Acute Coronary Syndrome (ACS)

Thrombosis

Deep vein thrombosis (DVT)

Pulmonary Embolism (PE)

Aspirin

• Antiplatelet
  
• Acetylsalicylic acid(ASA)
• MOA: Irreversibly inhibts the enzyme cyclooxygenase
• ADR: upset stomach and GI discomfort, GI ulcers
  
• DI: Ibuprofen may block antiplatelet benefits of aspirin. (aspirin administered 2 hours before or 4 hours after ibuprofen to maximize benefits)

Clopidogrel (Plavix^®)

• Antiplatelet
• MOA: Inhibits binding of platelets to each other by interfering with ADP. 3-7 day lag time for onset of action.
• 1xdaily with food.
• ADR: GI disturbance, diarrhea, abdominal pain, may cause dizziness or headache. Excessive bleeding!

Antiplatelet Drugs

Therapeutic Uses

• Primary prevention: for PT's who have not yet experienced clotting event, but are at risk. 
• Daily aspirin therapy appropriate for men ages 45-79 and women 55-79 who have cardiac risk factors (diabetes, HTN, high chol, smoker) and low risk of GI hemmorrhage.
• Secondary prevention: For PT's that have already experienced clotting issues.(Ischemic stroke, TIA, MI, angina, stent placement, etc..)
• Following cardiac-related clots(MI, angina, stent,..)
• Other uses: ACS
• chew and swallow 325g aspirin. One of the most important interventions a person can do! Sometimes clopidogrel also used.

Anticoagulants

• Inhibit parts of the coagulation cascade.
• Prevent clots from forming. 
• Allow the body time to naturally dissolve already formed clots

Heparin(unfractionated):

MOA

• Administered IV, SC
• MOA: binds to antithrombin III to inhibit fibrin formation.
• Liver metabolized
• Quick onset, fairly short duration

Heparin(unfractionated):

Therapeutic Uses

• DOC for rapid onset anticoagulant effects
• Acute stroke, acute MI, DVT, PE
• Prevent DVT&PE following surgeries known to incres clot potential (hip, knee) and bedridden/immobile PT.
• Prevent clotting during renal dialysis and open-heart surgery.
• Central line IV flushes to prevent clotting

Heparin(unfractionated):

 ADR & Contraindications

• Major and minor bleeding
• cerebral, GI tract, urinary tract, nosebleeds
• Heparin induced thrombocytopenia(HIT)
• Immune mediated destruction of platelets
• Contraindications: uncontrollable bleeding, pre-existing thrombocytopenia.
• Avoid after surgeries/procedures with high risk of bleeding 
• eye, brain, spinal cord, lumbar puncture, spinal epidural

Heparin(unfractionated):

Monitoring, Dosing, Antidote

• Heparin is prescribed in units rather than mg
• Monitoring: Activated partial thromboplastin time(APTT)
• measures length of time clot takes to form
• Normal: 30-40 seconds; Therapeutic:1.5-2xnorm
• Antidote: Protamine sulfate (infrequently used)

Low Molecular Weight Heparin(LMWH):

Drugs

• Enoxaparin (Lovenox^®)
• Dalteparin (Fragmin^®)
• Tinzaparin (Innohep^®)

Low Molecular Weight Heparin(LMWH)

• Composed of molecules shorter than found in standard heparin.
• Considered as effective as heparin
• Longer half-life, more selective.
• Cleared primarily by kidneys.
• Costs 4x more than heparin
• Therapeutic uses: similar to unfrac. heparin.
• ADR: Similar to unfrac. heparin; less thrombocytopenia.
• Monitoring Dosing: Fixed dosing in mg
• Dosing based on PT weight; 1-2x daily
• APTT not monitored with LMWH.