Читать книгу Practical Cardiovascular Medicine - Elias B. Hanna - Страница 115

1 Aspirin 325 mg.

2 Clopidogrel 300 mg load if patient is <75 years old, or 75 mg if >75 years old (300 mg rather than 600 mg is the dose studied with fibrinolytics, even in pharmacoinvasive trials; 75 mg is the only dose studied with fibrinolytics in elderly patients).79,80

3 UFH IV bolus 60 units/kg (not more than 4000 units), followed immediately by heparin drip 12 units/kg/h, adjusted Q6h to keep the PTT 1.5–2.0× the control.

If the patient is going to have fibrinolytic reperfusion rather than PCI reperfusion, and if PCI is not expected in the next 24 hours, enoxaparin SQ or fondaparinux SQ may be used instead of UFH. In the patient receiving primary fibrinolytic reperfusion, enoxaparin or fondaparinux has a more favorable effect on reinfarction risk than UFH, with less major bleeding with fondaparinux, vs. more major bleeding with enoxaparin.^81,82 Patients undergoing standalone fibrinolytic therapy should receive anticoagulants for at least 48 hours and preferably for the duration of the hospitalization. Regimens other than UFH are preferred for anticoagulation >48 hours, because UFH is of no proven benefit beyond 48 hours.

 Dosage of enoxaparin: initial 30 mg IV dose, followed 15 minutes later by 1 mg/kg SQ Q12hFor patients >75 years old, avoid IV dose and administer 0.75 mg/kg Q12hIf GFR <30 ml/min, administer 1 mg/kg SQ Q24h

 Dosage of fondaparinux: 2.5 mg IV initially, then 2.5 mg SQ Qday. Avoid if GFR <30 ml/min.

Clopidogrel 600 mg load, prasugrel, and ticagrelor have not been studied within 24 hours of fibrinolytics, and thus are generally avoided during this time frame. Conversely, if delayed PCI is performed >24 hours after fibrinolysis, one of these regimens should be used. For PCI within 24 hours of fibrinolysis, use clopidogrel 300 mg +/– GPI.44–46