2012 ACCP. Guías Tto antitrombótico. Chest

5/28/2018 2012 ACCP. Gu as Tto antitromb tico. Chest

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2012 Guyat.Executive Summary Antithrombotic Therapy and Prevention of Thrombosis, th ed! American"o##e$e of "hest Physicians Evidence%&ased "#inica# Practice Guide#ines.CHEST 2012;141(Suppl):7S47S.

INDICE:

Pg 2: Manejo de la terapia anticoagulante Basado en Evidencia

Pg 5: Prevencin del TEV en pacientes No-Quirrgicos

Pg 7: Prevencin de TEV en pacientes Quirrgicos no ortop!dicos

Pg 10: Prevencin del TEV en pacientes de cirug"a ortop!dica

Pg 12: Manejo perioperatorio de la Terapia antitro#$tica

Pg 14: Diagnstico de la TVP

Pg 19: Trata#iento antitro#$tico para el TEV %TVP

Pg 24: TEP

Pg 26: &EDVT: uppere'tre#it( DVT) PT* del $ra+o) Tro#$osis venosa espl,cnica

Pg 28: Trata#iento ( Prevencin de Tro#$ocitopenia inducida por eparina

Pg 31: Trata#iento antitro#$tico para la .i$rilacin /uricular

Pg 35: Terapia /ntitro#$tica ( Tro#$ol"tica para la En0er#edad Valvular

Pg 39: Trata#iento /ntitro#$tico ( Tro#$ol"tico para el Ictus Is1u!#ico % 2e#orr,gico

Pg 42: Prevencin pri#aria ( secundaria de en0er#edades cardiovasculares) * coronario) PCI) *tent3s

Pg 45: Trata#iento antitro#$tico en la En0er#edad /rterial Peri0!rica) Estenosis carotidea.

1


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Evidence-Based Manage#ent o0 /nticoagulant Terap(

2.1 Loading Dose for Initiation of Vitamin K Antagonist

(VKA) Therapy

4)5) .or patients su00icientl( ealt( to $e treated as

outpatients6 7e suggest initiating V8/ terap( 7it

7ar0arin 59 #g dail( 0or te 0i rst 4 da(s 0ollo7ed $(

dosing $ased on international nor#ali+ed ratio IN;H tid# or fondaparinu*(Grade 1B) .6.4. For acutely ill hospitali:ed edical patientsat low ris) of throosis# we recoend againstthe use of pharacologic prophyla*is or echanicalprophyla*is (Grade 1B) .6.7.1. For acutely ill hospitali:ed edicalpatients who are leeding or at high ris) forleeding# we recoend against anticoagulantthrooprophyla*is (Grade 1B) .6.7.6. For acutely ill hospitali:ed edical patients atincreased ris) of throosis who are leeding or

at high ris) for a8or leeding# we suggest theoptial use of echanical throoprophyla*iswith graduated copression stoc)ings (?-,"(Grade 2C) or interittent pneuatic copression(9-" (Grade 2C) # rather than no echanicalthrooprophyla*is. When leeding ris)decreases# and if %&' ris) persists# we suggestthat pharacologic throoprophyla*ise sustituted for echanical throoprophyla*is

(Grade 2B) .6.$. n acutely ill hospitali:ed edical patientswho receive an initial course of throoprophyla*is#

we suggest against e*tending the durationof throoprophyla*is eyond the periodof patient ioili:ation or acute hospital stay

(Grade 2B) .

-./ ,riticall" (ll Patients3.6. n critically ill patients# we suggest against routineultrasound screening for =%& (Grade 2C) .3.4.3. For critically ill patients# we suggest usingLMWH or L=>H throoprophyla*is over noprophyla*is (Grade 2C) .

3.4.4. For critically ill patients who are leeding# or areat high ris) for a8or leeding# we suggest echanicalthrooprophyla*is with ?-, (Grade 2C) or 9-(Grade 2C) until the leeding ris) decreases# ratherthan no echanical throoprophyla*is. Whenleeding ris) decreases# we suggest that pharacologicthrooprophyla*is e sustituted for echanicalthrooprophyla*is (Grade 2C) .

Prevencin del TEV en pacientes No-Quirrgicos

27> acientes m0dicos agdos hospitaliados

46=) En pacientes #!dicos ospitali+ados con en0er#edad

aguda con un alto riesgo de tro#$osis6 se reco#ienda

tro#$opro0ila'is anticoagulante con eparina de $ajo

peso 2BPM6 eparina no 0raccionada a dosis $ajas

2N.DB< $id6 2N.DB tres veces al d"a6 o 0ondaparinu'rado 5B


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./ Patients With ,ancer in the 2utpatient

3etting

4.6.1. n outpatients with cancer who have noadditional ris) factors for %&'# we suggest againstroutine prophyla*is with LMWH or L=>H (Grade 2B)and recoend against the prophylactic use of %/s

(Grade 1B) .4.6.6. n outpatients with solid tuors who haveadditional ris) factors for %&' and who are at lowris) of leeding# we suggest prophylacticdose LMWHor L=>H over no prophyla*is (Grade 2B) .4.4. n outpatients with cancer and indwelling centralvenous catheters# we suggest against routineprophyla*is with LMWH or L=>H (Grade 2B) and

suggest against the prophylactic use of %/s (2C) .

4./ ,hronicall" (o!ili0ed Patients+.1. n chronically ioili:ed persons residing athoe or at a nursing hoe# we suggest against theroutine use of throoprophyla*is (Grade 2C) .

5./ Persons Tra6eling [email protected]. For longdistance travelers at increased ris) of%&' (including previous %&'# recent surgery ortraua# active alignancy# pregnancy# estrogen use#advanced age# liited oility# severe oesity# or

)nown throophilic disorder"# we suggest freAuentaulation# calf uscle e*ercise# or sitting in an aisleseat if feasile (Grade 2C) [email protected]. For longdistance travelers at increased ris) of%&' (including previous %&'# recent surgery ortraua# active alignancy# pregnancy# estrogen use#advanced age# liited oility# severe oesity# or)nown throophilic disorder"# we suggest use ofproperly fi tted# elow)nee ?-, providing 1+ to 30 Hg of pressure at the an)le during travel (Grade2C) .For all other longdistance travelers# we suggest

against the use of ?-, (Grade 2C) [email protected]. For longdistance travelers# we suggest againstthe use of aspirin or anticoagulants to prevent %&'

(Grade 2C) .

7./ Persons With 's"ptoatic Thro!ophilia7.1. n persons with asyptoatic throophilia (ie#without a previous history of %&'"# we recoendagainst the longter daily use of echanical orpharacologic throoprophyla*is to prevent %&'(Grade 1C) .

.> acientes con cCncer en r0gimen am6latorio

A)4)5) En pacientes a#$ulatorios con c,ncer 1ue no tienen

0actores de riesgo adicionales de TEV6 sugeri#os contra

la pro0ila'is de rutina con 2BPM o 2N.BD rado 4B< (

en contra del uso pro0il,ctico de /V8 rado 5B


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epar#$a $o &ra""#o$ada. BP epar#$a Bao Pe!o oe"ar. B: epar#$a $o &ra""#o$ada a Baa! o!#!

9revention of %&' in 2onorthopedic ,urgical 9atients

-.5 Patients ndergoing eneral9 (9

rological9

"necologic9 *ariatric9 $ascular9 Plastic or

Reconstructi6e 3urger"[email protected]. For general and adoinalpelvic surgerypatients at very low ris) for %&' (B0.+CD ogers

score#


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$ter*#tte$t p$e*at#" "o*pre!!#o$ (PC)

3.@.$. For general and adoinalpelvic surgery

patients at high ris) for %&' (@CD -aprini score# +"in who oth LMWH and unfractionated heparin arecontraindicated or unavailale and who are not athigh ris) for a8or leeding coplications# we suggestlowdose aspirin (Grade 2C) # fondaparinu* (Grade 2C)# or echanical prophyla*is# preferaly with 9-(Grade 2C) # over no prophyla*is.

3.@.. For general and adoinalpelvic surgery patients# we suggest that an inferior vena cava (%-" fi ltershould not e used for priary %&' prevention (2C)

[email protected]. For general and adoinalpelvic surgerypatients# we suggest that periodic surveillance withvenous copression ultrasound shouldnot e perfored (Grade 2C) .

./ Patients ndergoing ,ardiac 3urger"4.4.1. For cardiac surgery patients with an uncoplicated postoperative course# we suggest use of echanical prophyla*is# preferaly with optially applied9-# over either no prophyla*is (Grade 2C) orpharacologic prophyla*is(Grade 2C) .4.4.6. For cardiac surgery patients whose hospitalcourse is prolonged y one or ore nonheorrhagic

surgical coplications# we suggest adding pharacologic prophyla*is with L=>H or LMWH toechanical prophyla*is (Grade 2C) .

4./ Patients ndergoing Thoracic 3urger"+.4.1. For thoracic surgery patients at oderate ris)for %&' who are not at high ris) for perioperativeleeding# we suggest L=>H (Grade 2B) # LMWH(Grade 2B) # or echanical prophyla*is with optiallyapplied 9- (Grade 2C) over no prophyla*is.

+.4.6. For thoracic surgery patients at high ris) for%&' who are not at high ris) for perioperativeleeding# we suggest L=>H (Grade 1B) or LMWH

(1B) over no prophyla*is. n addition# wesuggest thatechanical prophyla*is with elastic stoc)ings or 9-should e added to pharacologic prophyla*is (2C) .

+.4.3. For thoracic surgery patients who are at highris) for a8or leeding# we suggest use of echanicalprophyla*is# preferaly with optially applied 9-#over no prophyla*is until the ris) of leeding diinishand pharacologic prophyla*is ay e initiated (2C) .

5./ Patients ndergoing ,ranioto"@.4.1. For craniotoy patients# we suggest that echanical prophyla*is# preferaly with 9-# e used over no

=)F)H) En pacientes de cirug"a general ( a$do#ino-p!lvica

con alto riesgo de TEV FR Caprini < en 1ue tanto la

2BPM co#o la eparina no 0raccionada est!n

contraindica-das o no est!n disponi$les ( 1ue no est!n en

alto riesgo de co#plicaciones e#orr,gicas graves6 se

sugiere una dosis $aja de aspirina 4C


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prophyla*is (2C) or pharacologic prophyla*is (2C) .

10


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@.4.6. For craniotoy patients at very high ris) for%&' (eg# those undergoing craniotoy for alignantdisease"# we suggest adding pharacologic prophyla*isto echanical prophyla*is once adeAuate heostasis isestalished and the ris) of leeding decreases (Gr 2C) .

7./ Patients ndergoing 3pinal 3urger"7.4.1. For patients undergoing spinal surgery# we

suggest echanical prophyla*is# preferaly with 9-#over no prophyla*is (Grade 2C) # unfractionatedheparin (Grade 2C) # or LMWH (Grade 2C) .high ris) for %&' (including those with alignantdisease or those undergoing surgery with a coinedanteriorposterior approach"# we suggest addingpharacologic prophyla*is to echanical prophyla*isonce adeAuate heostasis is estalished and the ris) ofleeding decreases (Grade 2C) .

8./ Patients With Ma:or Traua; Trauatic

*rain (n:ur"9 'cute 3pinal (n:ur"9 and

Trauatic 3pine (n:ur"$.4.1. For a8or traua patients# we suggest use ofL=>H (2C)# LMWH (2C) # or echanical prophyla*is#preferaly with 9- (2C) # over no prophyla*is.

$.4.6. For a8or traua patients at high ris) for %&'(including those with acute spinal cord in8ury#trauatic rain in8ury# and spinal surgery for traua"we suggest adding echanical prophyla*is topharacologic prophyla*is (Grade 2C) when notcontraindicated y lowere*treityin8ury.

$.4.3. For a8or traua patients in who LMWH andL=>H are contraindicated# we suggest echanicalprophyla*is# preferaly with 9-# over no prophyla*is

(G 2C) when not contraindicated y lowere*treityin8ury. We suggest adding pharacologic prophyla*iswith either LMWH or L=>H when the ris) ofleedingdiinishes or the contraindication to heparin resolves

(2C) .$.4.4. For a8or traua patients# we suggest that an%- fi lter should not e used for priary %&'prevention (Grade 2C) .

$.4.+. For a8or traua patients# we suggest thatperiodic surveillance with venous copressionultrasound should not e perfored (Grade 2C) .

F)A)4) En pacientes con craneoto#"a con riesgo #u(

elevado de VTE p)ej6 a1uellos so#etidos a craneoto#"a

por en0er#edad #aligna


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9revention of %&' in rthopedic ,urgery 9atients

+./ Patients ndergoing Ma:or 2rthopedic

3urger";

Total Hip 'rthroplast" H (all Grade 2B) # ad8usteddose %/# or aspirin(all Grade 2C) .6.3.6. n patients undergoing HF,# irrespective of theconcoitant use of an 9-= or length of treatent# wesuggest the use of LMWH in preference to the otheragents we have recoended as alternativesGfondaparinu*# L=>H (Grade 2B) # ad8usteddose %/#or aspirin (all Grade 2C) .

6.4.For patients undergoing a8or orthopedic surgery#we suggest e*tending throoprophyla*is in the out

patient period for up to 3+ days fro the day ofsurgery rather than for only 10 to 14 days (Grade 2B) .

6.+. n patients undergoing a8or orthopedic surgery#we suggest using dual prophyla*is with an antithrootic agent and an 9-= during the hospital stay (2C).

6.@. n patients undergoing a8or orthopedic surgeryand increased ris) of leeding# we suggest using an9-= or no prophyla*is rather than pharacologictreatent (Grade 2C) .

Prevencin del TEV en pacientes de cirug"a ortop!dica

2.> acientes sometidos a cirgFa ortop0dica mayorG artro

plastia total de cadera (ATB)7 artroplastia total de rodilla

(AT*)7 BirgFa de fractra de cadera (B&B)

4)5)5) En pacientes so#etidos a artroplastia /TC o /T;6

se reco#ienda el uso durante un per"odo #"ni#o de 59 -

5A d"as 6 vs no-pro0ila'is antitro#$tica6 de uno de los

siguientes: 2BPM


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6.7. n patients undergoing a8or orthopedic surgeryand who decline or are uncooperative with in8ections

or an 9-=# we recoend using api*aan ordaigatran (alterna tively rivaro*aan or ad8usteddose %/ if api*aan or daigatran are unavailale"rather than alternative fors of prophyla*is (all Grade1B) .6.$. n patients undergoing a8or orthopedic surgery#we suggest against using %- fi lter placeent forpriary prevention over no throoprophyla*isin patients with an increased leeding ris) orcontraindications to oth pharacologic andechanical throoprophyla*is (Grade 2C) .6.. For asyptoatic patients following a8ororthopedic surgery# we recoend against=oppler (or duple*" ultrasound screening eforehospital discharge (Grade 1B) .

-./ Patients With (solated Lo>erLeg (n:uries

Distal

to the %nee3.0. We suggest no prophyla*is rather thanpharacologic throoprophyla*is in patients withisolated lowerleg in8uries reAuiring leg ioili:ation

(Grade 2C) .

./ Patients ndergoing %nee 'rthroscop"4.0. For patients undergoing )nee arthroscopy withouta history of prior %&'# we suggest no throoprophyla*is rather than prophyla*is (Grade 2B) .

46G) En pacientes so#etidos a cirug"a ortop!dica #a(or6 (

1ue reusan o no cooperan con las in(ecciones o CNI6 se

reco#ienda utili+ar api'a$an o da$igatr,n

alternativa#ente o dosis ajustadas de /V8 si no se

dispone de api'a$an o da$igatr,n< en lugar de 0or#as

alternativas de pro0ila'is todos los de rado 5B


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9erioperative Managent of ntithrootic &herapy

+.1 (nterruption of $%'s *efore 3urger"6.1. n patients who reAuire teporary interruptionof a %/ efore surgery# we recoend stopping

%/s appro*iately + days efore surgery instead ofstopping %/s a shorter tie efore surgery (1C) .

+.+ Resuption of $%'s 'fter 3urger"6.6. n patients who reAuire teporary interruptionof a %/ efore surgery# we recoend resuing%/s appro*iately 16 to 64 h aftersurgery (eveningof or ne*t orning" and when there is adeAuateheostasis instead of later resuption of %/s (2C) .

+. *ridging 'nticoagulation During

(nterruption of$%' Therap"6.4. n patients with a echanical heart valve# atrial firillation# or %&' at high ris) for throoeolis#

we suggest ridging anticoagulation instead of noridging during interruption of %/ therapy (2C) .n patients with a echanical heart valve# atrial firillation# or %&' at low ris) for throoeolis#we suggest no ridging instead of ridging anticoagulation during interruption of %/ therapy (2C) .

+.4 Perioperati6e Manageent of $%'Treated

Patients Who Re?uire Minor Procedures6.+. n patients who reAuire a inor dental procedure#we suggest continuing %/s with coadinistrationof an oral proheostatic agent or stopping %/s 6 to3 days efore the procedure instead of alternativestrategies (Grade 2C) . n patients who reAuire inorderatologic procedures and are receiving %/therapy# we suggest continuing %/s around the tieof the procedure and optii:ing local heostasisinstead of other strategies (Grade 2C) . n patients who

reAuire cataract surgery and are receiving %/therapy# we suggest continuing %/s around the tieof the surgery instead of other strategies (Grade 2C) .

-. Patients ndergoing a Minor Dental9

Deratologic9

or 2phthalologic Procedure3.4. n patients who are receiving acetylsalicylic acid(," for the secondary prevention of cardiovasculardisease and are having inor dental or deratologicprocedures or cataract surgery# we suggest continuing, around the tie of the procedure instead of

stopping , 7 to 10 days efore the procedure (Grade2C) .

Manejo perioperatorio de la Terapia antitro#$tica

2.1 Interrpci/n de la AVK antes de la cirgFa465) En pacientes 1ue re1uieren interrupcin te#poral de

/V8 antes de la cirug"a6 se reco#ienda detener la /V8

apro'i#ada#ente d"as antes de la cirug"a en lugar deinterru#pirla un lapso #as corto rado 5C


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15


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3.+. n patients at oderate to high ris) for cardiovascular events who are receiving , therapy andreAuire noncardiac surgery# we suggest continuing, around the tie of surgery instead of stopping, 7 to 10 days efore surgery (2C). n patients atlow ris) for cardiovascular events who are receiving

, therapy# we suggest stopping , 7 to 10 daysefore surgery instead of continuation of ,(2C).

-.5 Patients ndergoing ,'* 3urger"3.@. n patients who are receiving , and reAuirecoronary artery ypass graft (-?" surgery# wesuggest continuing , around the tie of surgeryinstead of stopping , 7 to 10 days efore surgery

(Grade 2C) . n patients who are receiving dualantiplatelet drug therapy and reAuire -? surgery#we suggest continuing , around the tie of surgeryand stopping clopidogrel!prasugrel + days efore

surgery instead of continuing dual antiplatelet therapyaround the tie of surgery (Grade 2C) .

-.7 3urgical Patients With ,oronar" 3tents3.7. n patients with a coronary stent who are receivingdual antiplatelet therapy and reAuire surgery# werecoend deferring surgery for at least @ wee)safter placeent of a areetal stent and for at least @onths after placeent of a drugeluting stent insteadof underta)ing surgery within these tie periods

(Grade 1C) . n patients who reAuire surgery within @wee)s of placeent of a areetal stent or within

@ onths of placeent of a drugeluting stent# wesuggest continuing dual antiplatelet therapy aroundthe tie of surgery instead of stoping dual antiplatelettherapy 7 to 10 days efore surgery (Grade 2C) .

.+ Perioperati6e se of ($ FH4.6. n patients who are receiving ridging anticoagulation with therapeuticdose % >FH# we suggeststopping >FH 4 to @ h efore surgery instead of closerto surgery (Grade 2C) .

.- Preoperati6e (nterruption of Therapeutic

Dose *ridging LMWH4.3. n patients who are receiving ridging anticoagulation with therapeuticdose ,- LMWH# wesuggest adinistering the last preoperative dose ofLMWH appro*iately 64 h efore surgery instead of16 h efore surgery (Grade 2C) .

. Postoperati6e Resuption of Therapeutic

Dose

*ridging LMWH4.4. n patients who are receiving ridging anticoagulation with therapeuticdose ,- LMWH and areundergoing highleedingris) surgery# we suggest

resuing therapeuticdose LMWH 4$ to 76 h aftersurgery instead of resuing LMWH within 64 h aftersurgery (Grade 2C) .

=6) En pacientes con riesgo #oderado a alto de eventos

cardiovasculares 1ue est,n reci$iendo trata#iento con

//*6 ( re1uieren cirug"a no cardiaca6 sugieren continuar

//* en todo el curso de la cirug"a6 en lugar de suspender

el //* G a 59 d"as antes de la cirug"a 4C


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=iagnosis of =%&

-./ Diagnosis of 3uspected First Lo>er

@xtreit" D$T

3.1. n patients with a suspected fi rst lower e*treity=% we suggest that the choice of diagnostic testsprocess should e guided y the clinical assessent ofpretest proaility rather than y perforing thesae diagnostic tests in all patients (Grade 2B) .

3.6. n patients with a low pretest proaility of fi rstlower e*treity =% we recoend one of the

following initial testsG (i" a oderately sensitive =dier# (ii" a highly sensitive =dier# or (iii"copression ultrasound (->," of the pro*ial veinsrather than (i" no diagnostic testing (Grade 1B for allcomparisons) # (ii" venography (Grade 1B for allcomparisons), or (iii" wholeleg ultrasound (>," (Grade2B for all comparisons). We suggest initial use of aoderately sensitive (Grade 2C) or highly sensitive(Grade 2B) =dier rather than pro*ial ->,.f the =dier is negative# we recoend no furthertesting over further investigation with (i" pro*ial->,# (ii" wholeleg >,# or (iii" venography (Grade 1B

for all comparisons) . f the pro*ial ->, is negative#we recoend no further testing copared with (i"repeat pro*ial ->, after 1 wee)# (ii" wholeleg >,#or (iii" venography (Grade 1B for all comparisons) .f the =dier is positive# we suggest further testingwith ->, of the pro*ial veins ratherthan (i" wholeleg >, (Grade 2C) or (ii" venography (Grade 1B) . f->, of the pro*ial veins is positive# we suggesttreating for =%& and perforing no further testingover perforing confi ratory venography (Grade 2C)

3.3. n patients with a oderate pretest proaility of

fi rst lower e*treity =% we recoend one of thefollowing initial testsG (i" a highly sensitive =dier or(ii" pro*ial ->,# or (iii" wholeleg >, rather than (i"no testing (Grade 1B for all comparisons) or (ii"venography (Grade 1B for all comparisons) . We suggestinitial use of a highly sensitive =dier rather than >,

(Grade 2C) .

f the highly sensitive =dier is negative# werecoend no further testing over furtherinvestigation with (i" pro*ial ->,# (ii" wholeleg >,#or (iii" venography (Grade 1B for all comparisons) . fthe highly sensitive =dier is positive# we recoendpro*ial ->, or wholeleg >, rather than no testing

(Grade 1B for all comparisons) or venography (Grade 1Bfor all comparisons) .

Diagnstico de la TVP

!,0 "iagnstico de sosec#a de rimera trom$osis %enosa

rofunda de e&tremidad inferior

=65) En los pacientes con sospeca de TVP en EEII6 se

sugiere 1ue la eleccin del proceso de prue$as de

diagnstico de$e guiarse por la evaluacin cl"nica de la

pro$a$ilidad pretest en lugar de #ediante la reali+acin

de prue$as de diagnstico en todos los pacientes r 4B


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S tra!o$ogra&a. CS :S de "o*pre!#'$

18


19/60

f pro*ial ->, is chosen as the initial test and isnegative# we recoend (i" repeat pro*ial ->, in 1wee) or (ii" testing with a oderate or highly sensitive=dier assay over no further testing (Grade 1C) orvenography (Grade 2B) . n patients with a negativepro*ial ->, ut a positive =dier# we recoend

repeat pro*ial ->, in 1 wee) over no further testing(Grade 1B) or venography (Grade 2B) .

n patients with (i" negative serial pro*ial ->, or (ii"a negative single pro*ial ->, and negative oderateor highly sensitive =dier# we recoend no furthertesting rather than further testing with (i" wholeleg>, or (ii" venography (Grade 1B for all comparisons) .

f wholeleg >, is negative# we recoend no furthertesting over (i" repeat >, in one wee)# (ii" =diertesting# or (iii" venography (Gr 1B for all comparisons) .

f pro*ial ->, is positive# we recoend treatingfor =%& rather than confi ratory venography (1B)

f isolated distal =%& is detected on wholeleg >,# wesuggest serial testing to rule out pro*ial e*tensionover treatent (Grade 2C) .We recoend that patients with a negative pro*ial->, undergo testing with a oderate or highsensitivity =dier# wholeleg >,# or repeat pro*ial->, in 1 wee) over no further testing (Grade 1B) orvenography (Grade 2B) . n patients with a negativepro*ial ->,# we suggest =dier rather thanroutine serial ->, (Grade 2B) or wholeleg >, (Grade2C) . We recoend that patients with a singlenegative pro*ial ->, and positive =dier undergofurther testing with repeat pro*ial ->, in 1 wee) orwholeleg >, rather than no further testing (Grade 1Bfor both comparisons) .

We recoend that in patients with (i" negative serialpro*ial ->,# (ii" a negative =dier following anegative initial pro*ial ->,# or (iii" negative wholeleg >,# no further testing e perfored rather thanvenography (Grade 1B) .

f pro*ial >, is positive for =% we recoendtreatent rather than confi ratory venography

(Grade 1B) . f isolated distal =%& is detected onwholeleg >,# we suggest serial testing to rule outpro*ial e*tension over treatent (Grade 2C) .

*i se elige C&* pro'i#al co#o prue$a inicial ( es

negativa6 se reco#ienda i< repetir C&* pro'i#al en 5

se#ana o ii< prue$as con D-d"#ero de #oderada o alta

sensi$lidad so$re no-test rado 5C< o venogra0"a

rado 4B


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3.@. n patients with suspected first lower e*treity=% we recoend against the routine use of -&venography or M (Grade 1C ) .

.1$enograph" in Patients With 3uspected

Recurrent D$T4.1. n patients suspected of having recurrent lowere*treity =% we recoend initial evaluation withpro*ial ->, or a highly sensitive =dier overvenography# -& venography# or M (all Grade 1B) .f the highly sensitive =dier is positive# werecoend pro*ial ->, over venography# -&venography# or M (Grade 1B for all com parisons) .

n patients with suspected recurrent lower e*treity=%& in who initial pro*ial ->, is negative

(noral or residual diaeter increase of < 6 "# we

suggest at least one further pro*ial ->, (day 7 1"or testing with a oderately or highly sensitive =

dier (followed y repeat ->, ;day 7 _ 1< if positive"rather than no further testing or venography (Gr 2B) .

We recoend that patients with suspected recurrentlower e*treity =%& and a negative highly sensitive=dier or negative pro*ial ->, and negativeoderately or highly sensitive =dier or negativeserial pro*ial ->, undergo no further testing forsuspected recurrent =%& rather than venography (1B)f ->, of the pro*ial veins is positive# we recoendtreating for =%& and perforing no further testingover perforing confi ratory venography (Grade 1B)

.+ ,opression ltrasonograph" in Patients

With

3uspected Recurrent D$T4.6. n patients with suspected recurrent lowere*treity =%& and anoral ut nondiagnostic >,results (eg# an increase in residual venous diaeter ofB4 ut 56 "# we recoend further testing withvenography# if availale (Grade 1B) D serial pro*ial->, (Grade 2B) or testing with a oderately or highlysensitive =dier with serial pro*ial ->, as aove if

the test is positive (Grade 2B) # as opposed to othertesting strategies or treatent.

3,6. $ pa"#e$te! "o$ !o!pe"a de P pr#*ar#a dee;tre*#dad #$&er#or, $o !e re"o*#e$da e !o rt#$ar#o de

+C, /e$ogra&a, o


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.- Pretest Pro!a!ilit" 'ssessent in Patients

With

3uspected Recurrent D$T4.3. n patients with suspected recurrent ipsilateral

=%& and an anoral >, without a prior result forcoparison# we recoend further testing withvenography# if availale (Grade 1B) or a highlysensitive =dier (Grade 2B) over serial pro*ial->,. n patients with suspected recurrent ipsilateral=%& and an anoral >, without prior result forcoparison and a negative highly sensitive =dier#we suggest no further testing over venography (Grade2C) . n patients with suspected recurrent ipsilateral=%& and an anoral >, without prior result forcoparison and a positive highly sensitive =dier# wesuggest venography if availale over epiricaltreatent of recurrence (Grade 2C) .

4.1 $enograph" in Pregnanc"Related D$T+.1. n pregnant patients suspected of having lowere*treity =% we recoend initial evaluation withpro*ial ->, over other initial tests# including awholeleg >, (Grade 2C) # oderately sensitive =dier (Grade 2C) # highly sensitive =dier (Grade 1B)# or venography (Grade 1B) .

4.+ ,opression ltrasonograph" in Pregnanc"

Related D$T

+.6. n pregnant patients with suspected =%& in whoinitial pro*ial ->, is negative# we suggest furthertesting with either serial pro*ial ->, (day 3 and day7" (Grade 1B) or a sensitive =dier done at the tie ofpresentation (Grade 2B) over no further testing for=%&. We recoend that patients with an initialnegative pro*ial ->, and a suseAuent negativesensitive =dier or negative serial pro*ial ->,undergo no further testing for =%& (Grade 1B), andthat patients with positive =dier have an additionalfollowup pro*ial ->, (day 3 and day 7" rather thanvenography (Grade 1B) or wholeleg >, (Grade 2C) .

4.- Pretest Pro!a!ilit" in Pregnanc"Related

D$T+.3. n pregnant patients with syptos suggestive ofisolated iliac vein throosis (swelling of the entireleg# with or without fl an)# uttoc)# or ac) pain" andno evidence of =%& on standard pro*ial ->,# wesuggest further testing with either =oppler >, of theiliac vein (Grade 2C) # venography (Grade 2C) # ordirect M (Grade 2C) # rather than standard serial->, of the pro*ial deep veins.

.! H#alaci/n de pro6a6ilidad retest en pacientes con

sospecha de TV recrrente

871VenografFa en TV relacionada con el em6arao

8.2 @S de Bompresi/nen TV relacionada con em6arao

8.! ro6a6ilidad pretesten TV relacionada con em6arao

21


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5.1 ltrasonograph" in Patients With pper

@xtreit" D$T '=% wesuggest initial evaluation with coined odality>, (copression with either =oppler or color=oppler" over other initial tests# including highlysensitive =dier or venography (Grade 2C) .

5.+ ,linical Pretest Pro!a!ilit" 'ssessent in

Patients

With @[email protected]. n patients with suspected >'=%& in who initial>, is negative for throosis despite a high clinicalsuspicion of =% we suggest further testing with aoderate or highly sensitive =dier# serial >,# orvenographicased iaging (traditional# -& scan# orM"# rather than no further testing (Grade 2C) .n patients with suspected >'=%& and an initialnegative coinedodality >, and suseAuentnegative oderate or highly sensitive =dier or -&or M# we recoend no further testing# rather thanconfi ratory venography (Grade 1C) . We suggestthat patients with an initial coined negativeodality >, and positive =dier or those with lessthan coplete evaluation y >, undergo venographyrather than no further testing# unless there is an

alternative e*planation for their syptos (Grade 2B),in which case testing to evaluate for the presence analternative diagnosis should e perfored. We suggestthat patients with a positive =dier or those with lessthan coplete evaluation y >, ut an alternativee*planation for their syptos undergo confi ratorytesting and treatent of this alternative e*planationrather than venography (Grade 2C) .

9.1 HcografFa en pacientes con trom6osis #enosa profnda

de etremidades speriores (@HDVT)

9.2 H#alaci/n de pro6a6lidad pretest en pacientes con

@HDVT

22


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ntithrootic &herapy for %&' =isease

+.1 (nitial 'nticoagulation for Patients With

'cute D$T

of the Leg6.1. n patients with acute =%& of the leg treated with%/ therapy# we recoend initial treatent withparenteral anticoagulation (LMWH# fondaparinu*# %>FH# or ,- >FH" over no such initial treatent (1B) .

+.+ Parenteral 'nticoagulation Prior to Receipt

of the

Results of Diagnostic Wor&up for [email protected]. n patients with a high clinical suspicion of acute%&'# we suggest treatent with parenteral anticoagulants copared with no treatent while awaitingthe results of diagnostic tests (Grade 2C) .6.6.6. n patients with an interediate clinical

suspicion of acute %&'# we suggest treatent withparenteral anticoagulants copared with no treatentif the results of diagnostic tests are e*pected to edelayed for ore than 4 h(Grade 2C) .6.6.3. n patients with a low clinical suspicion of acute%&'# we suggest not treating with parenteral anticoagulants while awaiting the results of diagnostic tests#provided test results are e*pected within 64 h (Gr 2C) .

+.- 'nticoagulation in Patients With (solated

Distal D$T6.3.1. n patients with acute isolated distal =%& of theleg and without severe syptos or ris) factors fore*tension# we suggest serial iaging of the deep veinsfor 6 wee)s over initial anticoagulation (Grade 2C) .6.3.6. n patients with acute isolated distal =%& of theleg and severe syptos or ris) factors for e*tension(see te*t"# we suggest initial anticoagulation over serialiaging of the deep veins (Grade 2C) .6.3.3. n patients with acute isolated distal =%& of theleg who are anaged with initial anticoagulation# werecoend using the sae approach as for patientswith acute pro*ial =%& (Grade 1B) .

6.3.4. n patients with acute isolated distal =%& of theleg who are anaged with serial iaging# werecoend no anticoagulation if the throus doesnot e*tend (Grade 1B) D we suggest anticoagulationif the throus e*tends ut reains confi ned to thedistal veins (Grade 2C)D we recoend anticoagulationif the throus e*tends into the pro*ial veins (1B) .

Trata#iento antitro#$tico para el TEV

2.1 Anticoaglaci/n inicial para pacientes con TV agda

de la pierna

465) En los pacientes con TVP aguda de la pierna tratada

con /V86 se reco#ienda iniciar anticoagulacin

parenteral 2BPM6 0ondaparinu'6 eparina no

0raccionada intravenosa o eparina no 0raccionada *CFH (Grade 2C) andover ,- >FH (Grade 2B for LMWH; Grade 2C forfondaparin!) .6.+.6. n patients with acute =%& of the leg treatedwith LMWH# we suggest once over twicedaily

adinistration (Grade 2C) .

+.7 'tHoe 6s (nHospital (nitial Treatent of

Patients

With D$T6.7. n patients with acute =%& of the leg and whosehoe circustances are adeAuate# we recoendinitial treatent at hoe over treat in hospital (1B) .

+.# ,atheterDirected Thro!ol"sis for Patients

With

'cute D$T6.. n patients with acute pro*ial =%& of the leg# wesuggest anticoagulant therapy alone over catheterdirected throolysis (-=&" (Grade 2C) .

+.1/ 3"steic Thro!ol"tic Therap" for

Patients With

'cute D$T6.10. n patients with acute pro*ial =%& of the leg#we suggest anticoagulant therapy alone over systeicthroolysis (Grade 2C) .

+.11 2perati6e $enous Thro!ecto" for 'cute

D$T6.11. n patients with acute pro*ial =%& of the leg#we suggest anticoagulant therapy alone over operativevenous throectoy (Grade 2C) .

+.1+ 'nticoagulation in Patients Who Ha6e Had

'n"

Method of Thro!us Reo6al Perfored6.16. n patients with acute =%& of the leg who

undergo throosis reoval# we recoendthe sae intensity and duration of anticoagulanttherapy as in coparale patients who do not undergothroosis reoval (Grade 1B) .

2. Tiempo de Iniciaci/n de AVK y draci/n de la terapia

anticoaglante parenteral asociada

2.8 Hlecci/n de r0gimen anticoaglante inicial en pacientes

con trom6osis #enosa profnda proimal

2.: Tratamiento inicial domiciliario #s hospitalario en

pacientes con TV

27E Trom6/lisis Dirigida por Bat0ter en pacientes con

TV agda

46L) En los pacientes con TVP aguda pro'i#al de la

pierna6 sugeri#os terapia anticoagulante so$re

tro#$lisis dirigida por cat!ter CDT< rado 4C Terapia trom6olFtica sist0mica para pacientes con

TV agda

4659) En los pacientes con TVP aguda pro'i#al de la

pierna6 sugeri#os terapia anticoagulante so$re

tro#$lisis sist!#ica rado 4C


25/60

25


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+.1- $ena ,a6a Filters for the (nitial Treatent

of

Patients With D$T6.13.1. n patients with acute =%& of the leg# werecoend against the use of an %- fi lter in

addition to anticoagulants (Grade 1B) .6.13.6. n patients with acute pro*ial =%& of the legand contraindication to anticoagulation# werecoend the use of an %- fi lter (Grade 1B) .6.13.3. n patients with acute pro*ial =%& of the legand an %- fi lter inserted as an alternative to anticoagulation# we suggest a conventional course of anticoagulant therapy if their ris) of leeding resolves (2B) .

+.1 @arl" '!ulation of Patients With 'cute

D$T6.14. n patients with acute =%& of the leg# we

suggest early aulation over initial ed rest ( 2C) .

-./ Longter 'nticoagulation in Patients With

'cute

D$T of the Leg3.0. n patients with acute %&' who are treated withanticoagulant therapy# we recoend longtertherapy (see section 3.1 for recoended duration oftherapy" over stopping anticoagulant therapy afteraout 1 wee) of initial therapy (Grade 1B) .

-.1 Duration of Longter 'nticoagulant

Therap"3.1.1. n patients with a pro*ial =%& of the legprovo)ed y surgery# we recoend treatent withanticoagulation for 3 onths over (i" treatent of ashorter period (Grade 1B) # (ii" treatent of a longertieliited period (eg# @ or 16 onths" (1B) # or (iii"e*tended therapy (Grad 1B re"ardless of bleedin" ris#) .3.1.6. n patients with a pro*ial =%& of the legprovo)ed y a nonsurgical transient ris) factor# werecoend treatent with anticoagulation for 3onths over (i" treatent of a shorter period (Grade1B) # (ii" treatent of a longer tieliited period (eg# @or 16 onths" (Grade 1B) # and (iii" e*tended therapy if

there is a high leeding ris) (Grade 1B) . We suggesttreatent with anticoagulation for 3 onths overe*tended therapy if there is a low or oderateleeding ris) (Grade 2B) .

3.1.3. n patients with an isolated distal =%& of the legprovo)ed y surgery or y a nonsurgical transient ris)factor (see rear)"# we suggest treatent withanticoagulation for 3 onths over treatent of ashorter period (Grade 2C), and recoend treatentwith anticoagulation for 3 onths over treatent of alonger tieliited period (eg# @ or 16 onths" (Grade

1B) or e*tended therapy (Grade 1B re"ardless ofbleedin" ris#) .

2.1! &iltros de Vena Ba#a para el tratamiento inicial de los

pacientes con trom6osis #enosa profnda

271 Deam6laci/n preco en pacientes con TV agda

!7> Anticoaglaci/n a largo plao en pacientes con TV

agda de la pierna

!.1 Draci/n del tratamiento anticoaglante a largo plao

26


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27


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3.1.4. n patients with an unprovo)ed =%& of the leg(isolated distal ;see rear)< or pro*ial"# werecoend treatent with anticoagulation for at least3 onths over treatent of a shorter duration (Grade1B) . fter 3 onths of treatent# patients withunprovo)ed =%& of the leg should e evaluated forthe ris)enefi t ratio of e*tended therapy .

3.1.4.1. n patients with a fi rst %&' that is anunprovo)ed pro*ial =%& of the leg and who have alow or oderate leeding ris)# we suggest e*tendedanticoagulant therapy over 3 onthsof therapy ( 2B) .3.1.4.6. n patients with a fi rst %&' that is anunprovo)ed pro*ial =%& of the leg and who have ahigh leeding ris)# we recoend 3 onths ofanticoagulant therapy over e*tended therapy (1B) .3.1.4.3. n patients with a fi rst %&' that is anunprovo)ed isolated distal =%& of the leg (seerear)"# we suggest 3 onths of anticoagulanttherapy over e*tended therapy in those with a low or

oderate leeding ris) (Grade 2B) and recoend 3onths of anticoagulant treatent in those with a highleeding ris) (Grade 1B) .3.1.4.4. n patients with a second unprovo)ed %&'# werecoend e*tended anticoagulant therapy over 3onths of therapy in those who have a low leedingris) (Grade 1B), and we suggest e*tendedanticoagulant therapy in those with a oderateleeding ris) (Grade 2B) .3.1.4.+. n patients with a second unprovo)ed %&'who have a high leeding ris)# we suggest 3 onths ofanticoagulant therapy over e*tended therapy (2B) .3.1.+. n patients with =%& of the leg and activecancer# if the ris) of leeding is not high# werecoend e*tended anticoagulant therapy over 3onths of therapy (Grade 1B) # and if there is a highleeding ris)# we suggest e*tendedanticoagulanttherapy (Grade 2B) .

-.+ (ntensit" of 'nticoagulant @ffect3.6. n patients with =%& of the leg who are treatedwith %/# we recoend a therapeutic 2 range of

6.0 to 3.0 (target 2 of 6.+" over a lower (2 < 6" orhigher (2 3.0+.0" range for all treatent durations

(Grade 1B) .

-.- ,hoice of 'nticoagulant Regien for Long

ter Therap"3.3.1. n patients with =%& of the leg and no cancer#we suggest %/ therapy over LMWH for longtertherapy (Grade 2C) . For patients with =%& and nocancer who are not treated with %/therapy# wesuggest LMWH over daigatran or rivaro*aan forlongter therapy (Grade 2C) .

!.2 Intensidad del efecto anticoaglante

=64) En los pacientes con tro#$osis venosa pro0unda de la

pierna 1ue reci$en trata#iento con /V86 se reco#ienda

un rango terap!utico de IN; de 469 a =69 IN; o$jetivo de

46< so$re un rango in0erior IN;J 4


29/60

3.3.6. n patients with =%& of the leg and cancer# wesuggest LMWH over %/ therapy (Grade 2B) . npatients with =%& and cancer who are not treatedwith LMWH# we suggest %/ over daigatran or

rivaro*aan for longter therapy(Grade 2B) .

-. ,hoice of 'nticoagulant Regien for

@xtended Therap"3.4. n patients with =%& of the leg who receivee*tended therapy# we suggest treatent with the saeanticoagulant chosen for the fi rst 3 onths (Grade 2C)

-.4 Treatent of Patients With 's"ptoatic

D$T of the Leg3.+. n patients who are incidentally found to haveasyptoatic =%& of the leg# we suggest the sae

initial and longter anticoagulation as forcoparale patients with syptoatic =%& (2B) .

.1 ,opression 3toc&ings and *andages to

Pre6ent PT34.1. n patients with acute syptoatic =%& of theleg# we suggest the use of copression stoc)ings (2B) .

.+ Ph"sical Treatent of Patients With PT34.6.1. n patients with 9&, of the leg# we suggest a trialof copression stoc)ings (Grade 2C) .

4.6.6. n patients with severe 9&, of the leg that is notadeAuately relieved y copression stoc)ings# wesuggest a trial of an interittent copression device

(Grade 2B) .

.- Pharacologic Treatent of Patients With

PT34.3. n patients with 9&, of the leg# we suggest thatvenoactive edications (eg# rutosides# defi rotide# andhidrosin" not e used (Grade 2C) .

!. Hlecci/n de r0gimen anticoaglante para tto prolongado

=6A) En los pacientes con TVP de la pierna 1ue reci$en

trata#iento prolongado6 se aconseja el trata#iento con el

#is#o anticoagulante los pri#eros = #eses rado 4C'=%& that involves thea*illary or ore pro*ial veins# we suggest LMWH orfondaparinu* over % >FH (Grade 2C) and over ,->FH (Grade 2B) .

#.+ Thro!ol"tic Therap" for the (nitial

Treatent of Patients With @D$T.6.1. n patients with acute >'=%& that involves thea*illary or ore pro*ial veins# we suggest anticoagulant therapy alone over throolysis (Grade 2C) ..6.6. n patients with >'=%& who undergo

throolysis# we recoend the sae intensity andduration of anticoagulant therapy as in siilarpatients who do not undergo throolysis (Grade 1B) .

#.- Longter 'nticoagulation for Patients

With @D$T.3.1. n ost patients with >'=%& that is associatedwith a central venous catheter# we suggest that thecatheter not e reoved if it is functional and there isan ongoing need for the catheter (Grade 2C) ..3.6. n patients with >'=%& that involves thea*illary or ore pro*ial veins#we suggest a iniu

duration of anticoagulation of 3 onths over a shorterperiod (Grade 2B) ..3.3. n patients who have >'=%& that is associated

7,1 ro*%oe$dartere"to*a p*o$ar, erap#a a$t#"oaga$

te, = tro de /e$a "a/a para e tto de a #perte$!#'$p*o$ar tro*%oe*%'#"a "r'$#"a (PC)

G)5)5) En pacientes con 2PTC6 se reco#ienda anticoagula

-cin prolongada so$re interru#pir el tto rado 5B


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with a central venous catheter that is reoved# werecoend 3 onths of anticoagulation over a longerduration of therapy in patients with no cancer (Grade1B) # and we suggest this in patients with cancer (2C) .

: ppere;tre*#t=

34


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.3.4. n patients who have >'=%& that is associatedwith a central venous catheter that is not reoved# werecoend that anticoagulation is continued as longas the central venous catheter reains over stoppingafter 3 onths of treatent in patients with cancer

(Grade 1C) # and we suggest this in patients with nocancer (Grade 2C) .

.3.+. n patients who have >'=%& that is notassociated with a central venous catheter or withcancer# we recoend 3 onths of anticoagulationover a longer duration of therapy (Grade 1B) .

#. Pre6ention of PT3 of the 'r.4. n patients with acute syptoatic >'=% wesuggest against the use of copression sleeves orvenoactive edications (Grade 2C) .

#.4 Treatent of Patients With PT3 of the 'r.+.1. n patients who have 9&, of the ar# we suggest

a trial of copression andages or sleeves to reducesyptos (Grade 2C) ..+.6. n patients with 9&, of the ar# we suggestagainst treatent with venoactive edications (Grade2C) .

1/./ Patients With 3planchnic $ein Thro!osis10.1. n patients with syptoatic splanchnic veinthroosis (portal# esenteric# and!or splenic veinthrooses"# we recoend anticoagulation over noanticoagulation (Grade 1B) .10.6. n patients with incidentally detected splanchnic

vein throosis (portal# esenteric# and!or splenicvein throoses"# we suggest no anticoagulation overanticoagulation (Grade 2C) .

11./ Patients With Hepatic $ein Thro!osis11.1. n patients with syptoatic hepatic veinthroosis# we suggest anticoagulation over noanticoagulation (Grade 2C) .11.6. n patients with incidentally detected hepatic veinthroosis# we suggest no anticoagulation overanticoagulation (Grade 2C) .

L)=)A) En pacientes 1ue tienen &EDVT asociada con un

cat!ter venoso central 1ue no se 1uita6 se reco#ienda 1ue

la anticoagulacin se #antenga #ientras el cat!ter venoso

central se #antiene so$re interru#pirla a los = #eses de

trata#iento en pacientes con c,ncer rado 5C


36/60

&reatent and 9revention of Heparinnduced&hroocytopenia

+.1 Platelet ,ount Monitoring ,o!ined With

the Ts 3core for Patients Recei6ing

HeparinALMWH6.1.1. For patients receiving heparin in who clinicianconsider the ris) of heparininduced throocytopenia(H&" to e 51C# we suggest that platelet countonitoring e perfored every 6 or 3 days fro day 4to day 14 (or until heparin is stopped# whicheveroccurs first" (Grade 2C) .6.1.6. For patients receiving heparin in who clinician

consider the ris) of H& to e < 1C#we suggest thatplatelet counts not e onitored (Grade 2C) .

-.1 Discontinuation of Heparin or (nitiation of

$%'s

6s Treatent With )onheparin 'nticoagulants

3.1. n patients with H& coplicated y throosis(H&&"# we recoend the use of nonheparin anticoagulants# in particular lepirudin# argatroan# anddanaparoid# over the further use of heparin or LMWHor initiation!continuation ofa %/ (Grade 1C)

-.+ ,hoice of )onheparin 'nticoagulants in

Patients

With H(TT3.6.1. n patients with H&& who have noral renalfunction# we suggest the use of argatroan or lepirudinor danaparoid over other nonheparin anticoagulants

(Grade 2C) .3.6.6. n patients with H&& and renal insufficiency wesuggest the use of argatroan over other nonheparinanticoagulants (Grade 2C) .

-.- Platelet Transfusions3.3 n patients with H& and severe throocytopenia#we suggest giving platelet transfusions only if leedingor during the perforance of an invasive procedurewith a high ris) of leeding (Grade 2C) .

-. 3tarting $%'s *efore Platelet Reco6er"3.4.1. n patients with strongly suspected or confiredH we recoend against starting %/ untilplatelets have sustantially recovered (ie# usually to at

least 1+0 x 10!L"over starting %/ at a lower plateletcount and that the %/ e initially given in low doses(a*iu# + g of warfarin or @ gphenprocouon" over using higher doses (Grade 1C) .3.4.6. We further suggest that if a %/ has alreadyeen started when a patient is diagnosed with Hvitain / should e adinistered (Grade 2C) .

Trata#iento ( Prevencin de Tro#$ocitopenia inducida

por eparina

2.1 Segimiento del recento de pla'etas en com6inaci/n

con el Ts score en pacientes 'e reci6en heparina $,%

4)5)5) En pacientes 1ue reci$en eparina en los 1ue los

#!dicos consideren 1ue el riesgo de TI2 es K 5R6 se

sugiere #onitori+ar las pla1uetas cada 4 = d"as a partir

de d"a A al d"a 5A o asta 1ue la eparina se suspenda6 lo

1ue ocurra pri#ero< rado 4C


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-.4 Discontinuation of Thro!in (nhi!itor 'fter

aMiniu of 4 Da"s of 26erlap With $%'s3.+. n patients with confi red H we recoendthat that the %/ e overlapped with a nonheparinanticoagulant for a iniu of + days and until the2 is within the target range over shorter periods ofoverlap and that the 2 e rechec)ed after the anticoagulant effect of the nonheparin anticoagulant hasresolved (Grade 1C) .

.1 Discontinuation of Heparin or (nitiation of

$%'s

6s Treatent With )onheparin 'nticoagulants4.1. n patients with isolated H& (H& withoutthroosis"# we recoend the use of lepirudin orargatroan or danaparoid over the further use ofheparin or LMWH or initiation!continuation of a%/ (Grade 1C) .

.+ ,hoice of )onheparin 'nticoagulants in

Patients With (solated H(T4.6. n patients with isolated H& (H& withoutthroosis" who have noral renal function# we

suggest the use of argatroan or lepirudin ordanaparoid over other nonheparin anticoagulants (2C)

4.1 Patients Who Re?uire rgent ,ardiac

3urger"+.1.1. n patients with acute H& (throocytopenic#H& antiody positive" or suacute H& (plateletsrecovered ut still H& antiody positive" who reAuireurgent cardiac surgery# we suggest use of ivalirudinover other nonheparin anticoagulants and overheparin plus antiplatelet agents (Grade 2C) .+.1.6. n patients with acute H& who reAuire nonurgent cardiac surgery# we recoend delaying thesurgery (if possile" until H& has resolved and H&antiodies are negative (see section @.1" (Grade 2C) .

4.+ Patients Who Re?uire rgent Percutaneous

,oronar" (nter6entions+.6. n patients with acute H& or suacute H&who reAuire percutaneous coronary interventions#we suggest the use of ivalirudin (Grade 2B)anticoagulants.

4.- Patients Who Re?uire Renal ReplaceentTherap"+.3.1. n patients with acute or suacute H& who

!.8 Interrpci/n del inhi6idor de la trom6ina desp0s de n

mFnimo de 8 dFas de coincidencia con las AVK

=6) En los pacientes con 2IT con0i r#ada6 se reco#ienda

1ue la /V8 se superponga con un noneparin

anticoagulante durante un #"ni#o de d"as6 ( asta 1ue

el IN; est, dentro del rango o$jetivo vs per"odos #,s

cortos de superposicin6 ( 1ue el IN; sea revisado de

nuevo despu!s de 1ue el e0ecto anticoagulante del

anti coagulante non-eparin se a(a resuelto rado 5C


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reAuire renal replaceent therapy# we suggest the useof argatroan or danaparoid over other nonheparinanticoagulants (Grade 2C) .+.3.6. n patients with a past history of H& whoreAuire ongoing renal replaceent therapy or catheterloc)ing# we suggest the use of regional citrate over theuse of heparin

38


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4. Pregnant Patients+.4. n pregnant patients with acute or suacute Hwe suggest danaparoid over other nonheparin anticoagulants (2C) . We suggest the use of lepirudin orfondaparinu* only if danaparoid is not availale (2C) .

5.1 Patients With a Histor" of H(T Who

Re?uire ,ardiac 3urger"@.1.1. n patients with a history of H& in whoheparin antiodies have een shown to e asent whoreAuire cardiac surgery# we suggest the use of heparin(shortter use only" over nonheparin anticoagulants(Grade 2C), or LMWH (Grade 2C) [email protected]. n patients with a history of H& in whoheparin antiodies are still present who reAuirecardiac surgery# we suggest the use of nonheparinanticoagulants (see +.1.1" over heparin orLMWH (Grade 2C) .

5.+ Patients Who Re?uire P,(@.6. n patients with a history of H& in whoheparin antiodies have een shown to e asent whoreAuire cardiac catheteri:ation orpercutaneous coronary interventions# therecoendedtreatent is the sae as +.6.

5.- Patients Who Re?uire Proph"laxis or

Treatent

of [email protected]. n patients with a past history of H& whohave acute throosis (not related to H&" andnoral renal function# we suggest the use offondaparinu* at full therapeutic doses untiltransition to a %/ can e achieved (Grade 2C) .

8. acientes em6araadas

6A) En pacientes e#$ara+adas con 2IT aguda o

su$aguda6 sugeri#os danaparoid so$re otros anti-

coagulantes non-eparin rado 4C


40/60

ntithrootic &herapy for trial Firillation

+.1 Patients With )onrheuatic 'trial

Fi!rillation


41/60

+.+ Patients With 'F and Mitral 3tenosis6.6. For patients with F and itral stenosis# werecoend ad8usteddose %/ therapy (target2 range# 6.03.0" rather than no therapy# aspirin (7+g to 36+ g once daily"# or coination therapy with

aspirin and clopidogrel (all Grade 1B) . For patientswith F and itral stenosis who are unsuitale for orchoose not to ta)e ad8usteddose %/ therapy (forreasons other than concerns aout a8or leeding"# werecoend coination therapy with aspirin andclopidogrel rather than aspirin (7+ g to 36+ g oncedaily" alone (Grade 1B) .

-.1 Patients With 'F and 3ta!le ,oronar"

'rter" Disease3.1. For patients with F and stale coronary arterydisease (eg# no acute coronary syndroe within the

previous year" and who choose oral anticoagulation#we suggest ad8usteddose %/ therapy alone (targetinternational norali:ed ratio ;2< range# 6.03.0"rather than the coination of ad8usteddose %/therapy and aspirin (Grade 2C) .

-.+ Patients With 'F and Placeent of an

(ntracoronar"

3tent3.6. For patients with F at high ris) of stro)e (eg#-H=, 2 score of 6 or greater" during the fi rst onthafter placeent of a areetal stent or the fi rst 3 to @onths after placeent of a drugeluting stent# wesuggest triple therapy (eg# %/ therapy# aspirin# andclopidogrel" rather than dual antiplatelet therapy (eg#aspirin and clopidogrel" (Grade 2C) . fter this initialperiod of triple therapy# we suggest a %/ (2 6.03.0" plus a single antiplatelet drug rather than %/alone (Grade 2C) . t 16 onths after intracoronarystent placeent# antithrootic therapy is suggestedas for patients with F and stale coronary arterydisease (see section 3.1".

For patients with F at low to interediate ris) ofstro)e (eg# -H=, 6 score of 0 or 1" during the fi rst16 onths after placeent of an intracoronary stent(are etal or drug eluting"# we suggest dualantiplatelet therapy rather than triple therapy (?rade6-" . t 16 onths after intracoronary stentplaceent# antithrootic therapy is suggested as forpatients with F and stale coronary artery disease(see section 3.1".

2.2 acientes con fi6rilaci/n ariclar y estenosis mitral464) En pacientes con estenosis #itral ( ./6 reco#iendan

trata#iento con dosis ajustadas de /V8 o$jetivo IN; de

469 a =69< en ve+ de no-trata#iento6 aspirina G #g a =4

#g una ve+ al d"a


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-.- Patients With 'F and ',3 Who Do )ot

ndergo

(ntracoronar" 3tent Placeent3.3. For patients with F at interediate to high ris)

of stro)e (eg# -H=, 2 score of 1 or greater" whoe*perience an acute coronary syndroe and do notundergo intracoronary stent placeent# we suggest forthe fi rst 16 onths# ad8usteddose %/ therapy (26.03.0" plus single antiplatelet therapy rather thandual antiplatelet therapy (eg# aspirin and clopidogrel"or triple therapy (eg# warfarin# aspirin# andclopidogrel (Grade 2C) . fter the first 16 onths#antithrootic therapy is suggested as for patientswith F and stale coronary artery disease (see section3.1".

For patients with F at low ris) of stro)e (eg# -H=,2 score of 0"# we suggest dual antiplatelet therapy (eg#aspirin and clopidogrel" rather than ad8usteddose%/ therapy (2 6.03.0" plus single antiplatelettherapy or triple therapy (eg# warfarin# aspirin# andclopidogrel" (Grade 2C) . fter the fi rst 16 onths#antithrootic therapy is suggested as for patientswith F and stale coronary artery disease (see section3.1".

-. Patients With 'F Managed !" a Rh"th

,ontrol

3trateg"3.4. For patients with F eing anaged with arhyth control strategy (pharacologic or catheteralation"# we suggest that antithrootic therapydecisions follow the general ris)ased recoendatiofor patients with F in section 6.1# regardless of theapparent persistence of noral sinus rhyth (2C) .

-.4 Patients With 'trial Flutter3.+. For patients with atrial fl utter# we suggest thatantithrootic therapy decisions follow the sae ris)ased recoendations as for F.

.1 Patients ndergoing @lecti6e ,ardio6ersion

of 'F4.1.1. For patients with F of greater than 4$ h orun)nown duration undergoing elective electrical orpharacologic cardioversion# we recoend therapeutic anticoagulation (ad8usteddose %/ therapy#target 2 range 6.03.0# lowolecularweightheparin at full venous throoeolis treatentdoses# or daigatran" for at least 3 wee)s efore cardioversion or a transesophageal echocardio graphy (&''" guided approach with areviated anticoagulationefore cardioversion rather than no anticoagulation(1B) . We recoend therapeutic anticoagulation forat least 4 wee)s after successful cardioversion to sinus

!.! acientes con &A y ABS 'e no sometidos a

colocaci/n de stent intracoronario=6=) Para los pacientes con ./ en riesgo inter#edio ( alto

de accidente cere$rovascular por eje#plo6 C2/D* 4 de

5 #,s< 1ue su0ren un s"ndro#e coronario agudo ( no seso#eten a la colocacin de un stent intracoronario6

sugeri#os para los pri#eros 54 #eses6 trata#iento con

dosis ajustadas de /V8 IN; 4)9-=)9


43/60

rhyth rather than no anticoagulation# regardless ofthe aseline ris) of stro)e (Grade 1B)

43


44/60

=ecisions aout anticoagulation eyond 4 wee)sshould e ade in accordance with our ris)asedrecoendations for longter antithrootictherapy in section 6.1.

4.1.6. For patients with F of docuented duration of4$ h or less undergoing elective cardioversion(electrical or pharacologic"# we suggest starting

anticoagulation at presentation (lowolecularweightheparin or unfractionated heparin at full venousthrooeolis treatent doses" and proceeding tocardioversion rather than delaying cardioversionfor 3 wee)s of therapeutic anticoagulation or a &''guided approach (Grade 2C) . fter successful cardioversion to sinus rhyth# we recoend therapeuticanticoagulation for at least 4 wee)s rather than noanticoagulation# regardless of aseline stro)e ris) (2C)=ecisions aout longter anticoagulation aftercardioversion should e ade in accordance with ourris)ased recoendations for longter

antithrootic therapy in section 6.1.

.+ Patients ndergoing rgent ,ardio6ersion

for

Heod"naicall" nsta!le 'F4.6. For patients with F and heodynaic instailityundergoing urgent cardioversion (electrical orpharacologic"# we suggest that therapeuticdoseparenteral anticoagulation e started eforecardioversion# if possile (Grade 2C) # ut thatinitiation of anticoagulation ust not delay anyeergency intervention (Grade 2C) . fter successful

cardioversion to sinus rhyth# we suggest therapeuticanticoagulation for at least 4 wee)s after successfulcardioversion to sinus rhyth rather than no anticoagulation# regardless of aseline stro)e ris) (Grade 2C) .=ecisions aout anticoagulation eyond 4 wee)sshould e ade in accordance with our ris)asedrecoendations for longter antithrootictherapy in section 6.1.

.- Patients ndergoing @lecti6e or rgent

,ardio6ersion for 'trial Flutter4.3. For patients with atrial flutter undergoing

elective or urgent pharacologic or electricalcardioversion# we suggest that the sae approach tothrooprophyla*is e used as for patients with atrialfi rillation undergoingcardioversion.

>as decisiones so$re anticoagulacin #,s all, de A

se#anas de$e acerse de acuerdo con las reco#enda

-ciones de terapia antitro#$tica $asadas en riesgo a

largo pla+o de la seccin 4)5)

A)5)4) En pacientes con ./ de duracin docu#entada de

AH oras o #enos so#etidos a cardioversin electiva

el!ctrica o 0ar#acolgica


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ntithrootic and &hroolytic &herapy for%alvular =isease

+./ Patients With Rheuatic Mitral $al6e

Disease6.0.1. n patients with rheuatic itral valve diseaseand noral sinus rhyth with a left atrial diaeter


46/60

T@@ B Transesophageal @chocardiograph"G BC @T@; @cocardiografa TransesofEgica. PF2 B

Patent Foraen 26ale F2P

@.6.3. n patients with cryptogenic stro)e and 9F or

atrial septal aneurys# who e*perience recurrentevents despite aspirin therapy# we suggest treatentwith %/ therapy (target 2# 6.+D range# 6.03.0"and consideration of device closure over aspirintherapy (Grade 2C) .

@.6.4. n patients with cryptogenic stro)e and 9F#with evidence of =% we recoend %/ therapyfor 3 onths (target 2# 6.+D range# 6.03.0" (Grade1B) and consideration of device closure over no %/therapy or aspirin therapy (Grade 2C) .

7.1 Role of 'nticoagulants and 'ntiplatelet

'gents in

Patients With )ati6e $al6e @ndocarditis7.1.1. n patients with infective endocarditis ('"# werecoend against routine anticoagulant therapy#unless a separate indication e*ists (Grade 1C) .7.1.6. n patients with '# we recoend againstroutine antiplatelet therapy# unless a separateindication e*ists (Grade 1B) .

7.+ Role of 'nticoagulants in Patients WithProsthetic

$al6e @ndocarditis7.6. n patients on %/ for a prosthetic valve whodevelop '# we suggest %/ e discontinued at thetie of initial presentation until it is clear that invasiveprocedures will not e reAuired and the patient hasstaili:ed without signs of -2, involveent. When thepatient is deeed stale without contraindications orneurologic coplications# we suggest reinstitution of%/ therapy (Grade 2C) .

7.- Patients With )on!acterial Thro!otic

@ndocarditis7.3. n patients with nonacterial throoticendocarditis and systeic or pulonary eoli# wesuggest treatent with fulldose % >FH or ,-LMWH over no anticoagulation (Grade 2C) .

8.+ 'ntithro!otic Therap" in the First -

Months 'fter 3urger"$.6.1. n patients with aortic ioprosthetic valves# whoare in sinus rhyth and have no other indication for%/ therapy# we suggest aspirin (+0100 g!d" over%/ therapy in the fi rst 3 onths (Grade 2C) .

F)4)=) En pacientes con ictus criptog!nico ( .P o

aneuris#a del septo auricular6 1ue e'peri#entan eventosrecurrentes a pesar de terapia con aspirina6 se sugiere

trata#iento con /V8 IN; o$jetivo de 466 rango6 469-

=69< ( considerar colocar un dispositivo de cierre vs

terapia con aspirina rado 4C


47/60

$.6.6. n patients with transcatheter aorticioprosthetic valves# we suggest aspirin (+0100 g!d"plus clopidogrel (7+ g!d" over %/ therapy and overno antiplatelet therapy in the fi rst 3 onths (Gr 2C) .

47


48/60

$.6.3. n patients with a ioprosthetic valve in theitral position# we suggest %/ therapy (target 2#6.+D range# 6.03.0" over no %/ therapy for the fi rst3 onths after valve insertion (Grade 2C) .

8.- Longter 'ntithro!otic Therap" for

Patients With *ioprosthetic $al6es

$.3. n patients with ioprosthetic valves in noralsinus rhyth# we suggest aspirin therapy over noaspirin therapy after 3 onths postoperative (Gr 2C) .

#.1 @arl" Postoperati6e *ridging to

(nterediateA

Longter Therap"


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#.5 'ntiplaelet 'gent in 'ddition to $%' Therap"

for

Patients With Mechanical 'ortic or Mitral $al6e

Prostheses.@. n patients with a echanical itral or aorticvalve at low ris) of leeding# we suggest adding overnot adding an antiplatelet agent such as lowdoseaspirin (+0100 g!d" to the %/ therapy (Grade 1B) .

Rear&s; Cation shold be sed in patients atincreased bleedin" ris#, sch as histor% of G& bleedin".

#.7 'ntiplatelet 'gent Therap" (nstead of $%'

Therap".7. For patients with echanical aortic or itral

valves we recoend %/ over antiplatelet agents(Grade 1B) .

1/.1 'ntithro!otic Therap" 'fter Mitral $al6e

Repair10.1. n patients undergoing itral valve repair with aprosthetic and in noral sinus rhyth# we suggestthe use of antiplatelet therapy for the fi rst 3 onthsover %/ therapy (Grade 2C) .

1/.+ Patients ndergoing 'ortic $al6e Repair10.6. n patients undergoing aortic valve repair# we

suggest aspirin at +0 to 100 g!d over %/ therapy(Grade 2C) .

11.1 Patients With Right3ided Prosthetic $al6e

Thro!osis11.1. For patients with rightsided prosthetic valvethroosis (9%&"# in the asence of contraindicationswe suggest adinistration of fi rinolytic therapy oversurgical intervention (Grade 2C) .

11.+ Patients With Left3ided Prosthetic $al6e

Thro!osis11.6.1. For patients with leftsided 9%& and largethrous area ( 50.$ c6"# we suggest early surgeryover fi rinolytic therapy (Grade 2C) . f contraindi Ications to surgery e*ist# we suggest the use offirinolytic therapy (Grade 2C) .

11.6.6. For patients with leftsided 9%& and sall

throus area ( , 0.$ c 2 "# we suggest adinistrationof fi rinolytic therapy over surgery. For very sall#nonostructive throus we suggest % >FHaccopanied y serial =oppler echocardiography todocuent throus resolution or iproveent overother alternatives (Grade 2C) .

E.9 Agentes antipla'etares7 ademCs de AVK7 enpacientes con pr/tesis mecCnica a/rtica o mitralL6F) En pacientes con v,lvula #ec,nica #itral o artica6

con $ajo riesgo de sangrado6 se sugiere aUadir6 vs no-aUadir6 un agente antipla1uetario co#o la aspirina a

dosis $ajas 9-599 #g % d


50/60

ntithrootic and &hroolytic &herapy forscheic ,tro)e

+.1 ($ Reco!inant Tissue Plasinogen

'cti6ator


51/60

51


52/60

3.1.6. n patients with acute ischeic stro)e andrestricted oility# we suggest prophylacticdoseLMWH over prophylacticdose >FH (Grade 2B).3.1.3. n patients with acute stro)e and restrictedoility# we suggest against elastic copressionstoc)ings (Grade 2B).

-.+ $T@ Pre6ention in Patients WithHeorrhagic 3tro&e3.6.1. n patients with acute priary intracereralheorrhage and restricted oility# we suggestprophylacticdose ,- heparin (>FH or LMWH"started etween days 6 and 4 or interittentpneuatic copression devices over no prophyla*is

(Grade 2C).3.6.6. n patients with acute priary intracereralheorrhage and restricted oility# we suggestprophylacticdose LMWH over prophylacticdose>FH (Grade 2B).

3.6.3. n patients with priary intracereralheorrhage and restricted oility# we suggestagainst elastic copression stoc)ings (Grade 2B).

.1 'ntithro!otic Therap" for the 3econdar"

Pre6ention of )oncardioe!olic 3tro&e4.1.1. n patients with a history of noncardioeolicischeic stro)e or we recoend longtertreatent with aspirin (7+100 g once daily"#clopidogrel (7+ g once daily"# aspirin!e*tendedrelease dipyridaole (6+ g!600 g id"# or cilosta:ol

(100 g id" over no antiplatelet therapy (Grade 1$)#oral anticoagulants (Grade 1B)# the coination ofclopidogrel plus aspirin (Grade 1B)# or triflusal (2B).

4.1.6. f the recoended antiplatelet regiens# wesuggest clopidogrel or aspirin!e*tended releasedipyridaole over aspirin (Gr 2B) or cilosta:ol (2C).

.+ 'ntithro!otic Therap" for the 3econdar"

Pre6ention of ,ardioe!olic 3tro&e4.6.1. n patients with a history of ischeic stro)e or

& and F# including paro*ysal F# werecoend oral anticoagulation over no antithrootic therapy (Grade 1$)# aspirin (Grade 1B)# orcoination therapy with aspirin and clopidogrel (1B)

4.6.6. n patients with a history of ischeic stro)e or& and atrial fi rillation# including paro*ysal F#we suggest oral anticoagulation with daigatran 1+0g id over ad8usteddose %/ therapy (target range#6.03.0" (Grade 2B).

=)5)4) En pacientes con ictus is1u!#ico agudo (

#ovilidad restringida6 sugieren dosis pro0il,cticas de

2BPM so$re dosis pro0il,cticas de 2N. rado 4B


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4.6.3. n patients with a history of ischeic stro)e or& and atrial fi rillation# including paro*ysal F#who are unsuitale for or choose not to ta)e an oralanticoagulant (for reasons other than concerns aout

a8or leeding"# we recoend coination therapywith aspirin and clopidogrel over aspirin (Grade 1B).

Rear&s; 'atients shold be treated (ie, brid"ed) ithaspirin ntil anticoa"lation has reached a therapeticleel. *ral anticoa"lation shold "enerall% be initiatedithin 1 to 2 ee#s after stro#e onset. +arlier anticoa" lation can be considered for patients at lo ris# ofbleedin" complications (e", those ith a small infarctbrden and no eidence of hemorrha"e on brain ima"in").-ela%in" anticoa"lation shold be considered forpatients at hi"h ris# of hemorrha"ic complications (e",those ith e!tensie infarct brden or eidence of si"nifi

cant hemorrha"ic transformation on brain ima"in").-abi"atran is e!creted primaril% b% the #idne%. &t has notbeen stdied and is contraindicated in patients ith seererenal impairment (estimated creatinine clearance of /mL0min or less).

.- 'ntithro!otic Therap" for 3tro&e

Pre6ention in

Patients With a Histor" of (ntracere!ral

Heorrhage


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&he 9riary and ,econdary 9revention of-ardiovascular =isease

+./ Priar" Pre6ention of ,ardio6ascular

Disease

6.1. For persons aged +0 years or older without syptoatic cardiovascular disease# we suggest lowdose aspirin7+ to 100 g daily over no aspirin therapy (2B) .

-.1 ,hoice of Longter 'ntithro!otic Therap"

in

Patients With @sta!lished ,oronar" 'rter"

Disease re#enci/n rimaria de Hnfermedades Bardio#asclares

465) En personas #a(ores de 9 aUos sin en0er#edad

cardiovascular sinto#,tica6 sugeri#os dosis $ajas deaspirina G a 599 #g al d"a 0rente a no-aspirina 4B o con $yass coronario re%io, ?3:

X *e reco#ienda terapia antipla1uetaria a largo pla+o conaspirina sola G a 599 #g al d"a o clopidogrel G #g al d"a

0rente a no - trata#iento anticoagulante grado 5/


55/60

ventricular (L%" throus# or at high ris) for L%

throus (e8ection fraction , 40C# anteroapical wallotion anorality"# who do not undergo stentingG

Coro$ar= +rter= #!ea!e (C+) $&er*edad +rter#a Coro$ar#a (+C). +"te Coro$ar= S=$dro*e (+CS)

S$dro*e Coro$ar#o +gdo (SC+). pPr"ta$eo! Coro$ar= $ter/e$t#o$ (PC) CP $ter/e$"#'$ Coro$ar#a Per"t$ea

55


56/60

8 We recoend warfarin (2 6.03.0" plus lowdoseaspirin 7+ to 100 g daily over single antiplatelettherapy or dual antiplatelet therapy for the fi rst 3onths (Grade 1B) .&hereafter# we recoend discontinuation ofwarfarin and continuation of dual antiplatelet therapyfor up to 16 onths as per the -, recoendations(see recoendations 3.6.13.6.+". fter 16 onths#

single antiplatelet therapy is recoended as per theestalished -= recoendations (see recoendations 3.1.13.1.+".

For patients with anterior M and L% throus# or at

high ris) for L% throus (e8ection fraction < 40C#anteroapical wall otion anorality"# who undergoareetal stent (M," placeentG

8 We suggest triple therapy (warfarin ;2 6.03.0ing @lecti6e

P,(4.1.14.3.+. For patients who have undergone elective9- with placeent of M,G

8 For the fi rst onth# we recoend dual antiplatelet therapy with aspirin 7+ to 36+ g daily andclopidogrel 7+ g daily over single antiplatelet therapy

(Grade 1$) .

X *e reco#ienda 7ar0arina IN; 4)9-=)9


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8 For the suseAuent 11 onths# we suggest dualantiplatelet therapy with coination of lowdoseaspirin 7+ to 100 g daily and clopidogrel 7+ g dailyover single antiplatelet therapy (Grade 2C) .8 fter 16 onths# we recoend single antiplatelettherapy over continuation of dual antiplatelet therapy

(Grade 1B) .

For patients who have undergone elective 9- withplaceent of =',G

8 For the fi rst 3 to @ onths# we recoend dualantiplatelet therapy with aspirin 7+ to 36+ g dailyand clopidogrel 7+ g daily over single antiplatelettherapy (Grade 1$) .8 fter 3 to @ onths# we suggest continuation of dualantiplatelet therapy with lowdose aspirin 7+ to 100 gand clopidogrel (7+ g daily" until 16 onths oversingle antiplatelet therapy (Grade 2C) .8 fter 16 onths# we recoend single antiplatelet therapy over continuation of dual antiplatelet therapy (1B) .,ingle antiplatelet therapy thereafter is recoended asper the estalished -= (see 3.1.13.1.+".

For patients who have undergone elective M, or=', stent placeentG

8 We recoend using lowdose aspirin 7+ to 100 gdaily and clopidogrel 7+ g daily alone rather thancilosta:ol in addition to these drugs (Grade 1B) .

8 We suggest aspirin 7+ to 100 g daily or clopidogrel7+ g daily as part of dual antiplatelet therapy ratherthan the use of either drug with cilosta:ol (Grade 1B) .

8 We suggest cilosta:ol 100 g twice daily as sustitute

for either lowdose aspirin 7+ to 100 g daily orclopidogrel 7+ g daily as part of a dual antiplateletregien in patients with an allergy or intolerance ofeither drug class (Grade 2C) .For patients with -= undergoing elective 9- ut nostent placeentG

8 We suggest for the fi rst onth dual antiplatelet therapy with aspirin 7+ to 36+ g daily and clopidogrel 7+g daily over single antiplatelet therapy (Grade 2C) .,ingle antiplatelet therapy thereafter is recoended asper the estalished -= (see 3.1.13.1.+".

4./ 'ntithro!otic Therap" in Patients With3"stolic

L$ D"sfunction+.1+.3. For patients with systolic L% dysfunctionwithout estalished -= and no L% throus# wesuggest not to use antiplatelet therapy or warfarin (2C)For patients with systolic L% dysfunction withoutestalished -= with identifi ed acute L% throus(eg# &a)otsuo cardioyopathy"# we suggest oderateintensity warfarin (2 6.03.0" for at least 3 onths

(Grade 2C) .For patients with systolic L% dysfunction andestalished -=# recoendations are as per theestalished -= recoendations (seerecoendations 3.1.13.1.+".

X Para los siguientes 55 #eses6 sugieren do$le

antiagregacin con la co#$inacin de dosis $ajas de

aspirina G a 599 #g al d"a ( clopidogrel G #g al d"a

0rente a trata#iento con un solo antiagregante

pla1uetario rado 4C


58/60

ntithrootic &herapy in 9eripheral rtery =isease

+./ Priar" Pre6ention of ,ardio6ascular

@6ents in Patients >ith 's"ptoatic P'D6.1. For persons with asyptoatic peripheral arterialdisease (9="# we suggest aspirin 7+ to 100 g dailyover no aspirin therapy (Grade 2B) .

-./ 3econdar" Pre6ention of ,ardio6ascular

@6ents in Patients >ith 3"ptoatic P'D3.13.4. For secondary prevention patients withsyptoatic 9=# we recoend one of the twofollowing antithrootic regiens to e continuedlong ter over no antithrootic treatentG aspirin7+ to 100 g daily or clopidogrel 7+ g daily (all Grade

1$) . We suggest not to use dual antiplatelet therapywith aspirin plus clopidogrel (Grade 2B) . Werecoend not to use an antiplatelet agent withoderateintensity warfarin (Grade 1B) .

./ 'ntithro!otic Therap" for the Manageent

of

Patients >ith ,laudication4.14.4. For patients with interittent claudicationrefractory to e*ercise therapy (and so)ing cessation"#we suggest the use of cilosta:ol in addition to reviously

recoended antithrootic therapies (aspirin 7+100 g daily or clopidogrel 7+ g daily" (Grade 2C) Dwe suggest against the use of pento*ifylline#heparinoids# or prostanoids (Grade 2C) .

4./ Patients With ,ritical Li! (scheia+.1. For patients with syptoatic 9= and criticalleg ischeia!rest pain who are not candidates forvascular intervention# we suggest the use ofprostanoids in addition to previously recoendedantithrootic therapies (aspirin 7+100 g daily orclopidogrel 7+ g daily"(Grade 2C) .

5./ 'cute Li! ([email protected]@.3. n patients with acute li ischeia due toarterial eoli or throosis# we suggest iediatesysteic anticoagulation with unfractionated heparinover no anticoagulation (Grade 2C) D we suggestreperfusion therapy (surgery or throolysis" overno reperfusion therapy (Grade 2C) D we recoendsurgery over throolysis (Grade 1B) . n patientsundergoing throolysis# we suggest recoinanttissuetype plasinogen activator (rt9" or uro)inaseover strepto)inase (Grade 2C) .

Trata#iento antitro#$tico en la En0er#edad

/rterial Peri0!rica

27> pre#enci/n primaria de e#entos cardio#asclares enpacientes con enfermedad arterial perif0rica asintomCtica465) En personas con en0er#edad arterial peri0!rica

asinto#,tica P/D


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7./ @ndo6ascular Re6asculari0ation in Patients

With

3"ptoatic P'D7.1. For patients undergoing peripheral arterypercutaneous transluinal angioplasty with orwithout stenting# we recoend longter aspirin (7+100 g!day" or clopidogrel (7+ g!day" (Grade 1$) .For patients undergoing peripheral arterypercutaneous transluinal angioplasty with stenting#we suggest single rather than dual antiplatelet therapy

(Grade 2C) .

8./ 'ntithro!otic Therap" Follo>ing

Peripheral 'rter" *"pass raft 3urger"$.1$.4. We recoend one of the following antithrootic regiens to e continued longter followingperipheral artery ypass graft surgery over noantithrootic treatentG aspirin 7+ to 100 g dailyor clopidogrel 7+ g daily (all Grade 1$) .We recoend single antiplatelet therapy overantiplatelet therapy and warfarin (Grade 1B) . npatients undergoing elow)nee ypass graft surgerywith prosthetic grafts# we suggest clopidogrel 7+ g!dplus aspirin (7+100 g!d" over aspirin alone for 1year (Grade 2C) . For all other patients# we suggest

single over dual antiplatelet therapy (Grade 2B) .

#./ Patients With ,arotid 'rter" 3tenosis.1. For patients with asyptoatic carotid stenosis#we suggest aspirin 7+ to 100 g daily over no aspirintherapy (Grade 2B) ..6.3. n patients with syptoatic carotid stenosis(including recent carotid endarterectoy"# werecoend longter antiplatelet therapy withclopidogrel (7+ g once daily" or aspirine*tendedrelease dipyridaole (6+ g!600 g id" or aspirin(7+100 g once daily" over no antiplatelet therapy

(Grade 1$) . We suggest either clopidogrel (7+ g oncedaily" or aspirine*tendedrelease dipyridaole (6+g!600 g id" over aspirin (7+100 g" (Grade 2B) .

:.> *e#asclariaci/n endo#asclar en pacientes con

HA sintomCtica

G65) En pacientes so#etidos a angioplastia translu#inal

percut,nea arterial peri0!rica con o sin colocacin de

stent6 se reco#ienda aspirina a largo pla+o G-599 #g %

d"a< o clopidogrel G #g % d"a< grado 5/


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2012 ACCP. Guías Tto antitrombótico. Chest

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Transcript of 2012 ACCP. Guías Tto antitrombótico. Chest