ACS in patients already on NOACs

[Sonne86]

I've been looking through the various cardiology guidelines for a consensus on what to do with these patients regarding anticoagulation (I am an emergency physician that works per diem at a critical access hospital, sometimes cardiology isn't readily available overnight unless it's for a STEMI).

• Do you start these patients on LMWH/UFH? Does my management in terms of anticoagulation change if you know they are going to the cath lab shortly.
• If the last dose of their NOAC was 12-24h (or they are due to take their NOAC), should I just start them on lovenox/heparin. They would probably still have some effect from the NOAC since most of them seem to have an elimination half life around 12h. If you're starting them on heparin/lovenox do you reduce the dose?
• For patients with NSTEMI on a NOAC in whom you are pursuing ischemia guided therapy, are you generally continuing the NOAC or bridging them to LMWH/UFH during their inpatient course?

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[ROBINHO]

There is no guideline that answers your question as far as I am concerned
But pathway for heparin and NOAC are different. So it is important that they get the heparin in ACS.
If its STEMI, they going to get the heparin during intervention irrespective of NOAC or no NOAC
The data for heparin in NSTEMI is not convincing so if you doing ischemia guided therapy--> will make sense to look out for their bleeding risk(ex. DAPT score). If bleeding risk is high then will definitely wait for appropriate timing to transition to heparin.
And I personally would favor heparin with no bolus or lower PTTs if I anticipate the NOAC to be at peak effect

 

[Sonne86]

There is no guideline that answers your question as far as I am concerned
But pathway for heparin and NOAC are different. So it is important that they get the heparin in ACS.
If its STEMI, they going to get the heparin during intervention irrespective of NOAC or no NOAC
The data for heparin in NSTEMI is not convincing so if you doing ischemia guided therapy--> will make sense to look out for their bleeding risk(ex. DAPT score). If bleeding risk is high then will definitely wait for appropriate timing to transition to heparin.
And I personally would favor heparin with no bolus or lower PTTs if I anticipate the NOAC to be at peak effect

Thank you!!!