WerdSalid

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Just wondering how you guys are managing ACS patients who are therapeutic on coumadin. For example, patients with chest pain that you plan to admit, either for NSTEMI or chest pain / angina for r/o MI. Do you routinely start heparin? How about ASA? I'm sure practices vary based on location but what kind of feedback and guidance are you getting from your cardiologists when these situations arise? Thanks for you feedback.
 

Pinner Doc

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Just wondering how you guys are managing ACS patients who are therapeutic on coumadin. For example, patients with chest pain that you plan to admit, either for NSTEMI or chest pain / angina for r/o MI. Do you routinely start heparin? How about ASA? I'm sure practices vary based on location but what kind of feedback and guidance are you getting from your cardiologists when these situations arise? Thanks for you feedback.
Correct me if I'm wrong, but at least in my practice, if our patients are therapeutic on coumadin, we don't start heparin. We do give ASA though - given that it has a different mechanism of aspirin (platelet inhibition vs clotting cascade). Almost everyone I see for chest pain gets aspirin -- there are very few reasons I don't, such as if they've already had 325mg that day. I don't readily start heparin in a rule out, though. If I'm sending them to the observation unit overnight, I usually think they're pretty low risk but deserve provocative testing. (These are the people with no EKG changes, normal enzymes and whose pain I have controlled). Anyone I actually get nervous about and admit to our cards team (usually those w known CAD, previous MI, or concerns for NSTEMI/unstable angina) do get heparin if they're not therapeutic on coumadin.

At least, that's how I do it. At my community hospital (I'm still a resident), we don't have an obs unit, so I do a lot of delta ekg/troponin/ck/ckmb and discharge with followup after 2 hours if their pain has been under 8 hours.
 

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ASA every pt when they hit the door; any EKG changes at all concerning for iscehmia: plavix; heparin if I am really concerned. All of this regardless of Warfarin usage, as it can take a while sometimes for INR to come back. Also, when you shut heparin off-- effects end quickly. Always put a finger in the butt prior to this. My chest pain recipe.
 

EMRAGE

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ASA every pt when they hit the door; any EKG changes at all concerning for iscehmia: plavix; heparin if I am really concerned. All of this regardless of Warfarin usage, as it can take a while sometimes for INR to come back. Also, when you shut heparin off-- effects end quickly. Always put a finger in the butt prior to this. My chest pain recipe.
I don't give ASA, plavix nor Heparin/Lovenox until I've at least seen a CXR.

I check radial pulses and DP pulses on evey chest pain. Some get BP in both arms if I'm concerned by the story.

Equal pulses and normal CXR, then I give ASA. If hx of CAD, stents or good story with no hx, then I anticoagulate. I usually never give Plavix at my academic center because many, surprisingly end up with a CABG. CV surgeons hate Plavix where I am and we always receive heat when we load with Plavix.

In the community centers where I moonlight, I usually have a cardiologist on the phone who can tell me what they want me to give. Documentation is sweet that way.

Careful of your recipe. Cookbook medicine will kill your disection.

As to the OP: Definitely ASA with Coumadin. I would have no reason to give Heparin to someone who is anticoagulated. This is not variable by region. This is standard of care.

Rage
 
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takotsubo

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we don't have an obs unit, so I do a lot of delta ekg/troponin/ck/ckmb and discharge with followup after 2 hours if their pain has been under 8 hours.[/QUOTE]



Do a lot of you guys do the delta ekg/trop thing? If so, can you guys educate me on what you are doing? (i.e. when you repeat the trop? and when you send them home)
 

Old_Mil

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ASA every pt when they hit the door; any EKG changes at all concerning for iscehmia: plavix; heparin if I am really concerned. All of this regardless of Warfarin usage, as it can take a while sometimes for INR to come back. Also, when you shut heparin off-- effects end quickly. Always put a finger in the butt prior to this. My chest pain recipe.
So if you put the finger in the butt of a stemi and your rectal is negative for gross blood but guiacs positive and the Guy has a good crit, and the guys h and p is negative for melena or hematochezia, then what? I've gotten two different opinions on this.
 

EMRAGE

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Do a lot of you guys do the delta ekg/trop thing? If so, can you guys educate me on what you are doing? (i.e. when you repeat the trop? and when you send them home)
This is easy in my opinion, If I do a second set of CEs and the trop, myoglobin CK or MB fraction goes up, I admit to observation or PCP. No questions asked.

I did have one situation where I did a third set because the CK and MB fraction was consistant with skeletal muscle and the lab result repeatedly said so. The trop was always as low as possibly reportable. I discharged that pt.

So if you put the finger in the butt of a stemi and your rectal is negative for gross blood but guiacs positive and the Guy has a good crit, and the guys h and p is negative for melena or hematochezia, then what? I've gotten two different opinions on this.
My opinion of the circumstance outlined above is not shared by everyone, with that said, I tend to anticoagulate for clotting disorders regardless of guiac positive or negative. I honestly don't check.

If someone begins to bleed on Heparin or after Lovenox, my theory is that replacing blood is easy with the potential for some side effects. At the same time, I can't definitively fix a clotting disorder without the use of lytics, which I would not do in someone who has a GI bleed. Again, not everyone agrees on this and I'm not sure of a standard of care for this situation. I would use the clinical situation to help guide my thought process.

As I've progressed through residency, I've become more comfortable with anticoagulation, especially in circumstances I know have a definitive indication. The side effect of bleeding, I feel, can be handled with medical therapy.

In cases of a massive, noticeable GI bleed, I would probably consult cardiology and make all decision in consultation with them. Document everything!

My thoughts,

RAGE
 
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So if you put the finger in the butt of a stemi and your rectal is negative for gross blood but guiacs positive and the Guy has a good crit, and the guys h and p is negative for melena or hematochezia, then what? I've gotten two different opinions on this.
if the patient is reliable enough and you can rule out melanotic stools by history alone, then no point doing the rectal exam, just go for anticoagulation.
 

pinipig523

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ASA in addition to warfarin improves outcome from what I recall in AHA based studies.
 

takotsubo

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This is easy in my opinion, If I do a second set of CEs and the trop, myoglobin CK or MB fraction goes up, I admit to observation or PCP. No questions asked.

I did have one situation where I did a third set because the CK and MB fraction was consistant with skeletal muscle and the lab result repeatedly said so. The trop was always as low as possibly reportable. I discharged that pt.



My opinion of the circumstance outlined above is not shared by everyone, with that said, I tend to anticoagulate for clotting disorders regardless of guiac positive or negative. I honestly don't check.

If someone begins to bleed on Heparin or after Lovenox, my theory is that replacing blood is easy with the potential for some side effects. At the same time, I can't definitively fix a clotting disorder without the use of lytics, which I would not do in someone who has a GI bleed. Again, not everyone agrees on this and I'm not sure of a standard of care for this situation. I would use the clinical situation to help guide my thought process.

As I've progressed through residency, I've become more comfortable with anticoagulation, especially in circumstances I know have a definitive indication. The side effect of bleeding, I feel, can be handled with medical therapy.

In cases of a massive, noticeable GI bleed, I would probably consult cardiology and make all decision in consultation with them. Document everything!

My thoughts,

RAGE


When do you check the second set? HOw many hours after the first?
 

zeitgeber

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There's a great podcast on the topic of Heparin in the setting of ACS at www.smartem.org, and at www.thennt.com by the same author... Basically stating that if ASA is given, it does not add any more incremental benefit and in fact may increase morbidity and mortality. I always give ASA, and while I'm a big EBM fan, I have yet to stop ordering Heparin/Lovenox on these patients -- mostly out of expectations from cardiology and my own colleagues. Any thoughts?
 

EMRAGE

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When do you check the second set? HOw many hours after the first?
Some places do 2 hour sets, which I feel is too soon. I like 3 hour sets at a minimum. 4 to 6 hours I feel is best. I find a lot of places have a protocol that often uses 3 hour repeat CEs.

RAGE
 

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Heparin is used widely in the er where I work, and most of the cardiology guys want it on board early in patients with ACS.

The evidence I have seen doesn't really back up heparin for primary end points such as mortality. It appears to help the reinfarction rate, which is in my mind a good primary end point probably preventing patients from developing CHF. So in other words the NNT to prevent death from MI with heparin is inifinite and the NNT to prevent a recurrent MI is around 35.

\http://www.ncbi.nlm.nih.gov/pubmed/18425889

the number needed to harm with heparin is diffrent depending on what your end points are (death, ICH, severe thrombocytopenia, GI bleed).

Oh and to add insult to injury these studies were done on high risk patients (bad story, elevated trop, bad ekg's), not your guy with chest pain who has HTN or HTN and IDDM.