What is the recommended anticoagulation regimen for patients with multivessel disease in the in-hospital setting?

Recommended Anticoagulation Regimen for Patients with Multivessel Disease in the In-Hospital Setting

For patients with multivessel coronary disease in the in-hospital setting, bivalirudin is the preferred anticoagulant, particularly for those undergoing percutaneous coronary intervention (PCI), with a recommended dose of 0.75 mg/kg IV bolus followed by 1.75 mg/kg/h infusion during the procedure.

Initial Anticoagulation Options for Multivessel Disease

Primary Recommendation: Bivalirudin

• Dosing regimen: 0.75 mg/kg IV bolus, followed by 1.75 mg/kg/h infusion for the duration of the procedure 1
• ACT assessment: Check activated clotting time 5 minutes after bolus to determine if additional 0.3 mg/kg bolus is needed 1
• Post-procedure: Consider extending infusion at 1.75 mg/kg/h for up to 4 hours post-procedure in STEMI patients 1
• Renal adjustment: For CrCl <30 mL/min, reduce infusion rate to 1 mg/kg/h; for hemodialysis patients, reduce to 0.25 mg/kg/h 1

Alternative Options:

Low-Molecular-Weight Heparin (LMWH)

• Enoxaparin: 1 mg/kg SC every 12 hours or 1.5 mg/kg once daily 2
  • For patients ≥75 years: 0.75 mg/kg SC every 12 hours without initial IV bolus 2
  • For impaired renal function (CrCl <30 mL/min): 1 mg/kg SC once daily 2
  • For STEMI with fibrinolysis: 30 mg IV bolus followed by 1 mg/kg SC every 12 hours 2

Unfractionated Heparin (UFH)

• Initial dosing: 80 U/kg IV bolus, then 18 U/kg/h IV infusion 3
• Target: Adjust dose to maintain aPTT 1.5-2.5 times control value 3
• Alternative: 5,000 U every 8 hours for hospitalized medical patients 2

Fondaparinux

• Dosing: 2.5 mg SC once daily 2
• Caution: Increased risk of catheter thrombi when used alone during PCI; additional UFH (50-100 U/kg bolus) may be needed 2

Special Considerations

For PCI Procedures

1. Bivalirudin advantages:

   • Preferred for patients with increased bleeding risk 2
   • Reasonable alternative to UFH plus GP IIb/IIIa inhibitors 2
   • Particularly beneficial for patients with heparin-induced thrombocytopenia 2, 1
   • Associated with lower bleeding risk compared to heparin plus GP IIb/IIIa inhibitors 2

2. Enoxaparin considerations:

   • If patient received one SC dose of enoxaparin and is taken to cath lab within 2-6 hours, an IV "booster" dose of 0.3 mg/kg is recommended 4
   • For STEMI patients undergoing PCI, enoxaparin may be a safe and effective alternative to UFH 2
   • Do not switch between enoxaparin and UFH due to increased bleeding risk 2

For Non-ST Elevation ACS

• Anticoagulant options (duration: hospitalization or until PCI) 2:
  • SC enoxaparin: 1 mg/kg SC every 12 hours (reduce to 1 mg/kg/day if CrCl <30 mL/min)
  • Bivalirudin: 0.10 mg/kg loading dose followed by 0.25 mg/kg/h until diagnostic angiography or PCI
  • SC fondaparinux: 2.5 mg SC daily (additional anticoagulant with anti-IIa activity needed if PCI is performed)
  • IV UFH: Initial loading dose 60 IU/kg (max 4000 IU) with initial infusion 12 IU/kg/h (max 1000 IU/h)

Antiplatelet Therapy in Combination with Anticoagulation

• Aspirin: Non-enteric coated aspirin 162-325 mg loading dose promptly after presentation, followed by maintenance dose of 81-325 mg/day 2
• P2Y12 inhibitor: In addition to aspirin, for up to 12 months 2
  • Clopidogrel: 300-600 mg loading dose, then 75 mg/day
  • Ticagrelor: 180 mg loading dose, then 90 mg twice daily (preferred over clopidogrel)

Monitoring Recommendations

• Baseline testing: CBC, renal and hepatic function panel, aPTT, and PT/INR 2
• Follow-up testing: Hemoglobin, hematocrit, and platelet count at least every 2-3 days for the first 14 days and every 2 weeks thereafter 2
• For bivalirudin: Check ACT 5 minutes after bolus dose 1
• For UFH: Monitor aPTT to maintain 1.5-2.5 times control value 3

Pitfalls and Caveats

1. Avoid switching between anticoagulants: Patients initially treated with enoxaparin should not be switched to UFH and vice versa due to increased bleeding risk 2

2. Renal function considerations:

   • Adjust doses for all anticoagulants in patients with renal impairment
   • For fondaparinux and enoxaparin, dose adjustment is necessary in renal impairment 2
   • Bivalirudin requires dose adjustment for CrCl <30 mL/min 1

3. Bleeding risk assessment:

   • Consider patient's age, weight, renal function, and concomitant medications
   • Bivalirudin's anticoagulant effect subsides approximately one hour after discontinuation 1

4. Drug compatibilities:

   • Do not administer certain drugs (e.g., alteplase, amiodarone, streptokinase) in the same IV line with bivalirudin 1

By following these evidence-based recommendations, clinicians can provide optimal anticoagulation therapy for patients with multivessel disease in the in-hospital setting, balancing efficacy in preventing thrombotic events while minimizing bleeding risks.