Continuous intravenous heparin is widely used in the initial treatment of patients with venous thromboembolism. However, because it has a narrow therapeutic window and because the anticoagulant response to it varies among patients, it is standard practice to adjust the dose of heparin to achieve a predefined anticoagulant effect (therapeutic range) using the activated partial thromboplastin time (APTT). There is evidence to suggest that the efficacy of heparin is critically dependent on the starting dose used and that failure to maintain APTT results above the lower limit of the therapeutic range leads to increased rates of recurrence. We review the evidence for a rel~tic~nship between the intensity of heparin treatment and recurrence and provide recommendations for optimal dosing regimens.
Hirsh J.Antithrombotic therapy in deep vein thrombosis and pulmonary embolism . Am Heart J1992;123:1115-22.
2.
Hull RDRaskob GE, Pineo GF, et al. Subcutaneous low molecular weight heparin compared with continuous intravenous heparin in the treatment of proximal vein thrombosis. N Engl J Med1992; 326:975-82.
3.
Lensing AW, Prins MH, Davidson BL, et al. Treatment of deep venous thrombosis with low molecular weight heparin: a meta-analysis. Arch Intern Med1994;155:601-7.
4.
Barrit DW, Jordan SCAnticoagulant drugs in the treatment of pulmonary embolism: a controlled clinical trial. Lancet1960;1: 1309-12.
5.
Brandjes DP, Heijboer H., Buller HR, DeRijk M.Jagt H., ten Cate JWAcencoumarol and heparin compared with acencoumarol alone in the initial treatment of proximal-vein thrombosis. N Engl J Med1992:327:1485-9:
6.
Hull RD, Raskob GE, Hirsh J., et al. Continuous intravenous heparin compared with intermittent subcutaneous heparin in the initial treatment of proximal vein thrombosis. N Engl J Med1986;315: 1109-14.
7.
Levine MN, Hirsh J., Gent M., et al. A randomized trial comparing activated thromboplastin time with heparin assay in patients with acute venous thromboembolism requiring large daily doses of heparin. Arch Intern Med1994 ;154:49-56,
8.
Chiu HM, Hirsh J., Yung WL, et al. Relationship between anticoagulant and antithrombotic effects of heparin. Blood1987;49: 171-84.
9.
Basu D., Gallus A., Hirsh J., Cade J.A prospective study of the value of monitoring heparin treatment with the activated partial thromboplastin time. N Engl J Med1972;287:324-7.
10.
Brill-Edwards P., Ginsberg JS, Johnston M., Hirsh J.Establishing a therapeutic range for heparin therapy. Ann Intern Med1993; 119: 104-9.
11.
Turpie AG, Robinson JG, Doyle DJ, et al. Comparison of high-dose with low-dose subcutaneous heparin to prevent left ventricular mural thrombosis in patients with acute transmural anterior myocardial infarction. N Engl J Med1989;320:352-94.
Elliot CG, Hiltunen SJ, Suchyta M., et al. Physician-guided treatment compared with a heparin protocol for deep vein thrombosis. Arch Intern Med1994;154:999-1004.
14.
Hull RD, Raskob GE, Rosenbloom D., et al. Heparin for 5 days as compared with 10 days in the initial treatment of proximal venous thrombosis. N Engl J Med1990;322:1260-4.
15.
Raschke RA, Reilly BM, Guidry JR, Fontana JR, Srinivas S.The weight-based heparin dosing nomogram compared with a standard care nomogram . Ann Intern Med1993;119:874-81.
16.
Prandoni P. , Lensing AW, Buller HR, et al. Comparison of subcutaneous low molecular weight heparin with intravenous standard heparin in proximal deep-vein thrombosis . Lancet1992;339:441-5.
17.
Simonneau G. , Charbonnier B., Decousus H., et al. Subcutaneous low-molecular weight heparin compared with continuous intravenous unfractionated heparin in the treatment of proximal deep vein thrombosis. Arch Intern Med1993;153:1541-6.
18.
Anand S., Ginsberg JS, Kearon C., Hirsh J.The relationship between the activated partial thromboplastin time response and recurrence in patients with venous thrombosis treated with continuous intravenous heparin. J Gen Intern Med1995 ;10(suppl 4):38.
19.
Cruickshank MK, Levine MN, Hirsh J., et al. A standard heparin nomogram for the management of heparin therapy. Arch Intern Med1991;151:333-7.
20.
Hull RD, Raskob GE, Rosenbloom D., et al. Optimal therapeutic level of heparin therapy in patients with venous thrombosis. Arch Intern Med1992;152:1589-95.
