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1. Antiplatelet, Anticoagulant, Vasodilator,
Thrombolytic Drugs
Faculty of Medicine Padjadjaran University
Vascular Surgery Division Hasan Sadikin General Hospital
2020
By : drg. Putri Nurfuadah
Mentor : dr. Teguh Marfen., Sp.B(K)V
7. Anticoagulants :
• parenteral
• oral
Parenteral anticoagulants
• unfractionated heparin
• low-molecular-weight heparin (LMWH)
• Fondaparinux
• parenteral direct thrombin inhibitors
Oral anticoagulants
• vitamin K antagonists (VKAs)
• warfarin
• direct oral anticoagulants (DOACs)
• Dabigatran etexilate, inhibits thrombin
• Rivaroxaban, apixaban, & edoxaban,
inhibit factor Xa
Rutherford's Vascular Surgery and Endovascular Therapy, 2-Volume Set, 9th Edition. By Anton N Sidawy, MD, MPH
and Bruce A Perler, MD, MBA. Page : 1763
8.
9. Heparin
• sulfated polysaccharide
• isolated from mammalian tissues rich in
mast cells
• most commercial heparin : derived from
porcine intestinal mucosa
• polymer of alternating D glucuronic acid
& N-acetyl-D-glucosamine residues
Rutherford's Vascular Surgery and Endovascular Therapy, 2-Volume Set, 9th Edition. By Anton N Sidawy, MD, MPH
and Bruce A Perler, MD, MBA. Page : 1764-1765
10.
11. Rutherford's Vascular Surgery and Endovascular Therapy, 2-Volume Set, 9th Edition. By Anton N Sidawy, MD, MPH
and Bruce A Perler, MD, MBA. Page : 1765
12. Rutherford's Vascular Surgery and Endovascular Therapy, 2-Volume Set, 9th Edition. By Anton N Sidawy, MD, MPH
and Bruce A Perler, MD, MBA. Page : 1769
13. Prophylaxis: 5000 units
subcutaneously two or three
times daily.
Fixed-dose or weight-based
heparin nomograms are used to
standardize heparin dosing and to
shorten the time required to
achieve a therapeutic
anticoagulant response.
After an intravenous heparin
bolus of 5000 units or 70 U/kg, a
heparin infusion rate of 12 to 15
U/kg per hour usually is
administered.
In contrast, weight-adjusted
heparin nomograms for patients
with VTE use an initial bolus of
5000 units or 80 U/kg followed by
an infusion of 18 U/kg per hour.
Thus patients with VTE appear to
require higher doses of heparin to
achieve a therapeutic aPTT than
do patients with acute coronary
syndromes. This may reflect
differences in the thrombus
burden.
Heparin binds to fibrin, and the
fibrin content of large deep
venous thrombi is greater than
that of small coronary thrombi.
For interventions, heparin is
usually given as a fixed
intravenous bolus of 5000 to
10,000 units or as a weight-
adjusted dose of 70 to 100 U/kg.
Rutherford's Vascular Surgery and Endovascular Therapy, 2-Volume Set, 9th Edition. By Anton N Sidawy, MD, MPH
and Bruce A Perler, MD, MBA. Page : 1768
14. Rutherford's Vascular Surgery and Endovascular Therapy, 2-Volume Set, 9th Edition. By Anton N Sidawy, MD, MPH
and Bruce A Perler, MD, MBA. Page : 1771-1772
15. Side Effects
• Bleeding.
• Thrombocytopenia.
• Osteoporosis.
• Elevated Transaminases.
Perioperative Management
• When given subcutaneously for thromboprophylaxis,
the last dose of heparin should be administered at least
2 hours before surgery.
• Full-dose intravenous heparin should be stopped 4 to 6
hours before surgery.
• Low-dose heparin can be restarted 12 to 24 hours after
surgery. Resumption of full-dose heparin should be
delayed until hemostasis is secure. Often in this setting,
heparin is started as an infusion without a loading
dose.
Rutherford's Vascular Surgery and Endovascular Therapy, 2-Volume Set, 9th Edition. By Anton N Sidawy, MD, MPH
and Bruce A Perler, MD, MBA. Page : 1772
16. Rutherford's Vascular Surgery and Endovascular Therapy, 2-Volume Set, 9th Edition. By Anton N Sidawy, MD, MPH
and Bruce A Perler, MD, MBA. Page : 1773
17. Rutherford's Vascular Surgery and Endovascular Therapy, 2-Volume Set, 9th Edition. By Anton N Sidawy, MD, MPH
and Bruce A Perler, MD, MBA. Page : 1765
18. For prophylaxis, oncedaily
subcutaneous doses of 4000 to
5000 units are often used,
whereas doses of 2500 to 3000
units are given when the drug is
administered twice daily.
For treatment of VTE, a dose of
150 to 200 U/kg is given if the
drug is administered once daily.
If a twice-daily regimen is
employed, a dose of 100 U/kg is
given.
In patients with unstable
angina, LMWH is given
subcutaneously on a twice-daily
basis at a dose of 100 to 120
U/kg.
Side Effects
• Bleeding.
• Thrombocytopenia.
• Osteoporosis.
Rutherford's Vascular Surgery and Endovascular Therapy, 2-Volume Set, 9th Edition. By Anton N Sidawy, MD, MPH
and Bruce A Perler, MD, MBA. Page : 1775
19. Perioperative Management
Prophylactic doses: the last
dose of LMWH should be
given at least 12 hours before
surgery.
With treatment doses of
LMWH, the drug should be
held for 24 hours before
surgery.
Thromboprophylaxis with
LMWH can be started 12 to 24
hours after surgery
• if started 12 hours after major
surgery, a half dose can be given
provided that hemostasis has been
secured.
Resumption of full-dose
LMWH should be delayed for
2 to 3 days.
Rutherford's Vascular Surgery and Endovascular Therapy, 2-Volume Set, 9th Edition. By Anton N Sidawy, MD, MPH
and Bruce A Perler, MD, MBA. Page : 1776
20. Rutherford's Vascular Surgery and Endovascular Therapy, 2-Volume Set, 9th Edition. By Anton N Sidawy, MD, MPH
and Bruce A Perler, MD, MBA. Page : 1777
21. Rutherford's Vascular Surgery and Endovascular Therapy, 2-Volume Set, 9th Edition. By Anton N Sidawy, MD, MPH
and Bruce A Perler, MD, MBA. Page : 1765
22. Rutherford's Vascular Surgery and Endovascular Therapy, 2-Volume Set, 9th Edition. By Anton N Sidawy, MD, MPH
and Bruce A Perler, MD, MBA. Page : 1779
23. Rutherford's Vascular Surgery and Endovascular Therapy, 2-Volume Set, 9th Edition. By Anton N Sidawy, MD, MPH
and Bruce A Perler, MD, MBA. Page : 1782
24. Rutherford's Vascular Surgery and Endovascular Therapy, 2-Volume Set, 9th Edition. By Anton N Sidawy, MD, MPH
and Bruce A Perler, MD, MBA. Page : 1790
25. management of
bleeding in patients taking DOACs.
Rutherford's Vascular Surgery and Endovascular Therapy, 2-Volume Set, 9th Edition. By Anton N Sidawy, MD, MPH
and Bruce A Perler, MD, MBA. Page : 1794
27. Rutherford's Vascular Surgery and Endovascular Therapy, 2-Volume Set, 9th Edition. By Anton N Sidawy, MD, MPH
and Bruce A Perler, MD, MBA. Page : 1812
28. Aspirin
Mechanism of Action
• cyclooxygenase enzyme (COX) inhibitor.
Indications and Dose
• prevention of cardiovascular events in
patients with established coronary
disease, peripheral arterial occlusive
disease, or cerebrovascular occlusive
disease.
• Aspirin doses range from 75 to 325
mg/daily.
Side-Effect Profile
• (GI) tract
• Allergy to aspirin is a rare phenomenon
(~0.3% of patients).
• Bronchospasm can occur in patients
allergic to aspirin
Perioperative Management
• discontinued 7 to 10 days before surgery
in those at moderate to high risk for
bleeding and a low estimated risk for
cardiovascular events while off the
medication.
Rutherford's Vascular Surgery and Endovascular Therapy, 2-Volume Set, 9th Edition. By Anton N Sidawy, MD, MPH
and Bruce A Perler, MD, MBA. Page : 1812-1813
29. Clopidogrel
Mechanism of Action
•inhibits P2Y12
Dose
•daily dose : 75 mg.
•bolus dose between 300 and 600
mg.
Side-Effect
•Bleeding
•Pruritus
•Epistaxis
Perioperative
Management.
•Clopidogrel should be
discontinued 7 to 10 days prior
to surgery (minimum of 5 days)
before elective surgery
Ticagrelor
Mechanism of Action
•binds the ADP P2Y12
Dose
•loading dose of 180 mg followed
by a maintenance dose of 60–90
mg twice daily (t1/2 = 7 to 9
hours)
Side-Effect
•Dyspnea
Perioperative
Management.
•As with clopidogrel
Prasugrel
•Mechanism of Action
•blocks the P2Y12
Dose
•loading dose of 60 mg followed
by maintenance dose of 10 mg
daily.
Rutherford's Vascular Surgery and Endovascular Therapy, 2-Volume Set, 9th Edition. By Anton N Sidawy, MD, MPH
and Bruce A Perler, MD, MBA. Page : 1814-1818
30. Perioperative Management of Dual
Antiplatelet Therapy
Rutherford's Vascular Surgery and Endovascular Therapy, 2-Volume Set, 9th Edition. By Anton N Sidawy, MD, MPH
and Bruce A Perler, MD, MBA. Page : 1827
32. Rutherford's Vascular Surgery and Endovascular Therapy, 2-Volume Set, 9th Edition. By Anton N Sidawy, MD, MPH
and Bruce A Perler, MD, MBA. Page : 1839
33. Rutherford's Vascular Surgery and Endovascular Therapy, 2-Volume Set, 9th Edition. By Anton N Sidawy, MD, MPH
and Bruce A Perler, MD, MBA. Page : 1850
34. Rutherford's Vascular Surgery and Endovascular Therapy, 2-Volume Set, 9th Edition. By Anton N Sidawy, MD, MPH
and Bruce A Perler, MD, MBA. Page : 1852
35. Rutherford's Vascular Surgery and Endovascular Therapy, 2-Volume Set, 9th Edition. By Anton N Sidawy, MD, MPH
and Bruce A Perler, MD, MBA. Page : 1846
39. Rutherford's Vascular Surgery and Endovascular Therapy, 2-Volume Set, 9th Edition. By Anton N Sidawy, MD, MPH
and Bruce A Perler, MD, MBA. Page : 686
40. Rutherford's Vascular Surgery and Endovascular Therapy, 2-Volume Set, 9th Edition. By Anton N Sidawy, MD, MPH
and Bruce A Perler, MD, MBA. Page : 689
41. Rutherford's Vascular Surgery and Endovascular Therapy, 2-Volume Set, 9th Edition. By Anton N Sidawy, MD, MPH
and Bruce A Perler, MD, MBA. Page : 686
42. Hydralazine is commonly used in
conjunction with nitrates for afterload
reduction in patients with heart failure
with reduced ejection fraction. It is
approved as a fixed-dose combination
drug with isosorbide dinitrate as BiDil,
which is indicated in African American
patients with systolic heart failure.
Another direct vasodilator, minoxidil,
is generally used only in resistant
hypertension and particularly in
patients with impaired renal function.
To prevent edema and tachycardia
associated with minoxidil use,
administration of alpha and
betablockers is frequently necessary
Rutherford's Vascular Surgery and Endovascular Therapy, 2-Volume Set, 9th Edition. By Anton N Sidawy, MD, MPH
and Bruce A Perler, MD, MBA. Page : 695
43. Intravenous vasodilators should be
used throughout the procedure to
maintain a systolic blood pressure
less than 180 mm Hg to minimize
risk of ICH.
As mentioned, small volumes of
nitroglycerin (100 to 200 μg) may
also be instilled through the guiding
sheath into the CCA to assist in
vasorelaxation in cases of persistent
ICA spasm after EDP removal.
However, both of these therapies
should be used judiciously because
excessive vasodilation in
combination with hemodynamic
depression after balloon dilation
may exacerbate the prolonged
hypotension that can be observed in
some CAS patients postoperatively.
Rutherford's Vascular Surgery and Endovascular Therapy, 2-Volume Set, 9th Edition. By Anton N Sidawy, MD, MPH
and Bruce A Perler, MD, MBA. Page : 4107
Antikoagulan adalah obat untuk mencegah pembekuan darah dengan jalan menghambat
pembentukan atau menghambat fungsi beberapa faktor pembekuan/ koagulasi. Heparin
merupakan obat yang paling sering dihubungkan dengan anti koagulan.
Heparin Polisakarida tersulfasi, heparin diisolasi dari mamalia jaringan kaya sel mast. Sebagian besar heparin komersial berasal dari mukosa usus babi dan merupakan polimer Dglucuronic bergantian residu asam dan N-asetil-D-glukosamin.
Heparin must be given parenterally. It is usually administered
subcutaneously when given for prophylaxis and by continuous
intravenous infusion when used for therapeutic purposes. If
heparin is given subcutaneously for treatment of thrombosis, the
dose of heparin must be high enough to overcome the limited
bioavailability associated with this method of delivery.
In the circulation, heparin binds to the endothelium, and this
explains its dose-dependent clearance. At low doses, the half-life of
heparin is short because it rapidly binds to the endothelium.3 With
higher doses of heparin, the endothelium is saturated and the halflife
is longer.3 Because of this phenomenon, the plasma half-life of
heparin ranges from 30 to 60 minutes with bolus intravenous doses
of 25 and 100 U/kg, respectively.3 Clearance of heparin is mainly
extrarenal; heparin binds to macrophages, which internalize and
depolymerize the long heparin chains and secrete shorter chains
back into the circulation.
