injury. Evidence Tables Evidence tables are compiled by SIGN executive staff based on the quality assessments of individual studies provided by guideline development group members.

Synthesising the Evidence Guideline recommendations are graded to differentiate between those based on strong evidence and those based on weak evidence. Considered Judgment It is rare for the evidence to show clearly and unambiguously what course of action should be recommended for any given question.

Each guideline group considers the following factors: Quantity, quality, and consistency of evidence External validity generalisability of studies. Directness of application to the target population for the guideline. Any evidence of potential harms associated with implementation of a recommendation. Clinical impact i. Implementability i. Peer Review All SIGN guidelines are reviewed in draft form by independent expert referees, who are asked to comment primarily on the comprehensiveness and accuracy of interpretation of the evidence base supporting the recommendations in the guideline.

Identifying Information and Availability Bibliographic Source s. Not applicable: The guideline was not adapted from another source. This is the current release of the guideline. This guideline was republished in June The following are available: Quick reference guide: Antithrombotic therapy. SIGN A guideline developer's handbook.

Clinical guide to the use of antithrombotic drugs in coronary artery disease

Atrial fibrillation Peripheral arterial disease Cerebrovascular disease Pregnancy Patients with intravascular devices Note : The use of antithrombotic therapy in the management of established ischaemic heart disease is not included, but is covered in SIGN's suite of cardiovascular guidelines. Recommendations Major Recommendations. Antiplatelet Agents A - To minimise the risk of bleeding, the lowest recommended dose of aspirin should be used for the clinical indication. Parenteral Anticoagulation Unfractionated Heparin Initiation, Dosage and Monitoring B - In patients given treatment dose unfractionated heparin therapy, routine monitoring of the activated partial thromboplastin time APTT ratio at least daily and adjustment of heparin doses according to a local protocol, to achieve the target therapeutic range of anticoagulant effect APTT ratio is recommended.

Pharmacogenomics and Warfarin A - Pharmacogenetic testing prior to initiation of therapy with a vitamin K antagonist is not recommended. Cardioversion D - Cardioversion of AF should be considered in selected patients. Novel Antithrombotics in AF Dabigatran Etexilate A - Dabigatran etexilate can be considered as an alternative to warfarin in the management of patients with atrial fibrillation with one or more risk factors for stroke. Rivaroxaban A - Rivaroxaban can be considered as an alternative to warfarin in the management of patients with atrial fibrillation with one or more risk factors for stroke.

Apixaban A - Apixaban can be considered as an alternative to warfarin in the management of patients with atrial fibrillation with one or more risk factors for stroke. Mechanical Heart Valves D - Patients with mechanical heart valves should receive long term prophylaxis with warfarin. Acute, Obstructive Heart Valve Thrombosis D - Systemic thrombolysis is recommended for the initial treatment of acute obstructive prosthetic heart valve thrombosis. Bioprosthetic Heart Valves D - Low-dose aspirin 75 mg daily is recommended in patients with a bioprosthetic valve in the aortic position who have no other indication for VKA therapy.

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Primary Prophylaxis of Vascular Disease Aspirin A - Aspirin is not recommended for primary prevention of vascular disease when benefits are considered against the increased risk of hemorrhage. Oral Anticoagulation A - In patients with PAD who have an indication for treatment with a vitamin K antagonist aspirin should not be added to improve anticoagulation.

Parenteral Anticoagulation Intermittent Claudication B - Heparin is not indicated in the management of intermittent claudication. Thrombolytic Therapy Acute Peripheral Arterial Occlusion B - In individual patients with acute peripheral arterial occlusion catheter-directed intra-arterial CDIA is preferred to systemic thrombolysis. Cerebrovascular Disease Acute Prophylaxis of Further Vascular Events Antiplatelet Agents A - Aspirin mg should be commenced within 48 hours of ischaemic stroke and continued for at least 14 days.

Parenteral Anticoagulation A - The routine use of anticoagulants is not recommended for the treatment of acute ischaemic stroke. A - Anticoagulants are not recommended in patients with progressing stroke. Acute Stroke and Atrial Fibrillation D - In patients with AF and acute stroke: In the absence of haemorrhage, anticoagulant therapy should begin after two weeks but may be delayed in the presence of a large infarct.

In the presence of haemorrhage, anticoagulant therapy should not be given. Parenteral Thrombolytic Therapy A - Patients admitted with stroke within four and a half hours of definite onset of symptoms, who are considered suitable, should be treated with 0.

A - Onset to treatment time should be minimised. Secondary Prevention After Acute Ischaemic Stroke or Transient Cerebral Attack Antiplatelet Therapy A - Clopidogrel monotherapy 75 mg daily or aspirin 75 mg in combination with dipyridamole mg extended release twice daily should be prescribed after ischaemic stroke or transient ischaemic attack for secondary prevention of vascular events.

Myeloproliferative Disorders B - Patients with polycythaemia rubra vera should be considered for treatment with aspirin, unless there are contraindications. Patients with Cancer A - Neither warfarin nor heparin should be used routinely to prevent catheter-related deep vein thrombosis in cancer patients. Maintaining Patency of Arterial and Venous Catheters Parenteral Anticoagulation B - Normal saline should be used to maintain the patency of arterial catheters. Two recent papers explored the thin line between the risks both ischemic and hemorrhagic and benefits lower mortality in the CKD setting, analyzing the existing evidence, indicating the missing information in terms of randomized controlled trials RCTs , and highlighting the persistent need for new robust scores or algorithms to minimize hemorrhage risk while maximizing benefits [ 4 , 5 ].

Further, we identify current shortcomings and new directions for future research. Our main interest was to assess the solidity of all new recommendations from the ESC focused update document [ 1 ] in the specific subgroup of CKD patients. However, the definition used to identify CKD patients was not specified. The score is a risk model for simultaneous ischemia and bleeding. Although the presence of CKD was significantly associated with more hemorrhagic events in the study population, it was excluded as an item from the score calculator as it was not associated with thrombotic events [ 6 ].

The score quantifies the risk of bleeding and eGFR is included as a continuous variable.

The other variables that compose the score are age, hemoglobin values, white blood cell count, and the presence of previous bleeding Fig. The score ranges from 0 to WBC white blood cells. Furthermore, in the new scores, certain clinical risk factors frequently present in CKD patients advanced age, anemia, leukocytosis, and previous bleeding have been included.

The CKD population is not well defined and is poorly represented in the databases through which the scores were created and validated.