Lovenox in Afib

[roja]

So, today in the ED, I had someone come in wiht your classic r/o ACS. EKG also showed a new (within the last year!) afib..... renal function was normal and the discussion (which became moot as pt was Heme Pos) began of using lovenox in afib.


What do you guys think?

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[Annette]

I've used full dose (1mg/kg) in a pt with line access troubles. Also, in a pat who wanted to go home, but wasn't theraputic on coumadin. Still prefer heparin because we can stop it so easily. If the patient is likely to be cathed, would use heparin because the CVS people hate lovenox.

 

[drpcb]

I've used full dose (1mg/kg) in a pt with line access troubles. Also, in a pat who wanted to go home, but wasn't theraputic on coumadin. Still prefer heparin because we can stop it so easily. If the patient is likely to be cathed, would use heparin because the CVS people hate lovenox.

I still give lovenox to patients who are heme positive. If they are blowing red blood out their rectum I will type and cross for 2 units as well. I do not let heme pos affect my treatment to heparanize. I find it weird that some people won't heparinize for heme pos, but forget to grill the patient about recent head trauma, bleeds or anything else in the noggin. The only bleeding I care about is CNS.

 

[drpcb]

I still give lovenox to patients who are heme positive. If they are blowing red blood out their rectum I will type and cross for 2 units as well. I do not let heme pos affect my treatment to heparanize. I find it weird that some people won't heparinize for heme pos, but forget to grill the patient about recent head trauma, bleeds or anything else in the noggin. The only bleeding I care about is CNS.

Back to your original question, I always use lovenox for a-fib, because it's such a pain to get any drips going in my ED. If the person in AF is a firy high risk USA and really going to the lab, I will do the heparin drip since cards really likes it, and it will soon be their patient. Same philosophy for PE that is submassive or bigger, only because it seems prudent to get ones levels up as quickly as possible. Smaller well compensated PE's get lovenox.

 

[southerndoc]

I still give lovenox to patients who are heme positive. If they are blowing red blood out their rectum I will type and cross for 2 units as well. I do not let heme pos affect my treatment to heparanize. I find it weird that some people won't heparinize for heme pos, but forget to grill the patient about recent head trauma, bleeds or anything else in the noggin. The only bleeding I care about is CNS.

I agree. Hemoccults rarely change management of patients needing heparinization.

 

[Annette]

I still give lovenox to patients who are heme positive. . . . The only bleeding I care about is CNS.

Yet another wonderful reason to use heparin instead of lovenox! If you get someone starting to bleed into the brain, how ya gonna reverse lovenox?

 

[drpcb]

Yet another wonderful reason to use heparin instead of lovenox! If you get someone starting to bleed into the brain, how ya gonna reverse lovenox?

Yes if someone bleeds in the brain, I would hope that they bled while on heparin, as it responds better to protamine- although brain bleeds on either usually are badness even if reversed. I prefer to minimize their risk of CNS bleed with screening history, and dose reductions in renal or liver disease whether lovenox or heparin.

 

[Annette]

I don't understand why the ED would be using lovenox at all. In a heart patient to be admitted, you have to assume, in a worse case scenario, the patient is going to need a cabg. If you use lovenox, the patient is going to have to wait 2-3 days at a minimum. Same with new onset afib. In PE, I want to know for certain the patient is fully anticoagulated. I assume that you are admitting the patient to medicine or ICU and the call for lovenox or heparin should be up to the admitting service. In pts with DVT, same thing applies.

 

[Apollyon]

I don't understand why the ED would be using lovenox at all. In a heart patient to be admitted, you have to assume, in a worse case scenario, the patient is going to need a cabg. If you use lovenox, the patient is going to have to wait 2-3 days at a minimum. Same with new onset afib. In PE, I want to know for certain the patient is fully anticoagulated. I assume that you are admitting the patient to medicine or ICU and the call for lovenox or heparin should be up to the admitting service. In pts with DVT, same thing applies.

Take a trip down the river, then turn left, and stop at Duke - here, you will get (forgive the pun) Lovenox out the ass. There is so much friggin' data that cards is ALL OVER about Lovenox (and yet, there are 3 active schools of thought in cards ALONE about it), and the interventional guys say just don't give the AM dose the morning of cath. Otherwise, the Lovenox bridge gets people out of the hospital faster.

 

[johnd]

Agree with annette. Lovenox is fine for ACS of course but no indication to give it for the Afib in the ER. Remember, this person has been likely walking around in this rhythm for a while. The risk of stroke is only around 5% per YEAR (depending on risk factors). This is why most cardiologists don't insist on pt's having therapeutic INR's prior to discharge for Afib. Of course its a different story if cardioversion is performed.

 

[roja]

Not use lovenox in the ED? your kidding right? I am going to concur with apollyon here. There are many reasons to use lovenox instead of heparin. decreased length of stay, less sticks for the patients. I have enough medicine friends to know they MUCH prefer lovenox as a good chunk of patients are hard sticks and they end up called to draw bloods...

 

[Annette]

I'm not saying NOT to use lovenox- I think it is great stuff. I'm just saying that I think the service responsible for final dispostion (follow up) should make the call to use lovenox instead of heparin, not the ED. It certainly is easy enough to stop the drip and give a shot. It is kind of hard to stop the lovenox once it has been given.