CHEST Guidelines 2012 Vs. 2008

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Anusha McNamara
CHEST Guidelines 2012 Vs. 2008

The American College of Chest Physicians published the 9th edition1 of the Chest guidelines in February 2012. These guidelines include recommendations for the treatment and prevention of medical conditions including venous thromboembolism, atrial fibrillation, and coronary artery disease. In an attempt to update pharmacists practicing in the ambulatory care setting, the following are important changes from the 8th edition2 published about four years ago. Anticoagulation and antiplatelet therapy recommendations have changed in various ways.

Chest 8th Edition Recommendations2

Chest 9th Edition Recommendations1

Starting dose of warfarin is 5 mg to 10 mg for 1-2 days bridged with LMWH* then dose based on INR

Starting dose of warfarin is 10 mg daily for 2 days bridged with LMWH* then dosed based on INR (Grade 2C)

Frequency of monitoring should be a maximum of every 4 weeks

Frequency of INR monitoring can go up to 12 weeks once stable (Grade 2B)

INRs <0.5 within therapeutic range should have warfarin dose adjusted and rechecked in 1 week

INR <0.5 within therapeutic range should be kept at the same dose and retested in 1-2 weeks (Grade 2C)

Vitamin K can be administered if INR is increased >0.5 from therapeutic range, and with INR >9 should get high dose vitamin K

Vitamin K should only be administered when bleeding is present or when INR > 10 (Grade 2C)

Patients with mechanical heart valves in either the mitral and aortic positions should have an INR goal of 2.5-3.5

Patients with mechanical heart valves in the mitral position should have an INR goal of 2.5-3.5, but if it is in the aortic position, the INR goal should be 2-3 (Grade 2C)

Length of anticoagulation treatment is atleast 3 months for the first unprovoked VTE§, and a second episode warrants indefinite therapy

It is recommended that the duration of anticoagulation for most VTEs§ is 3 months over long-term therapy. However, patient’s risk of bleeding should be considered when determining duration of treatment (Grade 1B)

Warfarin is recommended for anticoagulation of atrial fibrillation with a CHADS2 score of >2

Dabigatran is preferred over warfarin for anticoagulation of atrial fibrtillation when the CHADS2 score is >1 (Grade 2B)

Primary prevention with low dose aspirin is recommended for patients with at least moderate risk for a coronary event (10-year risk >10%)

Every patient over the age of 50 without symptomatic cardiovascular disease should be taking low dose aspirin (Grade 2B)

Dual antiplatelet therapy is recommended in patients after PCI+

Dual antiplatelet therapy is recommended for the first year after acute coronary syndrome with and without PCI+ (Grade 1B)

Clopidogrel in combination with low dose aspirin is recommended for antithrombotic therapy after acute coronary syndrome

Ticagrelor in combination with low dose aspirin is recommended over the use of clopidogrel with aspirin after acute coronary syndrome (Grade 2B)

*LMWH = low-molecular weight heparin
§VTE = venous thromboembolism 
+PCI = percutaneous coronary intervention

Chest guidelines are based on relevant literature and are graded based on this evidence. The AACP recommends that performance measures for quality improvement, performance-based reimbursement, and public reporting purposes should be based on higher graded recommendations (grades 1A, 1B). Few of the new recommendations related to primary care management of anticoagulation and antiplatelet therapy are graded highly in the new Chest guidelines. These are not necessarily appropriate for performance measures or for distinct patient care, and each one should be analyzed individually for importance, feasibility, usability, and scientific acceptability (grades 1C, 2A, 2B, 2C).3

References:

  1. Guyatt GH, et al. Executive Summary: Antithrombotic therapy and prevention of thrombosis, 9th ed: AACP evidence-based clinical practice guidelines. Chest. 2012;141:7S-47S.
  2. Hirsh J, et al. Executive Summary: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133:71S-109S.
  3. Chest Disclaimer. Chest 2012;141:1S.