Parenteral anticoagulation for thrombolytic therapy for STEMI
Give parenteral anticoagulation with enoxaparin or unfractionated heparin (UFH) with thrombolytic therapy.
Suitable regimens for enoxaparin are:
enoxaparin enoxaparin enoxaparin enoxaparin
younger than 75 years and CrCl 30 mL/min or more: 30 mg intravenously, followed 15 minutes later by 1 mg/kg subcutaneously, 12-hourly. Maximum 100 mg for each of the first 2 subcutaneous doses
younger than 75 years and CrCl less than 30 mL/min: 30 mg intravenously, followed 15 minutes later by 1 mg/kg subcutaneously, 24-hourly. Maximum 100 mg for the first subcutaneous dose
75 years or older and CrCl 30 mL/min or more: 0.75 mg/kg subcutaneously, 12-hourly. Maximum 75 mg for each of the first 2 subcutaneous doses1
75 years or older and CrCl less than 30 mL/min: 1 mg/kg subcutaneously, 24-hourly. Maximum 75 mg for the first subcutaneous dose1.
For information about enoxaparin (including management of bleeding), see Practical information on using low molecular weight heparin. See also Considerations for anticoagulation in patients with obesity if applicable.
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)White, 2007. Dose unfractionated heparin according to the local hospital protocol for acute coronary syndromes. If a local protocol is not available, a suitable starting dose is:
unfractionated heparin 60 units/kg (up to 4000 units) intravenously as a loading dose, followed by 12 units/kg/hour (up to 1000 units/hour) by intravenous infusion, adjusted according to APTT. unfractionated heparin heparin, unfractionated heparin, unfractionated
Bleeding can occur following treatment with a thrombolytic drug and a parenteral anticoagulant. Intracranial bleeding is devastating and life threatening. Systemic bleeding and gastrointestinal bleeding can also occur. If bleeding occurs:
- seek appropriate specialist advice, including haematological advice where available
- reverse low molecular weight heparin (LMWH) or unfractionated heparin with protamine; see Bleeding and overanticoagulation with LMWH or Bleeding and overanticoagulation with unfractionated heparin for protamine dosages
- replace fibrinogen using cryoprecipitate or fresh frozen plasma (as required)
- a blood transfusion may be required2