Pharmacologic and Interventional Therapies
Medications
Antiplatelets: aspirin plus a P2Y12 inhibitor (clopidogrel, ticagrelor, prasugrel) after PCI. Clopidogrel is a prodrug; CYP2C19 poor metabolizers gain less benefit.
Anticoagulants: unfractionated heparin monitored by aPTT or anti-Xa and reversed with protamine. Warfarin monitored by INR (target 2–3 for most indications), reversed with vitamin K and prothrombin complex concentrate. DOACs require renal dosing checks; dabigatran is reversed by idarucizumab, factor Xa inhibitors by andexanet alfa. HIT: platelets fall >50% at 5–10 days with thrombosis, not bleeding - stop heparin and use argatroban or bivalirudin.
Heart failure: sacubitril/valsartan requires a 36-hour washout from an ACE inhibitor; MRAs require potassium and creatinine monitoring; SGLT2 inhibitors are core therapy.
Antiarrhythmics: amiodarone needs thyroid, hepatic, pulmonary, and ocular monitoring and is given by central line when possible. Adenosine is pushed rapidly and has a seconds-long half-life; avoid in severe asthma. Digoxin toxicity is worsened by hypokalemia.
Interventions: PCI/stents, CABG, ablation, pacemakers, ICDs, and TAVR - each carries device-specific precautions and follow-up.
Traps
- HIT is a clotting disorder; platelet transfusion does not treat it.
- Never start warfarin alone in acute HIT.
- Avoid nitrates within 24–48 hours of a PDE-5 inhibitor.
- Beta-blockers are not for acute decompensated heart failure.
Rule of thumb
"Platelets down, clots up" = HIT. Stop all heparin immediately and document prior exposure.