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Evaluation of an intravenous heparin nomogram in a coronary care unit
F L Paradiso-Hardy1, B Cheung, W H Geerts
1Department of Pharmacy and Medicine, Sunnybrook Health Science Centre, University of Toronto, Ontario.
Insights
A new heparin nomogram effectively achieved therapeutic anticoagulation in acute cardiovascular disease patients. This method improved anticoagulation control compared to traditional approaches without increasing adverse events.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Medicine
Background:
- Intravenous heparin is crucial for managing acute coronary ischemic syndromes.
- Achieving and maintaining therapeutic anticoagulation with heparin can be challenging.
- Current heparin dosing strategies may lead to suboptimal anticoagulation levels.
Purpose of the Study:
- To develop and evaluate an effective and efficient heparin nomogram for patients with acute cardiovascular diseases.
- To compare the efficacy of the heparin nomogram against conventional dosing methods.
Main Methods:
- Retrospective and prospective data collection in a university hospital's coronary care unit.
- A historical control group (52 patients) receiving standard heparin therapy.
- Prospective evaluation of a heparin nomogram (56 patients) involving a weight-based bolus and infusion with aPTT-guided adjustments.
Main Results:
- The heparin nomogram group showed a trend towards higher achievement of therapeutic activated partial thromboplastin time (aPTT) range (84% vs 79%).
- A significantly higher percentage of nomogram patients reached the therapeutic aPTT threshold (100% vs 89%).
- The nomogram significantly reduced the time to reach the therapeutic aPTT and avoided periods of inadequate anticoagulation without increasing bleeding events.
Conclusions:
- The heparin nomogram is a successful strategy for achieving and maintaining adequate anticoagulation in acute cardiovascular disease.
- This nomogram offers an effective alternative to conventional heparin dosing, potentially requiring fewer aPTT measurements.
- The study highlights the nomogram's efficiency in managing heparin therapy for cardiovascular patients.
Objective:
To develop, implement and evaluate an effective and efficient heparin nomogram.
Design:
Retrospective and prospective data collection.
Setting:
Coronary care unit (CCU) of a university-affiliated hospital.
Patients:
Patients with acute coronary ischemic syndromes requiring intravenous (i.v.) heparin who were not receiving thrombolytic and/or warfarin therapy.
Interventions:
A retrospective chart review of 52 CCU patients receiving iv heparin provided the historical control group. The effectiveness of a heparin nomogram (5000 U bolus followed by an initial weight-based infusion of 15 U/kg/h with subsequent rate adjustments according to activated partial thromboplastin time [aPTT] results) was then prospectively assessed in a further 56 consecutive patients.
Main Results:
The historical control and nomogram groups did not significantly differ with respect to age, weight, duration of therapy or total number of aPTTs drawn. Approximately 79% and 84% of patients in the control and nomogram groups, respectively, achieved an aPTT within the therapeutic range (60 to 90 s, P > 0.05), whereas 89% and 100% of control and nomogram patients, respectively, surpassed the therapeutic threshold (longer than 60 s) at some point during treatment (P = 0.009). Compared with empiric dose adjustment, the nomogram more effectively avoided periods of inadequate anticoagulation. Similarly, the time to achieve the therapeutic threshold was significantly longer in the control than in the nomogram group (8.2 +/- 5.9 versus 6.7 +/- 3.7 h, P = 0.026). No adverse bleeding events were noted in either group.
Conclusions:
Compared with conventional approaches, the heparin nomogram successfully achieved and maintained adequate anticoagulation in a greater proportion of patients with acute cardiovascular diseases without the need for additional aPTT measurements.