Alternative anticoagulants for cardiac interventions and CV surgery
| Drug . | Mechanism . | T1/2 . | Recommendation on use by procedure* . | Dosing† . | Monitoring . | Additional precautions . | ||
|---|---|---|---|---|---|---|---|---|
| PCI . | CPB surgery . | Non-CPB surgery . | ||||||
| Bivalirudin | Direct thrombin inhibitor | 25 min (normal to mildly impaired renal function) 34 min (moderate renal impairment) 57 min (severe renal impairment) 3.5 h (dialysis) | Preferred alternative anticoagulant in patients with a history of HIT | Preferred alternative anticoagulant if acute HIT/subacute HIT A and surgery cannot be delayed | Preferred alternative anticoagulant if acute HIT/subacute HIT A and surgery cannot be delayed | PCI: 0.75 mg/kg bolus followed by 1.75 mg/kg/h for duration of procedure CPB‡: 1 mg/kg bolus then 2.5 mg/kg/h +50 mg added to priming solution for CPB Non-CPB‡: 0.75 mg/kg bolus then 1.75 mg/kg/h | PCI: weight-based dosing, ACT CPB†: ACT >2.5 times baseline Non-CPB†: ACT >300 s | Prolonged half-life in patients with renal impairment Avoid stasis in the CPB circuit Hypothermia should be minimized to avoid drug accumulation |
| Argatroban | Direct thrombin inhibitor | 39-51 min (normal hepatic function) 181 min (hepatic impairment) | Bivalirudin preferred but may be considered based on institutional experience | Not generally recommended for use in CPB | Bivalirudin preferred but may be considered based on institutional experience | PCI: begin infusion of 25 µg/kg/min and administer bolus of 350 µg/kg (over 3-5 min). Then adjust infusion rate based on ACT drawn 10 mins following bolus as follows: ACT <300 s: give additional 150 µg/kg bolus, and increase rate to 30 µg/kg/min (recheck ACT in 5-10 mins) ACT >450 s: decrease infusion rate to 15 µg/kg/min (recheck ACT in 5-10 min) CPB: NR Non-CPB‡: NR. Infusion of 2-5 µg/kg/min without bolus 30-60 min prior to surgery to maintain ACT 200-300 s has been described | PCI: ACT 300-450 s CPB: NR Non-CPB†: ACT 200-300 s | Prolonged half-life in patients with hepatic impairment Case reports describe prolonged bleeding after stopping argatroban at end of CPB Case reports describe clot formation in circuit with use of argatroban despite therapeutic ACT |
| Danaparoid§ | Indirect factor Xa inhibitor | 25 h (normal renal function) 29-35 h (renal impairment) | Not recommended | Not recommended | Case reports have been described, but not a preferred agent when other alternative anticoagulants available | PCI: NR CPB: NR Non-CPB‡: NR. Bolus of 40 U/kg for non-CPB surgery has been described. | Anti-Xa | Inappropriately long half-life for CPB surgery |
| Drug . | Mechanism . | T1/2 . | Recommendation on use by procedure* . | Dosing† . | Monitoring . | Additional precautions . | ||
|---|---|---|---|---|---|---|---|---|
| PCI . | CPB surgery . | Non-CPB surgery . | ||||||
| Bivalirudin | Direct thrombin inhibitor | 25 min (normal to mildly impaired renal function) 34 min (moderate renal impairment) 57 min (severe renal impairment) 3.5 h (dialysis) | Preferred alternative anticoagulant in patients with a history of HIT | Preferred alternative anticoagulant if acute HIT/subacute HIT A and surgery cannot be delayed | Preferred alternative anticoagulant if acute HIT/subacute HIT A and surgery cannot be delayed | PCI: 0.75 mg/kg bolus followed by 1.75 mg/kg/h for duration of procedure CPB‡: 1 mg/kg bolus then 2.5 mg/kg/h +50 mg added to priming solution for CPB Non-CPB‡: 0.75 mg/kg bolus then 1.75 mg/kg/h | PCI: weight-based dosing, ACT CPB†: ACT >2.5 times baseline Non-CPB†: ACT >300 s | Prolonged half-life in patients with renal impairment Avoid stasis in the CPB circuit Hypothermia should be minimized to avoid drug accumulation |
| Argatroban | Direct thrombin inhibitor | 39-51 min (normal hepatic function) 181 min (hepatic impairment) | Bivalirudin preferred but may be considered based on institutional experience | Not generally recommended for use in CPB | Bivalirudin preferred but may be considered based on institutional experience | PCI: begin infusion of 25 µg/kg/min and administer bolus of 350 µg/kg (over 3-5 min). Then adjust infusion rate based on ACT drawn 10 mins following bolus as follows: ACT <300 s: give additional 150 µg/kg bolus, and increase rate to 30 µg/kg/min (recheck ACT in 5-10 mins) ACT >450 s: decrease infusion rate to 15 µg/kg/min (recheck ACT in 5-10 min) CPB: NR Non-CPB‡: NR. Infusion of 2-5 µg/kg/min without bolus 30-60 min prior to surgery to maintain ACT 200-300 s has been described | PCI: ACT 300-450 s CPB: NR Non-CPB†: ACT 200-300 s | Prolonged half-life in patients with hepatic impairment Case reports describe prolonged bleeding after stopping argatroban at end of CPB Case reports describe clot formation in circuit with use of argatroban despite therapeutic ACT |
| Danaparoid§ | Indirect factor Xa inhibitor | 25 h (normal renal function) 29-35 h (renal impairment) | Not recommended | Not recommended | Case reports have been described, but not a preferred agent when other alternative anticoagulants available | PCI: NR CPB: NR Non-CPB‡: NR. Bolus of 40 U/kg for non-CPB surgery has been described. | Anti-Xa | Inappropriately long half-life for CPB surgery |
Recommendation based on opinion of authors as well as the ASH 2018 HIT guidelines (note certainty of evidence was “low” for PCI and “very low” for CPB and non-CPB).
Dosing as described in US Food and Drug Administration (FDA) label for approved indications. For off-label use, example of dosing regimen described in selected studies and/or case reports. Dose adjustments may be needed for hepatic or renal dysfunction depending on the agent. Refer to institutional dosing algorithms when available.
Off-label use of the medication. Not FDA approved for this indication.
Not available in the United States.
ACT, activated clotting time; NR, not recommended.