By the Book: Anticoagulation for CHD

The American Heart Association (AHA) has released its first evidence-based guidelines on anticoagulation in congenital heart disease (CHD).

Anticoagulation is a key element in managing patients with congenital heart disease. Despite the therapy’s widespread use, there are no established guidelines on anticoagulants in this patient population, which often leads to inconsistency and guesswork in how and when to use the drugs.

A new document from the American Heart Association and the American College of Cardiologists is changing that with the first-ever evidence-based recommendations on preventing and treating thrombosis in all types of congenital heart disease. The report, published in Circulation, is the result of an exhaustive review of published research on anticoagulation in children and adults.

Dozens of cardiologists from around the country spent nearly three years on the project, part of a larger initiative by the two groups to develop a series of tools to help cardiologists better care for their patients.

“When writing guidelines, a group of experts is assembled and literature is reviewed,” says Craig Sable, MD, chair of the AHA Council on Cardiovascular Disease in the Young and a cardiologist at Children’s National Medical Center in Washington, D.C. “In pediatrics, it is rare to have multicenter randomized controlled studies, so much of our guidelines are based on smaller studies or expert consensus.”

The 82-page report addresses the more common questions about anticoagulant use, such as whether to give postoperative aspirin therapy to patients with single ventricle defects. In the past, some cardiologists would give their patients low-dose aspirin following surgery, while others might have used a higher dose and still others wouldn’t have given aspirin at all. Under the new guidelines, low-dose aspirin is recommended. The guidelines include suggestions for how to respond to complications that arise and what to do if that response prompts additional complications.

Congenital heart disease is difficult to manage, in part, because each case is different. The new guidelines account for that, says Timothy Feltes, MD, a co-author of the new recommendations and co-director of The Heart Center at Nationwide Children’s Hospital.

“Guidelines typically fit for 90 percent of the patients, but there’s always going to be an exception,” Dr. Feltes says. “This document tries to put together what’s good for that 90 percent but also touches on many of the exceptions that we sometimes see.”