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Al-Mukhtar O, Stub D, Reid CM, Lo S, Lefkovits J, Walton A, Chew DP, Yong A, Nicholls SJ, Cox N, Peter K, Chan W. Variability in Contemporary Heparin Prescription and Activated Clotting Time Monitoring During Percutaneous Coronary Intervention: Call for Up-To-Date Evidence-Based Guidelines. Heart Lung Circ 2023; 32:1475-1481. [PMID: 37993342 DOI: 10.1016/j.hlc.2023.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 09/17/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Unfractionated heparin (UFH) is the preferred anticoagulant agent in percutaneous coronary intervention (PCI) procedures for minimising the risk of thrombotic complications. Because of the narrow therapeutic range of UFH, some society guidelines have advocated the use of the activated clotting time (ACT) test to monitor anticoagulation intensity during PCI to reduce thrombotic and bleeding complications. We aimed to assess the current practice of UFH prescription and its monitoring in Australia and New Zealand (ANZ). METHOD We conducted an anonymous voluntary cross-sectional survey of interventional cardiologists (ICs) who were members of the Cardiac Society of Australia and New Zealand in 2022. The survey included 10 questions pertaining to the current practice of anticoagulation during PCI. RESULTS Of 430 ICs surveyed, 148 responded (response rate, 34.4%). Most ICs (84.4%) prescribed 70-100 IU/kg of UFH for PCI. Over half of ICs (58.7%) routinely measured ACT during PCI, whereas only 22.2% routinely measured ACT after PCI to guide additional UFH prescription. Among ICs who prescribed additional UFH, approximately half (48%) aimed for ACT ≥250 seconds. Factors that influenced post-PCI UFH prescription included vascular access site and concomitant antiplatelet or anticoagulant therapy. CONCLUSIONS The contemporary practice of UFH prescription during PCI and ACT monitoring in ANZ is variable and based on outdated evidence preceding current drug-eluting stents, antiplatelet therapies, and radial-first practice. Current society guideline recommendations lack clarity and agreement, reflecting the quality of the available evidence. Up-to-date clinical trials evaluating UFH prescription and ACT monitoring are needed to optimise clinical outcomes in contemporary PCI procedures.
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Affiliation(s)
- Omar Al-Mukhtar
- Department of Cardiology (Monash Heart), Victorian Heart Hospital, Monash Health, Melbourne, Vic, Australia; Department of Cardiology, Northern Health, Melbourne, Victoria, Australia. http://www.twitter.com/O_AL_MUKHTAR
| | - Dion Stub
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Baker Heart and Diabetes Institute, Melbourne, Vic, Australia
| | - Christopher M Reid
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; National Health and Medical Research Council Centre of Research Excellence in Cardiovascular Outcomes Improvement, Curtin University, Perth, WA, Australia
| | - Sidney Lo
- Cardiology Department, Liverpool Hospital, Sydney, NSW, Australia
| | - Jeffrey Lefkovits
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Antony Walton
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Derek P Chew
- Department of Cardiology (Monash Heart), Victorian Heart Hospital, Monash Health, Melbourne, Vic, Australia; Victorian Heart Institute, Melbourne, Vic, Australia
| | - Andy Yong
- Department of Cardiology, Concord Repatriation General Hospital, Sydney, NSW, Australia; University of Sydney, Sydney, NSW, Australia
| | - Stephen J Nicholls
- Department of Cardiology (Monash Heart), Victorian Heart Hospital, Monash Health, Melbourne, Vic, Australia; Victorian Heart Institute, Melbourne, Vic, Australia
| | - Nicholas Cox
- Department of Cardiology, Western Health, Melbourne, Vic, Australia; Department of Medicine, Western Health, Melbourne Medical School, University of Melbourne, Melbourne, Vic, Australia
| | - Karlheinz Peter
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Baker Heart and Diabetes Institute, Melbourne, Vic, Australia
| | - William Chan
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Baker Heart and Diabetes Institute, Melbourne, Vic, Australia; Department of Cardiology, Western Health, Melbourne, Vic, Australia; Department of Medicine, Western Health, Melbourne Medical School, University of Melbourne, Melbourne, Vic, Australia.
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Abstract
Intravenous anticoagulation is standard of care in the treatment of ST-elevation myocardial infarction. Primary percutaneous coronary intervention is the most common reperfusion strategy. Four anticoagulant options are available: unfractionated heparin, enoxaparin, fondaparinux, and bivalirudin. This article discusses the mechanism of action and key pharmacodynamic characteristics of these agents. The evolution of outcomes with unfractionated heparin compared with bivalirudin in the changing landscape of contemporary percutaneous coronary intervention is chronicled. Current anticoagulation recommendations from practice guidelines are provided and unresolved issues including treatment of patient subsets such as women and chronic kidney disease are explored.
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Affiliation(s)
- Chirag Bavishi
- Lifespan Cardiovascular Institute, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903, USA; Warren Alpert Medical School at Brown University, 222 Richmond Street, Providence, RI 02903, USA
| | - J Dawn Abbott
- Lifespan Cardiovascular Institute, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903, USA; Warren Alpert Medical School at Brown University, 222 Richmond Street, Providence, RI 02903, USA.
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Matrai AB, Kastetter B, Cooley BC. Timing of Heparin Administration Modulates Arterial Occlusive Thrombotic Response in Rats. J Cardiovasc Dev Dis 2020; 7:E10. [PMID: 32197497 DOI: 10.3390/jcdd7010010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 03/16/2020] [Accepted: 03/17/2020] [Indexed: 11/17/2022] Open
Abstract
Background: The timing for initiation of effective antithrombotic therapy relative to the onset of arterial thrombosis may influence outcomes. This report investigates the hypothesis that early administration of heparin anticoagulation relative to the onset of thrombotic occlusion will effect a reduction in occlusion. Methods: A standard rat model of experimental thrombosis induction was used, injuring the carotid artery exposure with FeCl3-saturated filter paper, followed by flow monitoring for onset of occlusion and subsequent embolization events. Intravenous heparin administration (200 units/mL) was timed relative to the initiation of injury or onset of near occlusion, compared with controls (no heparin administration). Results: No occlusion was found for delivery of heparin 5 min prior to thrombus induction, whereas all vessels occluded without heparin. Unstable (embolic) thrombi were seen with heparin given at or shortly after initial occlusion. Only 9% (1/11) of the vessels had permanent occlusion when heparin was given at the time of thrombotic onset (p < 0.0001 vs. unheparinized), while 50% occluded when heparin was delayed by 5 min (p > 0.05). Conclusions: These findings provide evidence that antithrombotic therapy may need to be administered prior to the onset of anticipated loss of patency, with less effectiveness when given after occlusion has occurred.
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