What are the recommended approaches for inpatient anticoagulation and anti-platelet therapy?

Inpatient Anticoagulation and Anti-platelet Therapy Management

For inpatients requiring antithrombotic therapy, a combination of antiplatelet and anticoagulant medications should be selected based on the underlying condition, with specific agents and dosing regimens tailored to minimize mortality and bleeding risk while maximizing efficacy. 1

Acute Coronary Syndrome (ACS) Management

Antiplatelet Therapy for ACS

• Aspirin is recommended for all patients without contraindications at an initial oral loading dose of 150–300 mg (or 75–250 mg IV), followed by a maintenance dose of 75–100 mg daily long-term 1
• A P2Y12 inhibitor should be added to aspirin and maintained for 12 months unless contraindicated by excessive bleeding risk 1
  • Preferred options include:
    • Ticagrelor (180 mg loading dose, 90 mg twice daily) irrespective of prior P2Y12 inhibitor regimen 1
    • Prasugrel (60 mg loading dose, 10 mg daily) in P2Y12-inhibitor naïve patients proceeding to PCI 1
    • Clopidogrel (600 mg loading dose, 75 mg daily) only when prasugrel or ticagrelor are unavailable or contraindicated 1

Anticoagulation for ACS

• Anticoagulation is recommended for all ACS patients in addition to antiplatelet therapy 1
• Options include:
  • Unfractionated heparin (UFH): Initial loading dose of 60 IU/kg (maximum 4000 IU) with initial infusion of 12 IU/kg/hour (maximum 1000 IU/h) adjusted per aPTT 1
  • Enoxaparin: 1 mg/kg SC every 12 hours (reduce to 1 mg/kg once daily if CrCl <30 mL/min) 1, 2
  • Bivalirudin: 0.10 mg/kg loading dose followed by 0.25 mg/kg/hour (only for early invasive strategy) 1
  • Fondaparinux: 2.5 mg SC daily 1
    • If PCI is performed while on fondaparinux, add UFH or bivalirudin due to risk of catheter thrombosis 1

Special Considerations for Anticoagulation

Duration of Therapy

• For ACS patients treated with coronary stent implantation, dual antiplatelet therapy (DAPT) with aspirin plus a P2Y12 inhibitor is recommended for 12 months 1
• In ACS patients at high bleeding risk (e.g., PRECISE-DAPT ≥25), consider discontinuing P2Y12 inhibitor therapy after 6 months 1
• For patients transitioning to oral anticoagulants:
  • When converting from heparin to warfarin, continue full heparin therapy until INR reaches stable therapeutic range 3
  • For non-warfarin oral anticoagulants, stop IV heparin immediately after administering the first dose 3

Glycoprotein IIb/IIIa Inhibitors

• Consider GP IIb/IIIa inhibitors as bail-out therapy if there is evidence of no-reflow or thrombotic complications during PCI 1
• May be considered in P2Y12-inhibitor naïve patients undergoing PCI 1
• Pre-treatment with GP IIb/IIIa inhibitors in patients with unknown coronary anatomy is not recommended 1

Prophylactic Anticoagulation for Bedridden Patients

• Pharmacological prophylaxis with LMWH, UFH, or fondaparinux is strongly recommended for bedridden inpatients at increased risk of venous thromboembolism (VTE) 4
• Recommended options include:
  • UFH 5000 units SC three times daily 4, 3
  • LMWH (e.g., enoxaparin 40 mg SC daily) 4
  • Fondaparinux 2.5 mg SC daily 4
• For hospitalized cancer patients, prophylactic anticoagulation should be administered throughout hospitalization 1, 4

Management of Patients Requiring Both Anticoagulation and Antiplatelet Therapy

• For patients with atrial fibrillation undergoing PCI, a careful assessment of thrombotic versus bleeding risk is necessary 1, 5
• Triple therapy (dual antiplatelet plus anticoagulant) should be kept as short as possible to minimize bleeding risk 1
• De-escalation strategies should be considered in patients at high bleeding risk 1, 6
• For patients unable to tolerate oral medications, parenteral anticoagulants such as UFH or LMWH can be used within 24-48 hours post-PCI 1

Monitoring and Safety Considerations

• Adjust UFH dosage according to aPTT results (target 1.5-2 times normal) 3
• Monitor platelet counts, hematocrit, and occult blood in stool during heparin therapy 3
• For patients who develop major bleeding while on anticoagulation, initiate appropriate measures to control bleeding and consider reversal agents if necessary 1, 7
• Crossover between UFH and LMWH is not recommended 1

Pediatric Considerations

• Use preservative-free heparin sodium in neonates and infants 3
• Initial dose: 75-100 units/kg (IV bolus over 10 minutes) 3
• Maintenance dose varies by age:
  • Infants: 25-30 units/kg/hour (infants <2 months have highest requirements) 3
  • Children >1 year: 18-20 units/kg/hour 3
• Adjust heparin to maintain aPTT of 60-85 seconds 3

Common Pitfalls to Avoid

• Avoid administering prasugrel in patients with unknown coronary anatomy 1
• Avoid intramuscular route for heparin administration due to risk of hematoma 3
• Do not extend prophylactic anticoagulation beyond hospital discharge without clear indication 4
• Avoid triple therapy (dual antiplatelet plus full-dose anticoagulation) for extended periods due to increased bleeding risk 1, 5, 8