241 Risk of supratherapeutic APTT in the absence of an initial unfractionated heparin bolus

Bonenfant, Francis; Cossette, Benoȋt; Nault, Vincent; Turgeon, Marie-Hélène; Paulin, M.; Echenberg, Donald; Lépine, M.; Fayad, Tania; Farand, Paul

doi:10.1016/j.cjca.2011.07.177

Cited by 1 publication

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“…To our knowledge, only one previous study examined the effect of initial heparin boluses on aPTT lability. This study reported an association between withholding the initial bolus and recording supratherapeutic aPTTs at 24 hours (12). The authors theorize that this could be related to the phenomenon that patients who do not receive an initial bolus are more prone to being administered inappropriately high infusion rates (12).…”

Section: Discussionmentioning

confidence: 95%

“…Our study found that omission of the initial bolus was associated with signi cant delays in achieving therapeutic levels of anticoagulation compared to a cohort who received an initial bolus. Subtherapeutic aPTTs are commonly reported during initial treatment with UFH infusions (12,13,37). The delay in therapeutic anticoagulation may have signi cant clinical consequences in the treatment of those with VTE.…”

Section: Discussionmentioning

confidence: 99%

“…Low rates of therapeutic aPTT measurements within the initial days of treatment are a known issue with UFH use. Prior observational studies have reported therapeutic aPTTs in less than 50% of patients during the rst 24 hours of treatment (11)(12)(13).…”

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confidence: 99%

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Overused and Unpredictable: A Study of Unfractionated Heparin Treatment Including Appropriateness, Safety, and Bolus Dosing

Hahn,

Beresh,

Goubran

et al. 2024

Preprint

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Background Multiple recent guidelines advocate a preference for low molecular weight heparin (LMWH) over unfractionated heparin (UFH) infusions to reduce the risk of major bleeding (MB), heparin-induced thrombocytopenia (HIT) and improve cost-effectiveness (1–6). This study analyzed UFH use at a tertiary centre in Canada to identify cases in which UFH could have been avoided, identify characteristics associated with bleeding, and examine the efficacy and safety of infusions where the initial bolus was administered or withheld. Methods We identified adults who received between 48 to 96 hours of a UFH infusion in a single tertiary care hospital between January 2021 and December 2023. Consecutive patients were reviewed for bleeding events, patient factors known to influence bleeding, and whether patients had a contraindication to LMWH or another anticoagulant. Patients were deemed to have “appropriate” use of UFH in preference to more desirable anticoagulants if they had recent or ongoing bleeding, required an imminent procedure or surgery, an estimated glomerular filtration rate (eGFR) less than 30mL/min, or could foreseeably require thrombolysis. Results Of 127 patients, 16 (13%) were identified to have bleeding complications, including 14 episodes of MB. Bleeding episodes were significantly associated with any measured aPTT greater than 150 seconds (s) during treatment (p = 0.0285). Omission of initial bolus dosing was not associated with reduced bleeding events or the incidence of any aPTT measurement greater than 150s. Omission of initial bolus dosing was associated with subtherapeutic aPTT measurement at 6 hours (46%) and 12 hours (25%) post-UFH administration. We identified high rates (42%) of UFH selection where an alternative anticoagulant could have been used. Conclusion Use of intravenous UFH is associated with a high risk of MB, and bleeding complications are associated with markedly elevated aPTT (> 150s). An elevated risk of bleeding does not appear to be mitigated by omitting the initial bolus. Delivery of an initial UFH bolus decreases time to therapeutic anticoagulation.

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Section: Discussionmentioning

confidence: 95%

Section: Discussionmentioning

confidence: 99%