Heparin drip Nomogram for Acute Coronary Syndrome/Atrial Fibrillation
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Objectives
The purpose of this guideline is to provide dosing assistance for unfractionated heparin therapy for the treatment of acute coronary syndrome (ACS) or atrial fibrillation (AF) based on anti-factor Xa values (calibrated for heparin).
University of Michigan Health System Anticoagulation Program
Guideline for Managing Unfractionated Heparin for Treatment of Acute Coronary Syndrome or Atrial Fibrillation in Adult Patients Based upon Anti-Factor Xa Levels
Initial Dosing and Dosage Adjustments
Heparin should be dosed based upon actual body weight (kg): ____
- Bolus doses (round to nearest 10 units)
Note: DO NOT exceed the following initial bolus limits:
- ST-segment elevation MI treated with tPA, maximum bolus = 4,000 units
- Unstable angina or non-ST-segment elevation MI, maximum bolus = 5,000 units
- Initial bolus dose 60 units/kg
- Other initial bolus: _______ units/kg
- No initial bolus
- No bolus EVER
- Continuous infusion rate (round to nearest 10 units)
For unstable angina, non-ST-segment elevation MI or ST-segment elevation MI treated with tPA do not exceed maximum initial rate of 1,000 units/hour.
- Initiate infusion at 12 units/kg/h
- Other initial infusion rate : _________ units/kg/h
- Non-weight based initial infusion rate : _________ units/h
- Monitoring
- Draw INR/PT, CBC with platelet count and aPTT prior to starting heparin
- Draw STAT anti-factor Xa 6 hours after starting heparin
- Monitor anti-factor Xa and adjust per Weight-Adjusted Heparin Nomogram (target anti-factor Xa 0.2-0.5 units/mL)
- Platelet count should be monitored daily for a minimum of 2 weeks and hemoglobin/hematocrit at least weekly
Weight-Adjusted Heparin Nomogram
|
Anti-Xa (units/mL) |
Repeat Heparin Bolus Dose |
Hold Infusion (minutes) |
Rate Change |
Repeat Anti-Xa level |
|
Less than 0.1* |
70 units/kg† |
0 |
Increase 1.5 units/kg/h |
6 hours |
|
0.1-0.19 |
40 units/kg† |
0 |
Increase 1 units/kg/h |
6 hours |
|
0.2-0.5 |
None |
0 |
No change |
6 hours** |
|
0.51-0.6 |
None |
0 |
Decrease 1 units/kg/h |
6 hours |
|
0.61-0.89 |
None |
30 min |
Decrease 1.5 units/kg/h |
6 hours |
|
Greater than or equal to 0.9* |
None |
60 min |
Decrease 2 units/kg/h |
6 hours |
*Notify physician if 2 consecutive Anti-Xa values are in this range
**When 2 consecutive Anti-Xa values are in therapeutic range (0.2-0.5 units/mL), obtain Anti-Xa assay the next morning and every 24 hours thereafter
† Please ensure physician has not selected “No bolus ever” option above