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ANTITHROMBOTIC AND THROMBOLYTIC THERAPY - ACCP GUIDELINES

 RESPONSE This summary of the Seventh American College of Chest Physicians Conference on Antithrombotic and Thrombolytic Therapy Guidelines (2004) consists primarily of class 1A recommendations (ie, strongly recommended items that can apply to most patients in most circumstances without reservation). Class 1C+ guidelines (ie,strongly recommended items that can apply to most patients in most circumstances) pertaining to pregnant or pediatric patients were also included. PREVENTION OF VENOUS THROMBOEMBOLISMThe Seventh American College of Chest Physicians (ACCP) Conference on Antithrombotic and Thrombolytic Therapy developed the following recommendations for the prophylaxis of venous thromboembolism (VTE) [1]:General Recommendations: Use of aspirin alone NOT recommendedConsider manufacturer guidelines for each of the antithrombotic agentsConsider renal impairment and the elderly when deciding on doses of LMWH, fondaparinux, direct thrombin inhibitors, and other antithrombotic drugs.General Surgery: Other than early and persistent mobilization, specific prophylaxis is NOT recommended for low risk general surgery patients undergoing minor procedures, are under 40 years of age, and have no additional risk factorsLow dose unfractionated heparin (LDUH), 5000 Units twice daily, or low molecular weight heparin (LMWH), up to 3400 Units once daily, for moderate-risk general surgery patients; moderate risk patients: those with risk factors for VTE undergoing a nonmajor procedure, those between 40 to 60 years of age without additional risk factors undergoing a nonmajor procedure, or those less than 40 years of age undergoing major operation with no additional risk factorsLDUH, 5000 Units three times daily, or LMWH, more than 3400 Units daily, for higher-risk general surgery patients; high risk patients: those greater than 60 years of age undergoing nonmajor surgery, those with additional risk factors undergoing nonmajor surgery. those greater than 40 years of age undergoing major surgery or those with additional risk who are undergoing major surgeryLDUH, three times a day, or LMWH, greater than 3400 units daily, combined with graduate compression stockings (GCS) and/or intermittent pneumatic compression (IPC) for high risk general surgery patients with multiple risk factorsVascular Surgery: LDUH or LMWH for patients undergoing major vascular surgical procedures with additional thromboembolic risk factorsThromboprophylaxis NOT routinely recommended on patients without additional thromboembolic risk factorsGynecologic Surgery: Other than early and persistent mobilization, specific prophylaxis is NOT recommended for gynecologic surgery patients undergoing brief procedures (30 minutes or less) for benign disease.Thromboprophylaxis for all major gynecologic surgery patientsLDUH, 5000 Units twice daily, for patients undergoing major gynecologic surgery for benign disease with no additional risk factorsAlternative, LMWH of 3400 Units or less once per day or IPC started just before surgery and continuously while patient is not ambulating. LDUH, 5000 Units three times daily, or LMWH, greater than 3400 Units daily, for patients undergoing extensive surgery for malignancy and for patients with additional risk factorsAlternative, IPC alone until hospital discharge.Continue treatment until hospital discharge for patients undergoing major gynecological procedures,

and for 2 to 4 weeks after hospital discharge for patients who are at high risk, have undergone cancer surgery and who are >60 years of age or have previously experienced a venous thromboembolic event.Urologic Surgery: Other than early and persistent mobilization, specific prophylaxis is NOT recommended when the patients are undergoing transurethral or other low risk urological proceduresLDUH twice daily or three times daily in patients undergoing major, open urologic proceduresAlternative, prophylaxis with LMWHLDUH or LMWH combined with IPC or GCS for patients with multiple risk factorsLaproscopic Surgery: Routine thromboprophylaxis, other than aggressive mobilization, NOT recommended in patients undergoing laproscopic surgeryThromboprophylaxis with one or more of LDUH, LMWH, IPC, or GCS is recommended for laparoscopic procedures in patients who have additional thromboembolic risk factorsTotal Hip Replacement: For elective total hip replacement, one of the following: low molecular weight heparin (LMWH) at usual high-risk dose, started 12 hours before surgery or 12 hours to 24 hours after surgery, or 4 hours to 6 hours after surgery at one-half the usual high-risk dose then increasing to usual high-risk dose on the following dayfondaparinux 2.5 milligrams started 6 hours to 8 hours after surgeryadjusted-dose vitamin K antagonist (VKA) started preoperatively or evening after surgery; target INR 2.5, range 2 to 3Administer for at least 10 daysExtended prophylaxis (28 to 35 days postoperatively) with LMWH, a VKA, or fonadaparinux is recommendedRecommend AGAINST use of aspirin, dextran, low dose unfractionated heparin, graduated compression stockings, intermittent pneumatic compression, or venous foot pump as only method of thromboprophylaxis in total hip replacement patientsTotal Knee Arthroplasty: For patients undergoing total knee arthroplasty, routine thromboprophylaxis with low molecular weight heparin at usual high-risk dose, fondaparinux, or adjusted-dose vitamin K antagonist (target INR 2.5, range 2 to 3) for at least 10 daysUse of aspirin or low dose unfractionated heparin NOT recommended as sole method of thromboprophylaxis in patients undergoing total knee arthroplastyKnee arthroscopy: Other than early and persistent mobilization, specific prophylaxis is NOT recommendedLMWH for patients undergoing arthroscopic knee surgery who are at a higher than usual risk based on preexisting VTE risk factors or following a prolonged or complicated procedure.Hip fracture surgery: At least 10 days of thromboprophylaxis with low molecular weight heparin (LMWH; using high-risk dose), fondaparinux (2.5 milligrams daily), a vitamin K antagonist (VKA; target INR 2.5, range 2 ro 3) or LDUH for patients undergoing hip fracture surgeryExtended prophylaxis (28 to 35 days postoperatively) with fondaparinux, LMWH, or a VKA is recommendedUse of aspirin NOT recommended as sole method of thromboprophylaxisLDUH or LMWH to be initiated between hospital admission and surgery, if the surgery is to be delayedOther Major Orthopedic Surgery: Decision about timing of start of pharmacologic thromboprophylaxis based on efficacy-to-bleeding tradeoffs for that agent; for low molecular weight heparin, only small differences between preoperative or postoperative initiation of therapy are seen therefore both options are acceptable

Routine use of Doppler ultrasonography screening at time of hospital discharge in asymptomatic patients NOT recommendedElective Spine Surgery: Low dose postoperative LDUH alone as prophylaxis for patients with additional risk factorsAlternative, prophylaxis with LMWH alone or perioperative IPC aloneLDUH or LMWH combined with GCS and/ or IPC for patients with multiple risk factors for venous thromboembolism (VTE)Isolated lower extremity injuries: Thromboprophylaxis NOT recommended in patients with isolated lower extremity injuriesNeurosurgery: Routine thromboprophylaxis should be usedIPC, with or without GCS, for patients undergoing intracranial neurosurgeryTrauma: If possible, thromboprophylaxis for patients with at least one risk factor for venous thromboembolismLow molecular weight heparin prophylaxis should be started as soon as it is safe, if no major contraindications existThromboprophylaxis should be continued until hospital discharge, including inpatient rehabilitationLMWH or VKA (target INR: 2.5; INR range 2.0 to 3.0) continued after discharge of patients with major impaired mobility.Acute Spinal Cord Injury: Thromboprophylaxis recommended for all patientsSingle modality prophylaxis with low dose unfractionated heparin, graduated compression stockings, or intermittent pneumatic compression NOT recommendedIPC and/ or GCS recommended when anticoagulant prophylaxis is contraindicated early after injuryBurns: LDUH or LMWH initiation, as soon as it is considered safe, for burn patients with additional risk factors for VTE, and who have no other contraindications. Additional risk factors include one or more of the following: advanced age, morbid obesity, extensive or lower extremity burns, concomitant lower extremity trauma, use of femoral venous catheter, and/ or prolonged immobilityMechanical prophylaxis with GCS or IPC for patients who have risk factors for VTE but also have a contraindication to anticoagulant prophylaxisMedical conditions: Prophylaxis with low dose unfractionated heparin or low molecular weight heparin indicated in acutely ill hospitalized patients with congestive heart failure or severe respiratory disease, or who are confined to bed and have one or more risk factors, including active cancer, previous venous thromboembolism, sepsis, acute neurologic disease, or inflammatory bowel diseaseCancer: Cancer patients undergoing surgery should receive prophylaxis appropriate for their current risk stateHospitalized, acutely ill cancer patients who are bedridden should receive prophylaxis appropriate for their current risk stateLMWH and fixed dose warfarin NOT recommended as prophylaxis to thrombosis related to long term indwelling central venous cathetersCritical Care: Assess all patients for risk of venous thromboembolism upon admission to critical care unit, most patients should receive thromboprophylaxisMechanical prophylaxis with GCS or IPC for all patients at high risk for bleeding, until the bleeding risk decreases.Low dose unfractionated heparin or low molecular weight heparin (LMWH) prophylaxis for patients in ICU at moderate risk for venous thromboembolism (eg, medically ill or post-operative patients); LMWH prophylaxis for patients at higher risk (eg, following major trauma or orthopedic surgery)Long distance travel:

For flights longer than 6 hours duration, avoid constrictive clothing around lower extremities or waist, avoid dehydration, stretch calf muscles frequentlyFor travelers with additional risk factors for venous thromboembolism and if active prophylaxis is being considered, additional measures can be used such as below-knee graduated compression stockings providing 15 to 30 mm Hg of pressure at the ankle, or single prophylactic dose of low molecular weight heparin injected prior to departureAspirin NOT recommended for venous thromboembolism prophylaxis associated with travelDEEP VENOUS THROMBOSIS - TREATMENTThe Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy developed the following recommendations for the treatment of acute deep vein thrombosis (DVT) [2]:Patients with confirmed DVT, short term therapy with subcutaneous low molecular weight heparin (LMWH) or subcutaneous or intravenous unfractionated heparin (UFH)Patients with a high clinical suspicion of DVT, begin anticoagulant treatment while waiting for outcomes of diagnostic testingPatients with acute DVT, treat initially with LMWH or UFH for at least 5 daysAddition of a vitamin K antagonist (VKA) to LMWH or UFH therapy started on the first treatment dayFor intravenous UFH administered by continuous infusion, dose adjust to achieve and maintain an aPTT prolongation corresponding to plasma heparin levels from 0.3 to 0.7 IU/ml anti-Xa activity by amidolytic assayPatients with acute DVT, subcutaneous UFH is an adequate alternative to intravenous UFHPatients who receive SC UFH, initial dose is 35000 U/24h, with subsequent dosing to maintain a therapeutic aPTT Discontinue heparin when the INR is at least 2 and stableLMWH therapy preferred over UFH as an outpatient if possible and as inpatient if necessaryRoutine monitoring with anti-factor Xa levels in patients treated with LMWH, routine use of intravenous thrombolytic therapy, routine use of vena cava filter in addition to anticoagulants, NOT recommendedDose adjustments of VKA to maintain a target INR of 2.5 (range, 2 to 3) for all treatment durations; high-intensity and low-intensity VKA therapy NOT recommendedAdminister longer term treatment with VKA in patients with a first episode of DVT secondary to a transient risk factor (at least 3 months of treatment), in patients with a first episode of idiopathic DVT (6 to 12 months of treatment)Patients with a first episode of DVT with documented antiphospholipid antibodies or who have tow or more thrombophilic conditions, continue treatment for 12 months, and anticoagulant therapy indefinitelyLonger term treatment (6 to 12 months) in patients with first DVT episode who also have a documented protein C or S deficiency, the factor V Leiden or prothrombin 20210 gene mutation, homocysteinemia or high factor VIII levels (greater than 90th percentile of normal)LMWH for first 3 to 6 months of long-term anticoagulant therapy in patients with DVT and cancer and indefinite anticoagulation therapy or until the cancer is resolved.PULMONARY EMBOLISM - TREATMENTThe Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy made the following recommendations for the treatment of acute pulmonary embolism (PE) [2]:Patients with confirmed nonmassive PE, short term therapy with subcutaneous low molecular weight heparin (LMWH) or intravenous unfractionated heparin (UFH)Patients with a high clinical suspicion of PE, begin anticoagulant treatment while waiting for outcomes of diagnostic testingAddition of a vitamin K antagonist (VKA) to LMWH or UFH therapy started on the first treatment dayDiscontinue heparin when INR is stable and at least 2For intravenous UFH administered by continuous infusion, dose adjust to achieve and maintain an aPTT prolongation corresponding to plasma heparin levels from 0.3 to 0.7 IU/ml anti-Xa activity by amidolytic assay

LMWH therapy preferred over UFH in patients with acute nonmassive PERoutine monitoring with anti-factor Xa levels, routine use of systemic thrombolytic therapy, NOT recommendedDose adjustments of vitamin K antagonists to maintain a target INR of 2.5 (range, 2 to 3) for all treatment durations; high-intensity and low-intensity VKA therapy NOT recommendedLonger term treatment with vitamin K antagonists in patients with a first episode of PE secondary to a transient risk factor (at least 3 months) or in patients with a first episode of idiopathic PE (6 to 12 months)Patients with a first episode of PE with documented antiphospholipid antibodies or who have two or more thrombophilic conditions, continue treatment for 12 months, and anticoagulant therapy indefinitelyLonger term treatment (6 to 12 months) in patients with first PE episode who also have a documented antithrombin, protein C or S deficiency, the factor V Leiden or prothrombin 20210 gene mutation, homocysteinemia or high factor VIII levels (greater than 90th percentile of normal). Indefinite treatment for patients with idiopathic PELMWH for first 3 to 6 months of long-term anticoagulant therapy in patients with PE and cancerACUTE UPPER EXTREMITY DVTThe Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy made the following recommendations for the treatment of acute upper extremity DVT [2]:Patients with acute upper-extremity DVT, treat with UFH or LMWH, and long term with VKA.VENOUS THROMBOEMBOLISM - TREATMENT DURING PREGNANCYIn pregnant women with acute venous thromboembolism, ACCP guidelines recommend adjusted-dose low molecular weight heparin (LMWH) throughout pregnancy or intravenous unfractionated heparin (bolus, then continuous infusion to maintain aPTT in therapeutic range) for at least 5 days, then adjusted-dose unfractionated heparin or LMWH for remainder of pregnancy. Administer anticoagulants for at least 6 weeks postpartum [3].ATRIAL FIBRILLATIONThe Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy made the following recommendations for the management of atrial fibrillation [4]:Patients with atrial fibrillation (AF) of at least 48 hours or of unknown length of time and the pharmacologic or electric cardioversion is planned, anticoagulation with an oral VKA, such as warfarin, with a range of 2.0 to 3.0 and a target INR of 2.5, for three weeks before elective cardioversion and for at least four weeks after successful cardioversion.For patients with persistent or paroxysmal AF at high risk of stroke (prior ischemic stroke, transient ischemic attack or systemic embolism, age greater than 75 years, moderately or severely impaired left ventricular systolic function and/or history of congestive heart failure, history of hypertension, or diabetes mellitus), use an oral vitamin K antagonist, such as warfarin (target INR 2.5, range 2 to 3)For patients with persistent or paroxysmal AF at intermediate risk of stroke (age 65 to 75 years, no other risk factors) antithrombotic therapy with either an oral vitamin K antagonist, such as warfarin (target INR 2.5, range 2 to 3), or aspirin (325 milligrams per day)ATRIAL FLUTTERThe Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy made the following recommendations for the management of atrial flutter [4]:Patients with atrial flutter and mitral stenosis, recommend anticoagulation with oral VKA, such as warfarin, with a range of 2.0 to 3.0 and a target INR of 2.5Patients with atrial flutter and prosthetic heart valves, anticoagulation with an oral VKA, such as warfarinMITRAL VALVE PROLAPSEThe Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy recommends long term aspirin therapy (50 to 162 milligrams per day) for patients with mitral valve prolapse who have documented but unexplained transient ischemic attacks (TIAs) [5].PROSTHETIC HEART VALVES - Mechanical Prosthetic Heart Valves

The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy recommend for all patients with mechanical prosthetic heart valves VKA, unfractionated heparin or LMWH until the INR is stable and at a therapeutic level for two consecutive days [4].Patients with mechanical prosthetic heart valves who suffer systemic embolism despite a therapeutic INR , use aspirin, 75 to 100 milligrams per day (mg/day), in addition to VKA, and maintenance of the INR at target of 3.0 and a range of 2.5 to 3.5

Type of Heart valveTarget INR

Range INR

St Jude medical bileaflet valve in the aortic position 2.52.0 to 3.0

tilting disk valves and bileaflet mechanical valves in the mitral position 3.02.5 to 3.5

CarboMedics bileaflet valve in the aortic position, normal left atrium size and sinus rhythm

2.52.0 to 3.0

Medtronic Hall tilting disk mechanical valves in the aortic position, normal left atrium size and sinus rhythm

2.52.0 to 3.0

mechanical valves and additional risk factors (AF, myocardial infarction, left atrial enlargement, endocardial damage, and low ejection fraction)*

3.02.5 to 3.5

caged ball or caged disk valves* 3.02.5 to 3.5

* combined with low doses of aspirin, 75 to 100 mg/day

PROSTHETIC HEART VALVES - Bioprosthetic ValvesThe Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy made the following recommendations for the management of patients with bioprosthetic valves [4]:

All patients with who have received bioprosthetic heart valves VKA with unfractionated heparin or LMWH until the INR is stable and at a therapeutic level for two consecutive days Patients with bioprosthetic valves in the mitral position, VKA with a target INR of 2.5 and a range of 2.0 to 3.0, for the first three months after valve insertion Patients with bioprosthetic valves in the aortic position, VKA with a target INR of 2.5 and a range of 2.0 to 3.0, for the first three months after valve insertion or aspirin 80 to 100 mg/dayPatients with bioprosthetic valves who have a history of systemic embolism, VKA for 3 to 12 monthsPatients with bioprosthetic valves who have AF, long term treatment with VKA with a target INR of 2.5 (range 2.0 to 3.0)Patients with bioprosthetic valves who are in sinus rhythm and do not have AF, long term treatment therapy with aspirin, 75 to 100 mg/daySTROKEThe Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy made the following recommendations for the treatment of acute ischemic stroke [6]:For eligible patients, within 3 hours of symptom onset, intravenous tissue plasminogen activator (tPA; 0.9 milligrams per kilogram; maximum 90 milligrams), 10% of dose as initial bolus, remainder infused over 60 minutes Eligible patients: At least 18 years old with a clinical diagnosis of stroke with clinically meaningful neurologic deficitOnset less than 180 minutesBaseline CT showing no evidence of intracranial hemorrhageExcluded patients: Minor or rapidly improving signs and symptomsSigns of or history of intracranial hemorrhage; symptoms of subarachnoid hemorrhage or post-

myocardial infarction pericarditisSeizure at onset of strokeStroke or serious head injury within 3 months, major surgery or serious trauma within 2 weeksGastrointestinal or urinary tract hemorrhage within 3 weeksSystolic blood pressure greater than 185 mmHg or diastolic blood pressure greater than 110 mmHgAggressive therapy used to lower blood pressure, or to treat blood glucose less than 50 milligrams/deciliter (mg/dL) or greater than 400 mg/dLArterial puncture at a noncompressible site or lumbar puncture within 1 weekPlatelet count less than 100,000/microliterHeparin therapy within 48 hours associated with elevated activated partial thromboplastin timeCurrent oral anticoagulant therapy (prothrombin time greater than 15 seconds, INR greater than 1.7)Pregnant or lactating womenIntravenous streptokinase NOT recommended between 0 and 6 hours of symptom onsetFor patients not eligible for thrombolytic therapy, early aspirin therapy (160 to 325 milligrams per day)For acute stroke patients with limited mobility, prophylactic low-dose subcutaneous heparin or low molecular weight heparins or heparinoids to prevent deep vein thrombosis and pulmonary embolismAntiplatelet treatment consisting of aspirin 50 milligrams (mg) to 325 mg/day OR combination aspirin 25 mg and extended-release dipyridamole 200 mg twice daily OR clopidogrel 75 mg/dayPatients at moderate to high risk of bleeding complications, low doses of aspirin 50 to 100 mg/day in Patients allergic to aspirin, use clopidogrelAntiplatelet agents preferred over oral anticoagulationFor patients undergoing carotid endarterectomy, aspirin (81 to 325 milligrams per day) prior to and following the procedureThe ACCP guidelines for the prevention of cardioembolic cerebral ischemic events are as follows [6]:In patients with atrial fibrillation with a recent stroke or TIA, long term anticoagulation with target INR of 2.5 (range, 2 to 3)For patients with cardioembolic stroke with contraindications to anticoagulant therapy, aspirin should be usedPatients with stroke associated with aortic atherosclerotic lesions, use antiplatelet therapyPatients with cryptogenic ischemic stroke and patent foramen ovale (PFO), use antiplatelet therapy Patients with mitral valve strands or prolapse, with a history of TIA or stroke, use antiplatelet therapyACUTE CORONARY SYNDROMEThe Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy made the following recommendations for the management of non-ST-elevation acute coronary syndrome (NSTE ACS) [7]:For patients presenting with NSTE ACS, oral aspirin 75 milligrams (mg) to 325 mg immediately, then 75 mg to 162 mg dailyFor NSTE ACS patients with aspirin allergy, immediate treatment with clopidogrel, 300 mg oral bolus, followed by 75 mg per day indefinitelyIf diagnostic catheterization will be delayed or coronary bypass surgery will not occur for at least 5 days following coronary angiography, clopidogrel 300 mg as bolus therapy followed by 75 mg/day for 9 to 12 months with aspirinIn moderate to high-risk NSTE ACS patients, eptifibatide or tirofiban added to aspirin and heparin for initial treatmentAbciximab treatment NOT recommended as initial therapy except when coronary anatomy is known and percutaneous coronary intervention (PCI) is planned within 24 hoursUnfractionated heparin preferred over no heparin for short term use with antiplatelet therapiesWeight based dosing of UFH and maintenance of aPTT between 50 s and 75 sThe Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy made the following recommendations for the management of acute coronary syndrome (ACS) with and without ST-segment elevation [7]:

Aspirin therapy at initial doses of 160 milligrams (mg) to 325 mg, then indefinite therapy of 75 mg to 162 mg per dayLower doses of aspirin (100mg or less) are recommended if there is a history of aspirin-induced bleeding or risk factors for bleedingIf aspirin is contraindicated or not tolerated, clopidogrel (75 mg/day) for long term therapyOral aspirin therapy (75 milligrams to 162 milligrams) is recommended for the management of chronic, stable coronary artery disease [7].The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy recommends patients with congestive heart failure with or without CAD receive aspirin whether or not they are receiving ACE inhibitors [7].ACUTE MYOCARDIAL INFARCTIONFor the treatment of acute myocardial infarction, the guidelines developed at the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy recommend [8]:Use of any approved fibrinolytic agent for patients with ischemic symptoms characteristic of acute myocardial infarction of 12 hours duration or less and ST-segment elevation or left bundle-branch block on electrocardiogram; alteplase or tenecteplase is recommended over streptokinase in patients with a symptom duration of 6 hours or lessUse of streptokinase, anistreplase, alteplase, reteplase, or tenecteplaseFor symptom duration of 6 hours or less, alteplase or tenecteplase is recommendedAlteplase, reteplase or tenecteplase are recommended in patients with known allergy or sensitivity to streptokinaseIf prehospital administration of fibrinolytic therapy is feasible and primary angioplasty unavailable, prehospital fibrinolytic therapy onlyFor acute myocardial infarction patients who are candidates for fibrinolytic therapy, treatment initiation within 30 minutes of arrival to the hospital or first contact with health care systemFibrinolytic therapy NOT recommended if there is a history of intracranial hemorrhage, closed head trauma, or ischemic stroke in previous three monthsFor adjunctive treatment in patients with acute ST elevation myocardial infarction, with or without fibrinolytic therapy, aspirin (160 milligrams (mg) to 325 mg orally) at initial evaluation followed by 75 mg to 162 mg per day indefinitelyIf there is a high risk of systemic or venous thromboembolism (anterior MI, pump failure, previous embolus, atrial fibrillation, or left ventricular thrombus), use intravenous UFH with streptokinaseFor patients with known or suspected heparin-induced thrombocytopenia receiving fibrinolytic therapy, administration of hirudin with tPAPERCUTANEOUS CORONARY INTERVENTIONThe Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy made the following recommendations for patients undergoing percutaneous coronary intervention (PCI) [9]:Aspirin pretreatment (75 milligrams (mg) to 325 mg), followed by aspirin 75 mg to 162 mg per day for long term treatment after PCILower doses of aspirin (75 to 100 mg/day) for long term treatment in patients receiving antithrombotic agents, such as clopidogrel or warfarinIn patients who have undergone stent placement, combination therapy with aspirin and thienopyridine derivative (ticlopidine or clopidogrel) preferred over systemic anticoagulation therapy; clopidogrel preferred over ticlopidineClopidogrel (75 mg/day) in addition to aspirin for at least 9 to 12 months after PCIFor patients with low atherosclerotic risk (eg, isolated coronary lesion), clopidogrel for at least 2 weeks after bare metal stent placement, for 2 to 3 months after placement of a sirolimus-eluting stent, and after 6 months after placement of paclitaxel-eluting stentGP IIb-IIIa antagonist such as abciximab or eptifibatide for all patients undergoing PCI, particularly those undergoing primary PCI or those with refractory unstable angina or other high-risk featuresAbciximab administered as 0.25 mg per kilogram (mg/kg) bolus followed by 12 hour infusion at rate of 10 micrograms per minute

Eptifibatide administered as double bolus (each 180 micrograms per kilogram, 10 minutes apart) followed by 18 hour infusion of 2 micrograms per kilogram per minuteTirofiban NOT recommended as alternative to abciximabFor patients with non-ST-segment elevation myocardial infarction/unstable angina (NSTEMI/UA) rated moderate-to-high risk based on Thrombolysis in Myocardial Infarction (TIMI) score, upstream use of GP IIb-IIIa antagonist (eptifibatide or tirofiban) started as soon as possible prior to PCIIn NSTEMI/UA patients with elevated troponin level, start abciximab within 24 hours prior to PCIPatients not receiving a GP IIb-IIIa inhibitor, weight adjusted heparin bolus of 60 to 100 international units/ kilogram (IU/kg) should be administered in doses to produce an activated clotting time (ACT) 250s to 350sFor uncomplicated PCI, routine postprocedural heparin infusion NOT recommendedFor patients who do not receive GP IIb-IIIa antagonist, bivalirudin (0.75 mg/kg bolus followed by infusion of 1.75 mg/kg per hour for duration of PCI) preferred over heparin during PCIRoutine warfarin or other vitamin K antagonists NOT recommended after PCI in patients with no other indication for systemic anticoagulation therapyCORONARY ARTERY BYPASS GRAFTINGThe Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy made the following recommendations for the prevention of saphenous vein graft occlusion following coronary artery bypass grafting (CABG) [10]:Aspirin (75 milligrams (mg) to 162 mg per day) treatment for indefinite period of time for all patients with coronary artery diseasePostoperative aspirin (75 mg to 162 mg/day) starting 6 hours after CABG procedure preferred over preoperative aspirinAddition of dipyridamole to aspirin therapy NOT recommended in patients undergoing CABGClopidogrel 300 mg loading dose 6 hours postoperatively followed by 75 mg/day, for coronary artery disease patients undergoing CABG and who are allergic to aspirinClopidogrel (75 mg/day) in addition to aspirin for 9 to 12 months following procedure, in patients undergoing CABG for non-ST-segment elevation acute coronary syndromeAspirin (75 mg to 162 mg per day) treatment for indefinite period of time for all patients with coronary artery disease who undergo internal mammary artery bypass graftingPERIPHERAL ARTERIAL OCCLUSIVE DISEASEThe Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy guidelines for the management of peripheral arterial occlusive disease are as follows [11]:Chronic limb ischemia: Lifelong aspirin therapy (75 milligrams (mg) to 325 mg per day) preferred over no antiplatelet therapy in patients with clinically manifest coronary or cerebrovascular disease and in patients without clinically manifest coronary or cerebrovascular diseaseClopidogrel recommended over ticlopidine and over no antiplatelet therapyAnticoagulants NOT recommended in patients with intermittent claudicationVascular grafts: Unfractionated heparin at time of application of vascular cross-clamps for patients undergoing major vascular reconstructionAspirin therapy in patients undergoing prosthetic infrainguinal bypassVitamin K antagonists plus aspirin NOT recommended for routine use in patients without special risk factors for occlusion undergoing infrainguinal bypassCarotid endarterectomy: Aspirin (75 milligrams (mg) to 325 mg per day) should be given preoperatively and continued indefinitelyAsymptomatic and recurrent carotid stenosis: Lifelong aspirin therapy, 75 to 162 mg/day, for nonoperative patients with asymptomatic or recurrent carotid stenosisLower extremity endovascular procedures:

Long-term aspirin therapy, 75 to 162 mg/day, for lower extremity balloon angioplasty, with or without stentingHEPARIN-INDUCED THROMBOCYTOPENIA, TREATMENTNonheparin anticoagulant (eg, lepirudin, argatroban, bivalirudin, or danaparoid), in confirmed, or strongly suspected HIT, whether or not complicated by thrombosis. LMWH NOT recommended [12].HEPARIN-INDUCED THROMBOCYTOPENIA, PREVENTIONLow molecular weight heparin (LMWH) is preferred over unfractionated heparin (UFH) in postoperative orthopedic surgery patients for the prevention of heparin-induced thrombocytopenia. For the treatment of thrombosis, porcine UFH or LMWH is preferred over bovine UFH [12].PEDIATRICSThe Seventh American College of Chest Physicians (ACCP) Conference on Antithrombotic and Thrombolytic Therapy made the following recommendations for pediatric patients with systemic venous thromboembolic disease [13]:When the first thromboembolic event occurs in children older than 2 months, intravenous heparin to prolong aPTT to range corresponding to an anti-FXa level of 0.35 to 0.7 Units per milliliter, or with low molecular weight heparin (LMWH) to achieve an anti-FXa level of 0.5 to 1 Units per milliliter 4 hours after injection is recommendedInitial treatment with heparin or LMWH should continue for 5 to 10 days. If subsequent therapy will include vitamin K antagonists, begin oral therapy on day 1 and discontinue heparin/LMWH on day 6 if INR is within therapeutic range for 2 consecutive days. Longer duration of heparin/LMWH therapy is recommended in cases of massive pulmonary embolism or extensive deep vein thrombosisThe ACCP recommends using adult guidelines for pediatric patients with prosthetic heart valves [13].The use of intravenous heparin prophylaxis is recommended in neonates and children requiring cardiac catheterization via an artery [13].To prolong catheter patency in neonates and children with peripheral arterial catheters in situ, low-dose heparin through the catheter, preferably by continuous infusion, is recommended [13].For the treatment of Kawasaki disease, the ACCP recommendations are [13]:High dose aspirin therapy (80 to 100 milligrams per kilogram per day) during acute phase, for up to 14 days as an anti-inflammatory agent, then lower doses (3 to 5 milligrams per kilogram per day) for at least 7 weeks as an antiplatelet agentIntravenous gammaglobulin (2 grams per kilogram as a single dose) within 10 days of symptom onset

 CONCLUSION The Seventh ACCP Consensus Conference on Antithrombotic Therapy (2004) extensively reviewed all related literature and produced a set of recommendations for antithrombotic and thrombolytic therapy. However, the decision to initiate therapy should be based on the individual patient's particular risk for thrombosis combined with current knowledge and the recommendations .

 Reference 1. Geerts WH, Pineo GF, Heit JA, et al: Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.. Chest 2004; 126(3 Suppl):338S-400S.

2. Buller HR, Agnelli G, Hull RD, et al: Antithrombotic therapy for venous thromboembolic disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126(3 Suppl)::401S-428S.

3. Bates SM, Greer IA, Hirsh J, et al: Use of antithrombotic agents during pregnancy: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126(3 Suppl):627S-644S.

4. Singer DE, Albers GW, Dalen JE, et al: Antithrombotic therapy in atrial fibrillation: the seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest 2004; 126:429S-456S.

5. Salem DN, Stein PD, Al-Ahmed A, et al: Antithrombotic therapy in valvular heart disease - native and prosthetic: the seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest 2004; 126:457S-482S.

6. Albers GW, Amarenco P, Easton JD, et al: Antithrombotic and thrombolytic therapy for ischemic stroke: the Seventh ACCP Conference on antithrombotic and thrombolytic therapy. Chest 2004; 126(3 Suppl):483S-512S.

7. Harrington RA, Becker RC, Ezekowitz M, et al: Antithrombotic therapy for coronary artery disease: the seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest 2004; 126(3):513S- 548S.

8. Menon V, Harrington RA, Hochman JS, et al: Thrombolysis and adjunctive therapy in acute myocardial infarction: the seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest 2004; 126(Suppl 3):549S- 575S.

9. Popma JJ, Berger P, Ohman EM, et al: Antithrombotic therapy during percutaneous coronary intervention: the seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest 2004; 126(3):576S-599S.

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