Antithrombotic therapy form (refer to Antithrombotic Therapy Dictionary)
| Date antithrombotic therapy form completed | (MM/DD/YYYY): ________________ | ||||
| Indicate patient’s most recent documented or reported weight at the time of thrombotic event: | __________ kg, OR __________ lb, OR ☐ unknown | ||||
| Height | __________ cm, OR __________ inches, OR ☐ unknown | ||||
| Section 1: Anticoagulant treatment: | ☐ No ☐ Yes (indicate the type, dose, and frequency below) | ||||
| ☐ Low-molecular-weight heparin | Drug | Dose | Frequency | ||
| ☐ Enoxaparin | __________ | ☐ mg ☐ mg/kg ☐ units ☐ units/kg | ☐ Every 24 h ☐ Every 12 h ☐ Every 8 h ☐ Other (specify):________ | ||
| ☐ Dalteparin | __________ | ☐ units ☐ units/kg | ☐ Every 24 h ☐ Every 12 h ☐ Every 8 h ☐ Other (specify):________ | ||
| ☐ Tinzaparin | __________ | ☐ units ☐ units/kg | ☐ Every 24 h ☐ Every 12 h ☐ Every 8 h ☐ Other (specify):________ | ||
| ☐ Nadroparin | __________ | ☐ units ☐ units/kg | ☐ Every 24 h ☐ Every 12 h ☐ Every 8 h ☐ Other (specify):________ | ||
| ☐ Certoparin | __________ | ☐ units ☐ units/kg | ☐ Every 24 h ☐ Every 12 h ☐ Every 8 h ☐ Other (specify):________ | ||
| ☐ Bemiparin | __________ | ☐ units ☐ units/kg | ☐ Every 24 h ☐ Every 12 h ☐ Every 8 h ☐ Other (specify):________ | ||
| ☐ Other (specify):________ | __________ | ☐ mg ☐ mg/kg ☐ units ☐ units/kg | ☐ Every 24 h ☐ Every 12 h ☐ Every 8 h ☐ Other (specify):________ | ||
| ☐ Unfractionated heparin (indicate method of administration and dose, frequency): | Route of administration | Dose | Frequency | ||
| ☐ Intravenous infusion | __________ | Units/kg/h | Continuous infusion | ||
| ☐ Subcutaneous | __________ | ☐ units ☐ units/kg | ☐ Every 24 h ☐ Every 12 h ☐ Every 8 h ☐ Other (specify):________ | ||
| ☐ Fondaparinux (indicate dose and frequency): | Dose | Frequency | |||
| ________ mg | ☐ Every 24 h ☐ Every 12 h ☐ Every 8 h ☐ Other (specify):________ | ||||
| ☐ Direct oral anticoagulants (indicate drug, dose, frequency): | Drug | Dose and frequency | |||
| ☐ Apixaban | ☐ 2.5 mg twice daily ☐ 5 mg twice daily ☐ 10 mg twice daily ☐ Other (specify):________ | ||||
| ☐ Rivaroxaban | ☐ 2.5 mg twice daily ☐ 10 mg once daily ☐ 15 mg once daily ☐ 15 mg twice daily ☐ 20 mg once daily ☐ Other (specify):________ | ||||
| ☐ Edoxaban | ☐ 30 mg once daily ☐ 60 mg once daily ☐ Other (specify):________ | ||||
| ☐ Dabigatran | ☐ 75 mg twice daily ☐ 110 mg twice daily ☐ 150 mg twice daily ☐ 220 mg once daily ☐ Other (specify):________ | ||||
| ☐ Vitamin K antagonist (indicate drug and target INR): | Drug | Target INR | |||
| ☐ Warfarin ☐ Phenprocoumon ☐ Acenocoumarol ☐ Fluindione ☐ Other (specify): _______________ ☐ Unknown | ☐ INR 1.5 to 2.5 ☐ INR 2 to 3 ☐ INR 2.5 to 3.5 ☐ Other (specify): _____________________ ☐ Unknown | ||||
| ☐ Unknown anticoagulant | |||||
| ☐ Other anticoagulant not listed above (specify below): | Drug | Dose | Route | Frequency | |
| Argatroban | __________ | ☐ μg/kg/min ☐ Other (specify): ______ | Intravenous | ☐ Continuous infusion ☐ Other (specify):________ | |
| Bivalirudin | __________ | ☐ mg/kg/h ☐ Other (specify): _______ | Intravenous | ☐ Continuous infusion ☐ Other (specify):________ | |
| Other (specify): _______________ | __________ | ☐ mg ☐ mg/kg ☐ mg/kg/h ☐ units ☐ units/kg ☐ μg/kg/min | ☐ Oral ☐ Subcutaneous ☐ Intravenous | ☐ Every 24 h ☐ Every 12 h ☐ Every 8 h ☐ Continuous infusion ☐ Other (specify):________ | |
| Section 2: Antiplatelet therapy: | ☐ No ☐ Yes (indicate the type, dose, and frequency below) | ||||
| ☐ Aspirin (acetylsalicylic acid) | ☐ Low dose (≤100 mg daily) ☐ 325 mg once daily ☐ Other (specify): _____________ | ||||
| ☐ Clopidogrel | ☐ 75 mg once daily ☐ 150 mg once daily | ||||
| ☐ Ticagrelor | ☐ 60 mg twice daily ☐ 90 mg twice daily | ||||
| ☐ Prasugrel | ☐ 5 mg once daily ☐ 10 mg once daily | ||||
| ☐ Acetylsalicylic acid and dipyridamole ER | ☐ Aspirin 25 mg/dipyridamole ER 200 mg twice daily ☐ Aspirin 25 mg/dipyridamole ER 200 mg once daily | ||||
| ☐ Cangrelor | ☐ 30 μg/kg bolus then 4 μg/kg/min (for percutaneous intervention) ☐ 0.75 μg/kg/min (for bridging therapy before cardiac surgery) | ||||
| ☐ Other antiplatelet therapy, including nonsteroidal anti-inflammatory drugs (specify below): | Dose | Route | Frequency | ||
| ________ | ☐ mg ☐ units ☐ Other (specify): ________ | ☐ Oral ☐ Subcutaneous ☐ Intravenous | ☐ Every 24 h ☐ Every 12 h ☐ Every 8 h ☐ Continuous infusion ☐ Other (specify):________ | ||
| ________ | ☐ mg ☐ units ☐ Other (specify): ________ | ☐ Oral ☐ Subcutaneous ☐ Intravenous | ☐ Every 24 h ☐ Every 12 h ☐ Every 8 h ☐ Continuous infusion ☐ Other (specify):________ | ||
| Section 3: Mechanical thromboprophylaxis: | ☐ No ☐ Yes (indicate the type below) | ||||
| ☐ Intermittent pneumatic compression ☐ Graduated compression stockings ☐ Antiembolism stockings ☐ Other (specify): | |||||
| Date antithrombotic therapy form completed | (MM/DD/YYYY): ________________ | ||||
| Indicate patient’s most recent documented or reported weight at the time of thrombotic event: | __________ kg, OR __________ lb, OR ☐ unknown | ||||
| Height | __________ cm, OR __________ inches, OR ☐ unknown | ||||
| Section 1: Anticoagulant treatment: | ☐ No ☐ Yes (indicate the type, dose, and frequency below) | ||||
| ☐ Low-molecular-weight heparin | Drug | Dose | Frequency | ||
| ☐ Enoxaparin | __________ | ☐ mg ☐ mg/kg ☐ units ☐ units/kg | ☐ Every 24 h ☐ Every 12 h ☐ Every 8 h ☐ Other (specify):________ | ||
| ☐ Dalteparin | __________ | ☐ units ☐ units/kg | ☐ Every 24 h ☐ Every 12 h ☐ Every 8 h ☐ Other (specify):________ | ||
| ☐ Tinzaparin | __________ | ☐ units ☐ units/kg | ☐ Every 24 h ☐ Every 12 h ☐ Every 8 h ☐ Other (specify):________ | ||
| ☐ Nadroparin | __________ | ☐ units ☐ units/kg | ☐ Every 24 h ☐ Every 12 h ☐ Every 8 h ☐ Other (specify):________ | ||
| ☐ Certoparin | __________ | ☐ units ☐ units/kg | ☐ Every 24 h ☐ Every 12 h ☐ Every 8 h ☐ Other (specify):________ | ||
| ☐ Bemiparin | __________ | ☐ units ☐ units/kg | ☐ Every 24 h ☐ Every 12 h ☐ Every 8 h ☐ Other (specify):________ | ||
| ☐ Other (specify):________ | __________ | ☐ mg ☐ mg/kg ☐ units ☐ units/kg | ☐ Every 24 h ☐ Every 12 h ☐ Every 8 h ☐ Other (specify):________ | ||
| ☐ Unfractionated heparin (indicate method of administration and dose, frequency): | Route of administration | Dose | Frequency | ||
| ☐ Intravenous infusion | __________ | Units/kg/h | Continuous infusion | ||
| ☐ Subcutaneous | __________ | ☐ units ☐ units/kg | ☐ Every 24 h ☐ Every 12 h ☐ Every 8 h ☐ Other (specify):________ | ||
| ☐ Fondaparinux (indicate dose and frequency): | Dose | Frequency | |||
| ________ mg | ☐ Every 24 h ☐ Every 12 h ☐ Every 8 h ☐ Other (specify):________ | ||||
| ☐ Direct oral anticoagulants (indicate drug, dose, frequency): | Drug | Dose and frequency | |||
| ☐ Apixaban | ☐ 2.5 mg twice daily ☐ 5 mg twice daily ☐ 10 mg twice daily ☐ Other (specify):________ | ||||
| ☐ Rivaroxaban | ☐ 2.5 mg twice daily ☐ 10 mg once daily ☐ 15 mg once daily ☐ 15 mg twice daily ☐ 20 mg once daily ☐ Other (specify):________ | ||||
| ☐ Edoxaban | ☐ 30 mg once daily ☐ 60 mg once daily ☐ Other (specify):________ | ||||
| ☐ Dabigatran | ☐ 75 mg twice daily ☐ 110 mg twice daily ☐ 150 mg twice daily ☐ 220 mg once daily ☐ Other (specify):________ | ||||
| ☐ Vitamin K antagonist (indicate drug and target INR): | Drug | Target INR | |||
| ☐ Warfarin ☐ Phenprocoumon ☐ Acenocoumarol ☐ Fluindione ☐ Other (specify): _______________ ☐ Unknown | ☐ INR 1.5 to 2.5 ☐ INR 2 to 3 ☐ INR 2.5 to 3.5 ☐ Other (specify): _____________________ ☐ Unknown | ||||
| ☐ Unknown anticoagulant | |||||
| ☐ Other anticoagulant not listed above (specify below): | Drug | Dose | Route | Frequency | |
| Argatroban | __________ | ☐ μg/kg/min ☐ Other (specify): ______ | Intravenous | ☐ Continuous infusion ☐ Other (specify):________ | |
| Bivalirudin | __________ | ☐ mg/kg/h ☐ Other (specify): _______ | Intravenous | ☐ Continuous infusion ☐ Other (specify):________ | |
| Other (specify): _______________ | __________ | ☐ mg ☐ mg/kg ☐ mg/kg/h ☐ units ☐ units/kg ☐ μg/kg/min | ☐ Oral ☐ Subcutaneous ☐ Intravenous | ☐ Every 24 h ☐ Every 12 h ☐ Every 8 h ☐ Continuous infusion ☐ Other (specify):________ | |
| Section 2: Antiplatelet therapy: | ☐ No ☐ Yes (indicate the type, dose, and frequency below) | ||||
| ☐ Aspirin (acetylsalicylic acid) | ☐ Low dose (≤100 mg daily) ☐ 325 mg once daily ☐ Other (specify): _____________ | ||||
| ☐ Clopidogrel | ☐ 75 mg once daily ☐ 150 mg once daily | ||||
| ☐ Ticagrelor | ☐ 60 mg twice daily ☐ 90 mg twice daily | ||||
| ☐ Prasugrel | ☐ 5 mg once daily ☐ 10 mg once daily | ||||
| ☐ Acetylsalicylic acid and dipyridamole ER | ☐ Aspirin 25 mg/dipyridamole ER 200 mg twice daily ☐ Aspirin 25 mg/dipyridamole ER 200 mg once daily | ||||
| ☐ Cangrelor | ☐ 30 μg/kg bolus then 4 μg/kg/min (for percutaneous intervention) ☐ 0.75 μg/kg/min (for bridging therapy before cardiac surgery) | ||||
| ☐ Other antiplatelet therapy, including nonsteroidal anti-inflammatory drugs (specify below): | Dose | Route | Frequency | ||
| ________ | ☐ mg ☐ units ☐ Other (specify): ________ | ☐ Oral ☐ Subcutaneous ☐ Intravenous | ☐ Every 24 h ☐ Every 12 h ☐ Every 8 h ☐ Continuous infusion ☐ Other (specify):________ | ||
| ________ | ☐ mg ☐ units ☐ Other (specify): ________ | ☐ Oral ☐ Subcutaneous ☐ Intravenous | ☐ Every 24 h ☐ Every 12 h ☐ Every 8 h ☐ Continuous infusion ☐ Other (specify):________ | ||
| Section 3: Mechanical thromboprophylaxis: | ☐ No ☐ Yes (indicate the type below) | ||||
| ☐ Intermittent pneumatic compression ☐ Graduated compression stockings ☐ Antiembolism stockings ☐ Other (specify): | |||||
ER, extended release; INR, international normalized ratio.