LETTER
Preventing Anticoagulant-Related Bleeding
Bruce Davidson
15 January 1993 | Volume 118 Issue 2 | Pages 158-159
TO THE EDITOR:
In their excellent article on guideline-based consultation to prevent anticoagulant-related bleeding [1], Drs. Landefeld and Anderson recommend administering "intravenous heparin by continuous infusion to attain an activated partial thromboplastin time (APT) of 1.5 to 2.5 times that patient's baseline value," and cite reference 42. This study used an activated partial thromboplastin time between 55 and 75 seconds rather than some multiple of each patient's baseline APT to adjust heparin therapy. Most recommendations for heparin dosing for treatment of established deep venous thrombosis or pulmonary embolism do not refer to the patient's baseline APT but to a mean control APT [2-4].
This distinction is important. Using the authors' prescribed approach to identify a range in individual patients might lead to underdosing in the critical first few days of treatment [2]. Although not sufficiently used in North America [5], an international normalized ratio method of reporting prothrombin times has been agreed on. No such agreement exists for APT, although the International Society of Thrombosis and Hemostasis has a group working on this problem.
1. Landefeld CS, Anderson PA. Guideline-based consultation to prevent anticoagulant-related bleeding. Ann Intern Med. 1992; 116:829-37.
2. Hull RD, Raskob GE, Hirsh J, Jay RM, Ledera JR, Geerts WH, et al. Continuous intravenous heparin compared with intermittent subcutaneous heparin in the initial treatment of proximal-vein thrombosis. N Engl J Med. 1986; 315:1109-14.
3. Hirsh J. Drug therapy: heparin. N Engl J Med 1991; 324:1565-1574.
4. Hyers TM, Hull RD, Weg JG. Antithrombotic therapy for venous thromboembolic disease. Chest. 1989; 95(Suppl)37S-51S.
5. Hirsh J. Substandard monitoring of warfarin in North America. Arch Intern Med. 1992; 152:257-8.
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