CHEST-2012: High Points and Pearls

1. CHEST-2012: High Points and Pearls Alan Brush, MD, FACP Chief, Anticoagulation Management Service Harvard Vanguard Medical Associates

2. Language. . . • Suggestions vs. Recommendations: based on the weight of evidence

3. Evidence-based Management of Anticoagulation • Loading dose initiation of warfarin • Pharmacogenetic testing • Overlap with LMWH • Monitoring frequency • Management of single out of range result up to 0.5 above or below therapeutic range

4. Bridging with LMWH for stable patients with single low INR • Use of vitamin K for stable patients with single high INR • Self-testing and self-management • Drug interactions to avoid

5. Optimal therapeutic INR ranges • Dose Management of Subcutaneous (SC) UFH for DVT/PE • Fondaparinux Dose Management by Weight • VKA-associated major bleeding

6. Prophylaxis for higher risk patients in the ambulatory setting • Patients with Cancer but No Other Risk Factors for VTE • Patients with Solid Tumors and Additional Risk Factors for VTE (e.g. previous venous thrombosis, immobilization, hormonal therapy, angiogenesis) • Chronically immobilized patients residing at home or NH

7. Persons Traveling Long-Distance • Persons with Asymptomatic Thrombophilia without history of VTE

8. Prevention of VTE in Orthopedic Surgery Patients • Patients Undergoing Major Orthopedic Surgery: Total Hip Arthroplasty (THA), Total Knee Arthroplasty (TKA), and Hip Fracture Surgery (HFS) • Patients with Isolated Lower-Leg Injuries Distal to the Knee

9. Perioperative Management of Antithrombotic Therapy • Interruption of VKAs before Surgery • Resumption of VKAs after Surgery • Bridging Anticoagulation During Interruption of VKA Therapy • Perioperative Management of VKA-Treated Patients Who Require Minor Procedures

10. Patients taking Aspirin Undergoing a Minor Dental, Dermatologic, or Ophthalmologic Procedure • Patients Undergoing Coronary Artery Bypass Graft Surgery • Perioperative Use of IV UFH

11. Antithrombotic Therapy for VTE Disease • Initial anticoagulation for patients with acute DVT of the leg • Anticoagulation in patients with isolated distal DVT • Anticoagulation in patients with extensive superficial vein phlebitis

12. Patients with acute DVT of the leg treated with LMWH – dosing issues • Vena cava filters for the initial treatment of patients with DVT - considerations • Early ambulation of patients with acute DVT • Duration of long-term anticoagulant therapy for specific indications

13. Choice of anticoagulant regimen for long-term therapy without vs with cancer • Choice of anticoagulant regimen for extended therapy • Treatment of patients with asymptomatic DVT of the leg – same as symptomatic patients

14. Compression Stockings and IPCD to Prevent and Treat PTS • Parenteral anticoagulation prior to receipt of the results of diagnostic work-up for PE • Choice of initial parenteral anticoagulant regimen in patients with PE

15. Antithrombotic Therapy for Nonrheumatic Atrial Fibrillation

16. Antithrombotic and Thrombolytic Therapy for Acute Ischemic Stroke

17. VTE, Thrombophilia, Antithrombotic Therapy, and Pregnancy

18. The End