2. CHEST-2012: High Points and Pearls Alan Brush, MD, FACP Chief, Anticoagulation Management Service Harvard Vanguard Medical Associates

3. Language... Suggestions vs. Recommendations: based on the weight of evidence

4. Loading dose initiation of warfarin Pharmacogenetic testing Overlap with LMWH Monitoring frequency Management of single out of range result up to 0.5 above or below therapeutic range Loading dose initiation of warfarin Pharmacogenetic testing Overlap with LMWH Monitoring frequency Management of single out of range result up to 0.5 above or below therapeutic range Evidence-based Management of Anticoagulation

5. Bridging with LMWH for stable patients with single low INR Use of vitamin K for stable patients with single high INR Self-testing and self-management Drug interactions to avoid Bridging with LMWH for stable patients with single low INR Use of vitamin K for stable patients with single high INR Self-testing and self-management Drug interactions to avoid

6. Optimal therapeutic INR ranges Dose Management of Subcutaneous (SC) UFH for DVT/PE Fondaparinux Dose Management by Weight VKA-associated major bleeding

7. Patients with Cancer but No Other Risk Factors for VTE Patients with Solid Tumors and Additional Risk Factors for VTE (e.g. previous venous thrombosis, immobilization, hormonal therapy, angiogenesis) Chronically immobilized patients residing at home or NH Patients with Cancer but No Other Risk Factors for VTE Patients with Solid Tumors and Additional Risk Factors for VTE (e.g. previous venous thrombosis, immobilization, hormonal therapy, angiogenesis) Chronically immobilized patients residing at home or NH Prophylaxis for higher risk patients in the ambulatory setting

8. Persons Traveling Long-Distance Persons with Asymptomatic Thrombophilia without history of VTE Persons Traveling Long-Distance Persons with Asymptomatic Thrombophilia without history of VTE

9. Patients Undergoing Major Orthopedic Surgery: Total Hip Arthroplasty (THA), Total Knee Arthroplasty (TKA), and Hip Fracture Surgery (HFS) Patients with Isolated Lower-Leg Injuries Distal to the Knee Patients Undergoing Major Orthopedic Surgery: Total Hip Arthroplasty (THA), Total Knee Arthroplasty (TKA), and Hip Fracture Surgery (HFS) Patients with Isolated Lower-Leg Injuries Distal to the Knee Prevention of VTE in Orthopedic Surgery Patients

10. Interruption of VKAs before Surgery Resumption of VKAs after Surgery Bridging Anticoagulation During Interruption of VKA Therapy Perioperative Management of VKA-Treated Patients Who Require Minor Procedures Interruption of VKAs before Surgery Resumption of VKAs after Surgery Bridging Anticoagulation During Interruption of VKA Therapy Perioperative Management of VKA-Treated Patients Who Require Minor Procedures Perioperative Management of Antithrombotic Therapy

11. Patients taking Aspirin Undergoing a Minor Dental, Dermatologic, or Ophthalmologic Procedure Patients Undergoing Coronary Artery Bypass Graft Surgery Perioperative Use of IV UFH Patients taking Aspirin Undergoing a Minor Dental, Dermatologic, or Ophthalmologic Procedure Patients Undergoing Coronary Artery Bypass Graft Surgery Perioperative Use of IV UFH

12. Antithrombotic Therapy for VTE Disease Initial anticoagulation for patients with acute DVT of the leg Anticoagulation in patients with isolated distal DVT Anticoagulation in patients with extensive superficial vein phlebitis

13. Patients with acute DVT of the leg treated with LMWH – dosing issues Vena cava filters for the initial treatment of patients with DVT - considerations Early ambulation of patients with acute DVT Duration of long-term anticoagulant therapy for specific indications

14. Choice of anticoagulant regimen for long- term therapy without vs with cancer Choice of anticoagulant regimen for extended therapy Treatment of patients with asymptomatic DVT of the leg – same as symptomatic patients

15. Compression Stockings and IPCD to Prevent and Treat PTS Parenteral anticoagulation prior to receipt of the results of diagnostic work-up for PE Choice of initial parenteral anticoagulant regimen in patients with PE

16. Antithrombotic Therapy for Nonrheumatic Atrial Fibrillation CHADS2 Score Suggestion or Recommendation 0 No treatment recommended over anticoagulation or antiplatelet agent; if treatment preferred by patient, aspirin suggested over VKA or combination aspirin plus clopidogrel 1 Oral therapy recommended over no treatment, and anticoagulation suggested over aspirin or combined aspirin plus clopidogrel ≥2 Oral anticoagulation recommended over no treatment, aspirin or combined aspirin plus clopidogrel

17. Antithrombotic and Thrombolytic Therapy for Acute Ischemic Stroke ConditionRecommendationSuggestion Acute strokeIV r-tPA if treatment can be initiated within 3 h, perhaps 4.5 h of symptom onset. Early aspirin 160 to 325 mg Intraarterial r-tPA in patients ineligible for IV tPA if treatment can be initiated within 6 h; against use of mechanical thrombectomy Acute stroke and restricted mobility Prophylactic-dose heparin or IPC devices, against use of elastic compression stockings Noncardioembolic ischemic stroke or TIA Long-term aspirin (75-100 mg once daily), clopidogrel (75 mg once daily), aspirin/extended release dipyridamole (25 mg/200 mg bid), or cilostazol (100 mg bid) over no antiplatelet therapy, oral anticoagulants, combined clopidogrel plus aspirin, or triflusal Clopidogrel or aspirin/extended- release dipyridamole over aspirin or cilostazol History of stroke or TIA and atrial fibrillation Oral anticoagulation over no antithrombotic therapy, aspirin, and combined aspirin and clopidogrel

18. VTE, Thrombophilia, Antithrombotic Therapy, and Pregnancy ConditionRecommendationSuggestion Prevention and treatment of VTE in pregnant women LMWH, not UFH Pregnant women with acute VTE Continue anticoagulants at least 6 weeks postpartum (and at least total of 3 months) Women with APLA syndrome and three or more pregnancy losses Antepartum administration of prophylactic or intermediate- dose UFA or prophylactic LMWH in addition to low- dose aspirin (75-100 mg/d)

19. The End