Stemi Initial Dosing Guide

STEMI INITIAL DOSING GUIDE

(Referenced Version)

This dosing guide lists initial drugs and doses that should be highly considered based upon recent guidelines, emerging guidelines and medication package inserts.

WEIGHT AND CREATININE CLEARANCE

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1. Determine patient’s weight (kg).

2. CrCl ml/min = (140 – age) X weight (kg)/(serum creatinine X 72) multiply by 0.85 if female.

ASPIRIN and CLOPIDOGREL (ALL)

 Aspirin:Initial: 162 mg to 325 mg non-enteric chewed.[1]

Daily: 81 mg to 162 mg (or 162 to 325 mg after stent implantation).[2][3]

Clopidogrel: Fibrinolytic or No Reperfusion Patients[4]:

Initial: 300 mg orally(No evidence for loading dose in age ≥75 years)

Daily: 75 mg orally

PCI Patients[5]:

Initial: 300-600 mg orally (No evidence for loading dose in age ≥75 years)

Daily: 75 mg orally

FIBRINOLYTIC THERAPY

Streptokinase: 1.5 MU IV over 30-60 minutes[6]

Alteplase: Bolus: 15 mg IV

Infusion: 0.75 mg/kg IV over 30 minutes (not to exceed 50 mg); then 0.5 mg/kg over the next 60 minutes (not to exceed 35 mg over the next 60 minutes)[7]

Reteplase: 10 U IV over 2 minutes, repeat after 30 minutes[8]

Tenecteplase: if < 60 kg, give 30 mg single IV bolus;

if 60-69 kg, give 35 mg single IV bolus;

if 70-79 kg, give 40 mg single IV bolus;

if 80-89 kg, give 45 mg single IV bolus;

if 90kg, give 50 mg single IV bolus.[9]

ANTICOAGULANT THERAPY (FIBRINOLYTIC OR NO REPERFUSION PATIENTS)

Unfractionated Heparin:

Bolus: 60 U/kg IV (not to exceed 4000 U regardless of weight)

Infusion: 12 U/kg/hr IV (not to exceed 1000U/hr regardless of weight) to goal PTT 1.5 to 2.0 times local reference standard; check PTT in 6 hours and adjust heparin as indicated)[10]

If PTT < 1x control: re-bolus 60 units/kg (max 4000 unit) and increase infusion by 2 units/kg/hr

PTT 1 to 1.5x control: increase infusion by 2 units/kg/hr

PTT 1.5 to 2x control (approx 50-70 sec): no change (therapeutic range)

PTT 2 to 3x control: decrease infusion rate by 2 units/kg/hr

PTT > 3x control: stop infusion, recheck PTT in 1 hour, follow algorithm based on repeat PTT

Enoxaparin*: Bolus: 30 mg IV (no IV bolus if age >75 years)

Maintenance: 1mg/kg subcutaneously every 12 hours, first dose 15 minutes after bolus (if age >75 years, give 0.75 mg/kg every 12 hours with no bolus; if CrCl <30 mL/min, give 1 mg/kg every 24 hours after bolus)[11]

Fondaparinux*: 2.5 mg IV initial dose, then 2.5 mg subcutaneously dailythereafter (avoid if CrCl <30ml/min).[12] UFH not to be continued for >48 hours unless otherwise indicated. Enoxaparin or fondaparinux therapy continued for at least 48 hours, and preferably for duration of hospitalization, up to 8 days.)

ANTICOAGULANT THERAPY (PRIMARY PCI PATIENTS)

Unfractionated Heparin:

Bolus: 60 U/kg IV (not to exceed 4000 U)

Infusion: 12 U/kg/hr (not to exceed 1000 U/hr) to goal PTT 1.5 to 2.0 times local reference standard (target ACT in catheterization lab: 200-250 sec if concomitant GP IIb-IIIa therapy, 250-300 sec if no concomitant GP IIb/IIIa therapy; re-bolus with heparin to achieve target ACT if measured values below recommended ranges)[13]

Enoxaparin: Bolus: 30 mg IV (no IV bolus if age >75 years)

Maintenance: 1mg/kg subcutaneously every 12 hours, first dose 15 minutes after bolus (if age >75 years, give 0.75 mg/kg every 12 hours with no bolus; if CrCl <30 mL/min, give 1 mg/kg every 24 hours after bolus)[14]

(If last subcutaneous dose less than 8 hours prior to PCI, no additional enoxaparin required; if last subcutaneous dose 8-12 hours earlier or never given, intravenous dose of 0.3mg/kg should be given.)

GLYCOPROTEIN IIB/IIIA THERAPY (PRIMARY PCI PATIENTS)

Abciximab: Bolus: 0.25 mcg/kg IV bolus

Infusion: 0.125 mcg/kg/min IV for 12 hours[15]

Eptifibatide: Bolus: 180mcg/kg IV bolus, repeat bolus after 10 minutes

Infusion: 2.0 mcg/kg/min IV for 12-18 hours (Reduce to 1.0 mcg/kg/min if CrCl <50 mL/min)[16]

Tirofiban: Bolus: 0.4 mcg/kg/min IV for 30 minutes (Reduce to 0.2 mcg/kg/min for CrCl ≤ 30 mL/min)

Infusion: 0.1 mcg/kg/min IV for 12-18 hours (Reduce to 0.05 mcg/kg/min if CrCl ≤30 mL/min)[17]

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(Continue for the shorter of the duration of hospitalization, 8 days, or until PCI)Bottom of Form

End Notes

1

[1]Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction; A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of patients with acute myocardial infarction). J Am Coll Cardiol. 2004;44:E1-E211.

[2]Antman EM, Anbe DT, Armstrong PW, et al, 2004, e73.

[3] Antman EM, Hand M, Armstrong PW, et al. 2008 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction: a report of the AmericanCollege of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2008;51:235.

[4] Antman EM, Hand M, Armstrong PW, et al. 2008 , p230.

[5] King SB, 3rd, Smith SC, Jr., Hirshfeld JW, Jr., et al. 2007 focused update of the ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice guidelines. J Am Coll Cardiol. 2008; p192.

[6]Antman EM, Anbe DT, Armstrong PW, et al, 2004, e53.

[7]Antman EM, Anbe DT, Armstrong PW, et al, 2004, e53.

[8]Antman EM, Anbe DT, Armstrong PW, et al, 2004, e53.

[9]Antman EM, Anbe DT, Armstrong PW, et al, 2004, e53.

[10] Antman EM, Hand M, Armstrong PW, et al. 2008, p224.

[11] Antman EM, Hand M, Armstrong PW, et al. 2008, p224.

[12] Antman EM, Hand M, Armstrong PW, et al. 2008, p224

[13] Antman EM, Hand M, Armstrong PW, et al. 2008, p224

[14] Antman EM, Hand M, Armstrong PW, et al. 2008, p224

[15] Reopro (abciximab) Package Insert. Available at: Accessed June 12, 2008.

[16] Integrilin (eptifibatide) Package Insert. Available at: Accessed June 12, 2008.

[17] Aggrastat (Tirofiban) Package Insert. Available at: Accessed June 12, 2008.