Chapter 29

Long-term anticoagulation is important in the treatment of many cardiac conditions. Intracardiac thrombi can form and lead to devastating consequences as a result of obstruction of blood flow and peripheral embolization. Treatment for intracardiac thrombi involves the use of anticoagulants for both primary and secondary prevention of thrombosis and embolization. There are, however, risks associated with the use of these agents, and an understanding of the risks and benefits of anticoagulant therapy for various cardiac conditions is important.

### Anticoagulants

These agents affect the coagulation protein cascade to reduce thrombosis. Their greatest use is in primary and secondary prevention of intravascular and intracardiac thrombosis and embolization.

#### Unfractionated Heparin

Unfractionated heparin (UFH) binds to antithrombin III, markedly increasing the effect of antithrombin III in neutralizing thrombin. It also inhibits the activation of factors IX and X. The effectiveness of UFH varies greatly from person to person due to its interactions with a number of plasma proteins and the endothelium. Monitoring the effects of full dose UFH on hemostasis is mandatory. Routinely, the activated partial thromboplastin time (aPTT) is used to monitor the effects of UFH, which should be titrated to 1.5–2.0 times greater than control. In certain situations, a higher level of anticoagulation is needed, ie, during coronary interventions. In those instances, the activated clotting time (ACT) is used to monitor its effect, and the dose of UFH is adjusted to keep the ACT 250–300 seconds or greater. When given intravenously, the effects of UFH are immediate. It is usually given as a bolus, followed by a continuous infusion. It may also be given subcutaneously. The effects of UFH will dissipate within 6 hours. Protamine can be given to reverse its effects more quickly. UFH can be given subcutaneously in smaller doses, which will not affect the aPTT, for primary prevention of deep venous thrombosis in certain high-risk situations.

#### Low-Molecular-Weight Heparin

Low-molecular-weight heparins (LMWHs) are breakdown products of UFH. They have a greater affect on factor X than on thrombin. Low-molecular-weight heparins bind less to plasma proteins than UFH and therefore, the dosing is more predictable. They are more resistant to neutralization by platelet factor 4 than UFH and have less inhibitory affect on platelet function than UFH. Low-molecular-weight heparins have a more predictable affect on coagulation than UFH and laboratory monitoring is usually not necessary. Monitoring the effects of LMWHs is difficult, since the commonly used tests for anticoagulation are not helpful and activated factor Xa levels need to be measured. Low-molecular-weight heparins are usually administered subcutaneously twice daily. They are not easily reversed by protamine. Low-molecular-weight heparin can also be given in smaller doses for the primary prevention of deep venous thrombosis in certain high-risk situations.

#### Oral Vitamin K Antagonists

Coumarins, or vitamin K antagonists, are the mainstay of oral anticoagulants and have been used for more than ...

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.

Ok

## Subscription Options

### AccessMedicine Full Site: One-Year Subscription

Connect to the full suite of AccessMedicine content and resources including more than 250 examination and procedural videos, patient safety modules, an extensive drug database, Q&A, Case Files, and more.