Parenteral anticoagulant therapy for NSTEACS

For patients with non–ST elevation acute coronary syndrome (NSTEACS) who are at high or very high risk (see Overview of management of non-ST elevation acute coronary syndrome (NSTEACS)), parenteral anticoagulant therapy with a low molecular weight heparin (LMWH) (eg enoxaparin, dalteparin) or unfractionated heparin (UFH) is recommended unless the patient has an increased risk of bleeding, or urgent invasive coronary angiography is planned.

The timing of parenteral anticoagulant therapy should be determined with consideration of bleeding risk and the likely time to invasive coronary angiography. Parenteral anticoagulation is usually continued either until close to the time of invasive coronary angiography, until troponin levels have peaked and are declining, or longer depending on the clinical response. These should be determined in consultation with the cardiology team.

For anticoagulation with a LMWH, in addition to dual antiplatelet therapy, use:

If dalteparin is required for a patient with a calculated creatinine clearance (CrCl) less than 30 mL/min, seek expert advice.

The dose of LMWH due within 12 hours before a scheduled angiogram is usually omitted to minimise the risk of bleeding from the procedure. For more information about enoxaparin and dalteparin, such as determinants of bleeding and management of bleeding, see Practical information on using low molecular weight heparin. See also Considerations for anticoagulation in patients with obesity if applicable.

Fondaparinux is not commonly used but can also be considered. For information about fondaparinux, see Practical information on using fondaparinux.

Unfractionated heparin is used for patients with severe kidney impairment or who have a high risk of active bleeding that may require rapid reversal of anticoagulation (see Practical information on using unfractionated heparin for information, including management of bleeding). Dose according to the local hospital protocol for acute coronary syndromes. If a local protocol is not available, in addition to dual antiplatelet therapy, a suitable starting dose is:

Bivalirudin can be considered if invasive management is planned for a patient with a high risk of bleeding or a contraindication to heparin. In addition to dual antiplatelet therapy, use: