Excess Dosing of Antiplatelet and Antithrombin Agents in the Treatment of Non–ST-Segment Elevation Acute Coronary Syndromes

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Abstract
Current quality improvement efforts in acute cardiovascular care are focused on closing treatment gaps so more eligible patients receive evidence-based therapies.1,2 Beyond ensuring that effective therapies are administered, attention should also be directed at ensuring these therapies are given both correctly and safely. In acute coronary syndromes (ACS), early use of antiplatelet and antithrombin therapy plays a key role in altering the thrombotic process resulting from plaque rupture, thereby improving patient outcomes.1,3-10 Numerous studies have also helped define dosing strategies for antithrombotic therapy; these individualized dosing strategies based on weight and renal function minimize bleeding risk while preserving therapeutic benefits.11-19 Despite these guidelines, bleeding complications remain a major concern in patients with non–ST-segment elevation (NSTE) ACS and occur in approximately 3% to 9% of selected clinical trial populations; even higher rates have been reported in the community.9,10,20,21 Antithrombotic agents have narrow therapeutic windows, which makes dosing an important concern. In addition, patient factors have been associated with greater risk of bleeding. However, the variation and impact of antithrombotic dosing on the safety of evidence-based medicine has yet to be carefully studied outside of the standardized clinical trial environment, or after adjusting for patient factors.

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