STEMI

E. Antithrombin Therapy — continued 1. UFH: . . a For patients receiving streptokinase, the ACCP suggests administration of either IV UFH (5,000 U bolus followed by 1,000 U/h for patients > 80 kg, 800 U/h for < 80 kg) with a target activated partial thromboplastin time (APTT) of 50 to 75 seconds or subcutaneous (subcut) UFH (12,500 U q12h) over no UFH therapy for 48 h (both Grade 1B). b For patients receiving alteplase, tenecteplase, or reteplase for fibrinolysis in acute MI, the ACCP recommends administration of weight-adjusted heparin (60 U/kg bolus for a maximum of 4,000 U, followed by 12 U/kg/h [1,000 U/h maximum]) adjusted to maintain an APTT of 50 to 70 seconds for 48 hours (Grade 1B). c For patients with STEMI undergoing primary PCI, the ACCP recommends administration of IV UFH over no UFH therapy (Grade 1C). The recommended periprocedural dosing in patients receiving a glycoprotein (GP) IIb/IIIa inhibitor is 50 to 70 U/kg (target activated clotting time [ACT] > 200 s); in patients not receiving a GP IIb/IIIa inhibitor, the recommended periprocedural dosing is 60 to 100 U/kg (target ACT, 250 to 350 s). . 2. Low-Molecular-Weight Heparin . a For patients with acute STEMI, regardless of whether or not they receive reperfusion therapy, the ACCP recommends the use of reviparin over no therapy (Grade 1B). Recommended dosing for reviparin is 3,436 IU for < 50 kg, 5,153 IU for 50 to 75 kg, or 6,871 IU for > 75 kg q12h subcut up to 7 days. For patients undergoing primary PCI, UFH should be used periprocedurally and reviparin initiated 1 h after sheath removal. b For patients with acute STEMI receiving fibrinolytic therapy who have preserved renal function (serum creatinine ≤ 2.5 mg/dL [220 mmol/L] in male patients and < 2.0 mg/dL [175 mmol/L] in female patients), the ACCP recommends the use of enoxaparin over UFH, continued up to 8 days (Grade 2A). Recommended dosing for enoxaparin is for age < 75 years, 30 mg IV bolus followed by 1 mg/kg subcut q12h (maximum of 100 mg for the first two subcut doses); and for age ≥ 75 years, no IV bolus, 0.75 mg/kg subcut q12h (maximum of 75 mg for the first two subcut doses). . 3. Fondaparinux . . a For patients with acute STEMI and not receiving reperfusion therapy, the ACCP recommends fondaparinux over no therapy (Grade 1A). Recommended dosing for fondaparinux is 2.5 mg IV for the first dose and then subcut daily up to 9 days. . b For patients with acute STEMI receiving fibrinolytic therapy and thought not to have an indication for anticoagulation, the ACCP recommends fondaparinux over no therapy (2.5 mg IV for the first dose and then subcut daily up to 9 days) [Grade 1B]. d. For patients with acute STEMI and undergoing primary PCI, the ACCP recommends against using fondaparinux (Grade 1A). c For patients with acute STEMI receiving fibrinolytic therapy and thought to have an indication for anticoagulation, the ACCP suggests fondaparinux (2.5 mg IV for the first dose and then subcut daily up to 9 days) could be used as an alternative to UFH (Grade 2B). 4. Direct Thrombin Inhibitors > For patients with acute STEMI treated with streptokinase, the ACCP suggests clinicians not use bivalirudin as an alternative to unfractionated heparin (Grade 2B).

• Cover