• Any heparin requires a platelet count check twice a week.
• Early relay by vitamin K antagonists (VKA) reduces the risk of thrombocytopenia.
• Thrombocytopenia heparin must be confirmed in vitro (Immuno-Allergy-indicating definitely against heparin, except in exceptional situations).
• Monitoring of VKA based on the assessment of the International Normalized Ratio (INR) and either prothrombin time (PT), which varies depending on the reagents.
• Although the substances interfering with vitamin K antagonists, do not hesitate to check the INR.
• To evaluate the benefit / risk ratio of VKA therapy depending on the terrain.
Low molecular weight heparin (LMWH):
They are obtained by fractionation of heparin and have an anti-Xa activity (antithrombotic) without hémorragipare anticoagulant activity (especially anti-IIa).
They prophylactic and curative indications, according to the dosage or specialty. The risk of thrombocytopenia is less than under unfractionated heparin (UFH).
– Haemorrhagic manifestations, may bleed organic lesion.
– Evolutionary digestive ulcer.
– Hemorrhagic Stroke (CT so prior to any stroke).
– Acute pericarditis.
– Acute endocarditis, except mechanical prosthesis.
– Previous history of thrombocytopenia heparin.
– The caution in case of injury to the membrane of the retina, kidney or liver failure, hypertension not balanced.
Order No. 1: low risk of thromboembolism
– LOVENOX [enoxaparin sodium] 2000 IU, or INNOHEP [tinzaparin sodium] 3500 IU, 1 subcutaneous injection daily.
– Platelet count prior ++, then 2 times a week.
Ordinance No. 2: increased thromboembolic risk (cancer, history of thromboembolism)
– INNOHEP [tinzaparin sodium] 3500 IU, 1 subcutaneous injection daily.
– Even platelet monitoring.
No.3: thromboembolic risk high
– LOVENOX [enoxaparin sodium] or 4,000 IU INNOHEP [tinzaparin sodium] 4500 IU, 1 subcutaneous injection daily.
– Even platelet monitoring.
Curative use in the treatment of deep vein thrombosis:
– In a single injection per day: FRAXODI [nadroparin calcium] 0.1 ml / 10 kg or INNOHEP [tinzaparin sodium] 175 IU / kg.
– Monitoring of platelet 2 times a week.
– The monitoring of plasma anti-Xa activity may be necessary especially if renal failure, unusual weight, clinical ineffectiveness of treatment, bleeding. This must be between 0.5 and 1 anti-Xa IU / ml. For INNOHEP[tinzaparin sodium] Specifically, the plasma anti-Xa levels should not exceed 1.8 UI antiXa / ml.
– Start as soon as possible to balance the AVK for the INR before the 10th day of heparin +++.
Curative use in the treatment of atrial fibrillation and atrial flutter recently discovered (pending the effectiveness of AVK):
– It takes TWO injections per day: LOVENOX [enoxaparin sodium] 1 mg / kg twice daily.
– This LMWH has no authorization in this indication, but is the only LMWH used in studies of anticoagulation in atrial arrhythmias.
– Bleeding can exceptionally neutralize treatment PROTAMINE (sulfate or hydrochloride), dose for dose, preferably in multiple injections.
– Hematoma at the injection site: in connection with the purging of the syringe, not necessary.
– Osteoporosis in prolonged treatment over several months.
– Cutaneous necrosis at the injection site: stopping treatment, relays AVK.
– Cholesterol embolism (rare) appearance of a reticular livedo on the legs, painful purple toes without coldness, sometimes kidney failure: stop treatment immediately.
– Thrombocytopenia immunoallergic +++ interrupt heparin from a decrease of 30% of initial digits; immediately check the platelet count for confirmation; if confirmed, immediately relay AVK and antiplatelet (during the necessary time for equilibration of AVK).
– Biological confirmation of immuno-Free is required (laboratories).
Vitamin K antagonists (VKA):
– Action in the liver resulting in decreased factors II, VII, IX and X, and proteins C and S.
– Three specialties used: PREVISCAN, SINTROM and MINISINTROM (equivalent to 1/4 cp SINTROM), coumadin.
– The use of PREVISCAN or coumadin seems preferable: longer half-life, a single daily dose, steady INR relatively fixed dose according to the patient; Counterparty longer persistence of the AVK effect.
– Do not make loading doses.
– The equilibration is rarely reached before ten days of treatment.
– Taking the evening allows immediate correction of the daily dose, depending on the INR done that morning.
– These heparins.
– Plus: pregnancy and lactation, alcoholism, psychological context unfit for a proper understanding and observance.
Interactions (drug, non-drug):
long and non-exhaustive list.
Cons-indications intramuscular injections +++ (subcutaneously possible), intra-articular injections +++.
Need to control the INR for dose adjustment.
– Aspirin, NSAIDs, TICLID (cons-indicated)
– Statins, fibrates,
– Inhibitors of proton pump and cimetidine
– Thyroid hormones,
– Fluconazole, miconazole, ketoconazole,
– Broad-spectrum antibiotics, antibacterial sulfonamides and quinolones.
– Gastrointestinal protectants, coal,
– Lubricant laxatives,
– Barbiturates, carbamazepine, phenytoin,
– Rifampicin, griseofulvin,
– Foods rich in vitamin K: cabbage, cereals, broccoli, carrots, vegetables, organ meats.
– PREVISCAN 1 tab night.
– Simultaneously pursuing heparin (early overlap between the 2nd and 4th day).
– The overlap lasts at least 4 days.
– Control of the INR 48 hours later and careful dose adjustment (1/4 cp).
– Frequent INR controls in the first weeks, then 1 time per month.
– Stop heparin once the INR target is reached.
– In very elderly in AC / FA, a compromise between the risk of bleeding and thrombotic risk can be achieved by bringing the INR between 2 and 2.5.
– If last generation mechanical prosthesis in the aortic position, in the absence of risk factor for thromboembolism, the INR target is 2 to 3.
– Doing a blood test for PT and INR once a month, more if necessary according to medical advice, qs X months
– Do not take any medication without informing the doctor.
Patient Education +++
usefulness of treatment, risk sports and activities against-indicated, interactions with certain treatments for self-medication, wearing a card / treatment diary with postponement of INR and dose control in doubt.
Special case of antithrombotic therapy in atrial fibrillation:
– Atrial fibrillation and atrial flutter have the same potential embolic (indeed, they often alternate in the same patient).
– The paroxysmal and permanent forms also have the same potential embolic
– CHADS2 score stratified the thromboembolic risk of a patient and used to select the antithrombotic treatment most suited.
– However, other elements such as the atrium size G on ultrasound, the existence of a mitral valve, also come into consideration … Leave the specialist decide the most appropriate treatment.
CHADS2 Score: Add the points
Criteria for calculating the score Points
Age> 75 years 1
heart failure 1
ATCD transient or established stroke
or peripheral embolism 2
Antithrombotic Therapy recommended:
CHAD2 score = 0: aspirin 100-325 mg daily
CHADS2 score = 1: aspirin 100-325 mg daily or vitamin K antagonists
CHADS2 score> 1: anticoagulants
Preparation for electrical cardioversion: anticoagulants (electric shock itself thrombogenic)
Thus, it is not wrong to let a patient 65 who made the paroxysmal atrial fibrillation “on apparently healthy heart” aspirin … And, apart from absolute cons-indications to a patient of 84 years, hypertensive balanced makes paroxysmal atrial fibrillation under AVK …