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(Circulation. 2002;105:1270.)
© 2002 American Heart Association, Inc.

Clinician Update

Oral Anticoagulation for Acute Coronary Syndromes

Marc A. Brouwer, MD; Freek W.A. Verheugt, MD, PhD

From the Heartcenter, Department of Cardiology, University Medical Center Nijmegen, the Netherlands.

Correspondence to Freek W.A. Verheugt, MD, PhD, FAHA, FACC, Heartcenter, 540 Department of Cardiology, PO Box 9101, University Medical Center Nijmegen, 6500 HB Nijmegen, The Netherlands. E-mail f.verheugt@cardio.umcn.nl

Key Words: anticoagulants • aspirin • myocardial infarction

	Introduction

 
The following 2 case presentations illustrate the range of considerations when formulating plans for oral anticoagulation in patients with acute coronary syndromes.

	Case A

 
A 59-year-old patient presented within 5-hours of the onset of an electrocardiographic wave segment (ST) elevation anterior myocardial infarction and was treated with the accelerated dose regimen of alteplase, adjunctive unfractionated heparin, aspirin, and a ß-blocker. The maximum isoenzyme of creatine kinase with muscle and brain subunits was >10 times the upper limit of normal. At day 4, echocardiography revealed a mass suggestive of a mural left ventricular thrombus and important apical wall motion abnormalities. ACE inhibition therapy was initiated. To reduce the risk of systemic embolization, heparinization with a target activated partial thromboplastin time of 1.5 to 2.0 times control was started, followed by 6 months of dose-adjusted warfarin, target international normalized ratio (INR) 2.5 to 3.5 (Table 1).

View this table: [in this window] [in a new window]   Table 1. Established Indications for Oral Anticoagulant Therapy and Recommended Therapeutic Range

	Case B

 
A 66-year-old diabetic patient, taking aspirin daily because of a prior transient ischemic attack, presented with chest pain at rest and dynamic ST depression >1 mm. He recovered from the acute phase after treatment with low-molecular-weight heparin, nitroglycerine, aspirin, and ß-blocker therapy. Cardiac markers remained negative. During the convalescence period, no recurrent chest pain occurred, and exercise testing was negative with respect to symptoms and electrocardiographic signs of ischemia. Before discharge, dose-adjusted medium-intensity oral anticoagulation therapy (target INR, 2 to 3) was started in addition to aspirin (80 mg daily) as a strategy for secondary prevention . . . [Full Text of this Article]

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