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2012 Guyat. Executive Summary Antithrombotic Therapy and Prevention of Thrombosis, th ed!

American "o##e$e of "hest Physicians Evidence%&ased "#inica# Practice Guide#ines. CHEST 2012;141(Suppl):7S47S.

INDICE:

Pg 2: Pg 5: Pg 7:

Manejo de la terapia anticoagulante Basado en Evidencia Prevencin del TEV en pacientes No-Quir rgicos Prevencin de TEV en pacientes Quir rgicos no ortop!dicos

Pg 10: Prevencin del TEV en pacientes de cirug"a ortop!dica Pg 12: Manejo perioperatorio de la Terapia antitro#$tica Pg 14: Diagnstico de la TVP Pg 19: Trata#iento antitro#$tico para el TEV %TVP Pg 24: TEP Pg 26: &EDVT: uppere'tre#it( DVT) PT* del $ra+o) Tro#$osis venosa espl,cnica Pg 28: Trata#iento ( Prevencin de Tro#$ocitopenia inducida por -eparina Pg 31: Trata#iento antitro#$tico para la .i$rilacin /uricular Pg 35: Terapia /ntitro#$tica ( Tro#$ol"tica para la En0er#edad Valvular Pg 39: Trata#iento /ntitro#$tico ( Tro#$ol"tico para el Ictus Is1u!#ico % 2e#orr,gico Pg 42: Prevencin pri#aria ( secundaria de en0er#edades cardiovasculares) * coronario) PCI) *tent3s Pg 45: Trata#iento antitro#$tico en la En0er#edad /rterial Peri0!rica) Estenosis carotidea .

Evidence-Based Manage#ent o0 /nticoagulant T-erap( 2.1 Loading Dose for Initiation of Vitamin K Antagonist (VKA) Therapy 4)5) .or patients su00icientl( -ealt-( to $e treated as outpatients6 7e suggest initiating V8/ t-erap( 7it7ar0arin 59 #g dail( 0or t-e 0i rst 4 da(s 0ollo7ed $( dosing $ased on international nor#ali+ed ratio :IN;< #easure#ents rat-er t-an starting 7it- t-e esti#ated #aintenance dose :4C< ) 2.2 Initial Dose Selection and harmacogenetic Testing 4)4) .or patients initiating V8/ t-erap(6 7e reco##end against t-e routine use o0 -ar#acogenetic testing 0or guiding doses o0 V8/ (Grade 1B) ) 2.! Initiation "#erlap for $eparin and VKA 4)=) .or patients 7it- acute VTE6 7e suggest t-at V8/ t-erap( $e started on da( 5 or 4 o0 lo7-#olecular-7eig-t -eparin :>M?2< or lo7-dose un0ractionated -eparin :&.2< t-erap( rat-er t-an 7aiting 0or several da(s to start (Grade 2C) )

Manejo de la terapia anticoagulante Basado en Evidencia 2.1 Dosis de carga para el inicio de Terapia con AVK (Antagonistas de #itamina K) 465) En pacientes su0iciente#ente saluda$les co#o para ser tratados en 0or#a a#$ulatoria6 se sugiere iniciar trata#iento /V8 con 7ar0arina 59 #g al d"a durante los 5Cs 4 d"as6 seguido de la dosi0icacin $asada en "ndice internacional nor#ali+ado :IN;< en lugar de co#en+ar con la dosis de #anteni#iento esti#ada :Drado 4C< ) 2.2 Selecci/n de dosis inicial y Test farmacogen0ticos 464) En los pacientes 1ue inician trata#iento con /V86 no se reco#ienda uso rutinario de test 0ar#acogen!ticos para guiar la dosis de /V8 :Drado 5B<) 2.! S(perposici/n inicial de heparina y AVK 46=) En pacientes con tro#$oe#$olis#o venoso agudo6 VTE6 sugeri#os 1ue la terapia con /V8 se inicie el d"a 5 o 4 de -eparina de $ajo peso #olecular :2BPM< o dosis $ajas de terapia de -eparina no 0raccionada 2N.6 en ve+ de esperar varios d"as para co#en+ar :4C< )

!.1 %onitoring &re'(ency for VKAs !.1 &rec(encia de %onitori1aci/n de las AVK =)5) .or patients ta@ing V8/ t-erap( 7it- consistentl( =65) En pacientes tratados con /V86 con IN;3s esta$les6 sta$le IN;s6 7e suggest an IN; testing 0re1uenc( o0 up to se sugiere una 0recuencia de prue$as de IN; de -asta 54 54 7ee@s rat-er t-an ever( A 7ee@s (Grade 2B) ) se#anas en lugar de cada A se#anas :Drado 4B<) !.2 %anagement of the Single "(t)of)*ange I+* =)4) .or patients ta@ing V8/s 7it- previousl( sta$le t-erapeutic IN;s 7-o present 7it- a single out-o0-range IN; o0 9)B $elo7 or a$ove t-erapeutic6 7e suggest continuing t-e current dose and testing t-e IN; 7it-in 5 to 4 7ee@s (Grade 2C) ) !.! ,ridging for Lo- I+*s =)=) .or patients 7it- sta$le t-erapeutic IN;s presenting 7it- a single su$t-erapeutic IN; value6 7e suggest against routinel( ad#inistering $ridging 7it- -eparin (Grade 2C) ) !.. Vitamin K S(pplementation =)A) .or patients ta@ing V8/s6 7e suggest against routine use o0 vita#in 8 supple#entation (Grade 2C) ) !.2 %ane2o de (n I+* 3nico f(era del rango =64) En pacientes 1ue to#an /V8 con IN;3s previos terape ticos esta$les6 1ue se presentan con un solo IN; 0uera de rango terap!utico de E 96B por de$ajo o por enci#a6 se sugiere continuar con la dosis actual ( testar el IN; dentro de 5 a 4 se#anas :Drado 4C<) !.! Terapia 4 (ente5 en I+* 6a2o =6=) Para los pacientes con IN; esta$les terap!uticas 1ue se presentan con un valor de IN; su$terap!utico nico6 sugeri#os en contra la ad#inistracin rutinaria de -eparina-puente :Drado 4C<) !7. S(plementaci/n con #itamina K =6A) Para los pacientes 1ue to#an /V86 sugeri#os en contra del uso -a$itual de suple#entos de vita#ina 8 :Drado 4C<)

!.8 Anticoag(lation %anagement Ser#ices for VKAs =)B) :Best Practices *tate#ent< ?e suggest t-at -ealt-care providers 7-o #anage oral anticoagulation t-erap( s-ould do so in a s(ste#atic and coordinated 0as-ion6 incorporating patient education6 s(ste#atic IN; testing6 trac@ing6 0ollo7-up6 and good patient co##unication o0 results and dosing decisions) !.9 atient Self)Testing and Self)%anagement =)F) .or patients treated 7it- V8/s 7-o are #otivated and can de#onstrate co#petenc( in sel0#anage#ent strategies6 including t-e sel0-testing e1uip#ent6 7e suggest patient sel0#anage#ent rat-er t-an usual outpatient IN; #onitoring (Grade 2B) ) .or all ot-er patients6 7e suggest #onitoring t-at includes t-e sa0eguards in our $est practice state#ent =)B) !.: Dosing Decision S(pport =)G) .or dosing decisions during #aintenance V8/ t-erap(6 7e suggest using validated decision support tools :paper no#ogra#s or co#puteri+ed dosing progra#s< rat-er t-an no decision support (Grade 2C)) !.; VKA Dr(g Interactions to A#oid =)H) .or patients ta@ing V8/s6 7e suggest avoiding conco#itant treat#ent 7it- nonsteroidal anti -in0la##ator( drugs6 including c(cloo'(genase-4selective nonsteroidal antiin0l a##ator( drugs6 and certain anti$iotics :see Ta$le H in #ain article< (Grade 2C) ) .or patients ta@ing V8/s6 7e suggest avoiding conco#itant treat#ent 7it- antiplatelet agents e'cept in situations 7-ere $ene0i t is @no7n or is -ig-l( li@el( to $e greater t-an -ar# 0ro# $leeding6 suc- as patients 7it#ec-anical valves6 patients 7it- acute coronar( s(ndro#e6 or patients 7it- recent coronar( stents or $(pass surger( (Grade 2C) ) ..1 "ptimal Therape(tic I+* *ange A)5) .or patients treated 7it- V8/s6 7e reco##end a t-erapeutic IN; range o0 4)9 to =)9 :target IN; o0 4)B< rat-er t-an a lo7er :IN; , 4< or -ig-er :IN; =)9-B)9< range (Grade 1B) ) ..2 Therape(tic *ange for $igh)*is< =ro(ps A)4) .or patients 7it- antip-osp-olipid s(n dro#e 7itprevious arterial or venous t-ro#$oe#$olis#6 7e suggest V8/ t-erap( titrated to a #oderateintensit( IN; range :IN; 4)9-=)9< rat-er t-an -ig-er intensit( :IN; =)9-A)B< (Grade 2B) ) 8.> Discontin(ation of Therapy B)9) .or patients eligi$le to discontinue treat#ent 7itV8/6 7e suggest a$rupt discontinuation rat-er t-an gradual tapering o0 t-e dose to discontinuation (2C) )

!.8 Ser#icios para mane2o de la anticoag(laci/n con AVK?s =6B) *e sugiere 1ue los proveedores de cuidados de salud 1ue #anejan anticoagulantes orales de$en -acerlo de una #anera siste#,tica ( coordinada6 incorporando la educacin del paciente6 las prue$as siste#,ticas de IN;6 el segui#iento ( $uena co#unicacin con el paciente so$re resultados ( decisiones de dosi0icacin) :Best Pract< !.9 A(to)Test y A(togesti/n del aciente =6F) En pacientes #otivados tratados con /V8 1ue puedan de#ostrar co#petencia en las estrategias de autogestin6 inclu(endo el e1uipo de auto-test6 sugeri#os autogestin del paciente en lugar de control a#$ulatorio -a$itual del IN; :Drado 4B<) En todos los de#,s pacientes6 sugeri#os #onitori+acin 1ue inclu(a las garant"as de nuestra declaracin de B)P) =)B) 3,7 Soporte de a! de"#!#o$e! !o%re do!#&#"a"#'$ =6G) Para las decisiones durante la terapia con /V86 sugeri#os utili+ar -erra#ientas validadas de apo(o a las decisiones :no#ogra#as o progra#as in0or#ati+ados de dosi0icacin< #ejor 1ue 1ue no -a(a soporte para las decisiones :Drado 4C<) !.; Interacciones medicamentosas AVK '(e de6en e#itarse =6H En pacientes 1ue to#an /V86 sugeri#os evitar el trata#iento conco#itante con anti-in0la#atorios no esteroideos6 inclu(endo antiin0la#atorios cicloo'igenasa4- selectivos ( ciertos anti$iticos :ver Ta$la H del art"culo principal < :Drado 4C<) En pacientes 1ue to#an /V86 sugeri#os evitar el trata#iento conco#itante con antiagregantes6 e'cepto en situaciones en 1ue el $ene0icio sea conocido6 o 1ue #u( pro$a$le#ente sea #a(or 1ue el riesgo de sangrado6 tales co#o pacientes con v,lvulas #ec,nicas6 pacientes con s"ndro#e coronario agudo6 o pacientes con recientes stents coronarios o cirug"a de $(pass :Drado 4C<) ..1 *ango /ptimo de I+* terap0(tico A65) En pacientes tratados con /V86 se reco#ienda un rango terap!utico de IN; de 469 a =69 :IN; o$jetivo de 46B< en lugar de un rango in0erior :IN;6 4< o superior :IN; =)9-B)9< :Drado 5B<) .72 *ango terap0(tico para gr(pos de alto riesgo A64) En pacientes con s"ndro#e anti0os0ol"pido con tro#$oe#$olis#o arterial o venoso previo6 sugeri#os trata#iento con /V8 de #odera da intensidad6 rango de IN; :IN; 4)9-=)9< en lugar de :IN; =69 a A6B< :grado 4B<) 5.0 ($terr)p"#'$ de trata*#e$to B69) En pacientes elegi$les para interru#pir el trata#iento con /V86 sugeri#os la interrupcin a$rupta en lugar de una dis#inucin progresiva de la dosis para interru#pirlo :4C<)

+,-. +$t#/#ta*#$a -.

9.1 @nfractionated $eparin (@&$) Dose Ad2(stment 6y Aeight F)5) .or patients starting IV &.26 7e suggest t-at t-e initial $olus and t-e initial rate o0 t-e continuous in0usion $e 7eig-t adjusted :$olus H9 units%@g 0ollo7ed $( 5H units%@g per - 0or VTEI $olus G9 units%@g 0ollo7ed $( 5B units%@g per 0or cardiac or stro@e patients< or use o0 a 0i'ed dose :$olus B6999 units 0ollo7ed $( 56999 units%-< rat-er t-an alternative regi#ens (Grade 2C) ) 9.2 Dose %anagement of S(6c(taneo(s (SB) @&$ F)4) .or outpatients 7it- VTE treated 7it- *C &.26 7e suggest 7eig-t-adjusted dosing :0i rst dose === units%@g6 t-en 4B9 units%@g< 7it-out #onitoring rat-er t-an 0i 'ed or 7eig-tadjusted dosing 7it- #onitoring (Grade 2C) )

9.1 A2(ste de la dosis de heparina no fraccionada ($+&) por peso F65) Para los pacientes 1ue inician 2N. IV6 sugeri#os 1ue el $olo inicial ( la velocidad inicial de la in0usin continua se ajuste seg n el peso :$olo H9 unidades % @g seguido de 5H unidades % @g % -ora para el TEVI $olo de G9 unidades % @g seguido de 5B unidades % @g % - en ictus o pacientes card"acos< o el uso de una dosis 0i ja :$olo de B)999 unidades seguida por 5)999 unidades % -< en lugar de reg"#enes alternativos :Drado 4C<) 9.2 %ane2o de la dosis s(6c(tCnea (SB) de $+& F64) En pacientes a#$ulatorios con TEV tratados con 2N. *C6 se sugieren dosis ajustada al peso :pri#ero dosis de === unidades % @g6 luego 4B9 unidades % @g< sin #onitori+acin6 #ejor 1ue dosi0icacin 0ija o ajustada al peso con #onitori+acin :Drado 4C<) :71 Dosis terap0(tica de $, % en pacientes con dismin(ci/n de la f(nci/n renal G65) En pacientes 1ue reci$en 2BPM terap!utica ( tienen insu0iciencia renal grave :CCr calculado J de =9 #l % #in<6 sugeri#os una reduccin de la dosis en lugar de utili+ar las dosis est,ndar :Drado 4C<) ;71 %ane2o de la dosis de &ondaparin(D por peso H65) En pacientes con TEV ( peso K de 599 @g6 sugieren 1ue la dosis de 0ondaparinu' pase de los -a$ituales G6B #g a 59 #g s)c) diarios :Drado 4C<)

7.1 Therapeutic Dose of LMWH in Patients With Decreased Renal Function 7.1. For patients receiving therapeutic LMWH who have severe renal insuffi ciency (calculated creatinine clearance , 30 L! in"# we suggest a reduction of the dose rather than using standard doses (Grade 2C) .

8.1 Fondaparinux Dose Manage ent !" Weight $.1. For patients with %&' and (ody weight over 100 )g# we suggest that the treat ent dose of fondaparinu* (e increased fro the usual 7.+ g to 10 g daily ,E.1 La #itamina K en pacientes '(e toman los AVK con I+* (Grade 2C) . alto sin hemorragia L65) :a< En pacientes 1ue to#an /V8 con IN; entre A6B ( #.1 $ita in % for Patients Ta&ing $%'s With 59 ( sin evidencia de sangrado6 sugeri#os en contra del uso rutinario de vita#ina 8 :Drado 4B< High ()Rs Without *leeding :$< En pacientes to#ando /V8 con IN;K 59 ( sin ..1. (a" For patients ta)ing %/0s with 123s (etween evidencia de sangrado6 se sugiere 1ue se ad#inistre 4.+ and 10 and with no evidence of (leeding# we vita#ina 8 por v"a oral :Drado 4C<) suggest against the routine use of vita in /(Grade 2B) ((" For patients ta)ing %/0s with 123s 5 10 and with no evidence of (leeding# we suggest that oral vita in / E.2 *eglas de predicci/n clFnica para el sangrado mientras se toma AVK (e ad inistered (Grade 2C) . L64) En los pacientes 1ue inician trata#iento con /V86 sugeri#os en contra del uso rutinario de reglas de #.+ ,linical Prediction Rules for *leeding While prediccin cl"nica de sangrado co#o criterio nico para Ta&ing $%' interru#pir el trata#iento con /V8 :Drado 4C<) ..6. For patients initiating %/0 therapy# we suggest E.! Tratamiento de la hemorragia relacionada con against the routine use of clinical prediction rules for (leeding as the sole criterion to withhold %/0 therapy anticoag(lante L6=) En pacientes con -e#orragias graves asociadas a (Grade 2C) . /V86 se sugiere una reversin de la anticoagulacin r,pida con concentrado de co#plejo de protro#$ina de #.- Treat ent of 'nticoagulant.Related cuatro 0actores en lugar de con plas#a) :Drado 4C<) *leeding *e sugiere el uso adicional de la vita#ina 86 B a 59 #g6 ..3. For patients with %/07associated a8or (leeding# ad#inistrado por in(eccin intravenosa lenta en lugar de we suggest rapid reversal of anticoagulation with four7 reversin con los 0actores de coagulacin sola#ente factor prothro (in co ple* concentrate rather than :Drado 4C<) with plas a. (Grade 2C) . We suggest the additional use of vita in / + to 10 g

ad inistered (y slow 1% in8ection rather than reversal with coagulation factors alone (Grade 2C) .

012. 0epar#$a $o &ra""#o$ada. 34, . 3ro*%oe*%o #!*o /e$o!o. . ,34

9revention of %&' in 2onsurgical 9atients +./ Hospitali0ed 'cutel" (ll Medical Patients 6.3. For acutely ill hospitali:ed edical patients at increased ris) of thro (osis# we reco end anticoagulant thro (oprophyla*is with low olecular7 weight heparin ;LMWH<# low7dose unfractionated heparin (L=>H" (id# L=>H tid# or fondaparinu* (Grade 1B) . 6.4. For acutely ill hospitali:ed edical patients at low ris) of thro (osis# we reco end against the use of phar acologic prophyla*is or echanical prophyla*is (Grade 1B) . 6.7.1. For acutely ill hospitali:ed edical patients who are (leeding or at high ris) for (leeding# we reco end against anticoagulant thro (oprophyla*is (Grade 1B) . 6.7.6. For acutely ill hospitali:ed edical patients at increased ris) of thro (osis who are (leeding or at high ris) for a8or (leeding# we suggest the opti al use of echanical thro (oprophyla*is with graduated co pression stoc)ings (?-," (Grade 2C) or inter ittent pneu atic co pression (19-" (Grade 2C) # rather than no echanical thro (oprophyla*is. When (leeding ris) decreases# and if %&' ris) persists# we suggest that phar acologic thro (oprophyla*is (e su(stituted for echanical thro (oprophyla*is (Grade 2B) . 6.$. 1n acutely ill hospitali:ed edical patients who receive an initial course of thro (oprophyla*is# we suggest against e*tending the duration of thro (oprophyla*is (eyond the period of patient i o(ili:ation or acute hospital stay (Grade 2B) . -./ ,riticall" (ll Patients 3.6. 1n critically ill patients# we suggest against routine ultrasound screening for =%& (Grade 2C) . 3.4.3. For critically ill patients# we suggest using LMWH or L=>H thro (oprophyla*is over no prophyla*is (Grade 2C) . 3.4.4. For critically ill patients who are (leeding# or are at high ris) for a8or (leeding# we suggest echanical thro (oprophyla*is with ?-, (Grade 2C) or 19(Grade 2C) until the (leeding ris) decreases# rather than no echanical thro (oprophyla*is. When (leeding ris) decreases# we suggest that phar acologic thro (oprophyla*is (e su(stituted for echanical thro (oprophyla*is (Grade 2C) .

Prevencin del TEV en pacientes No-Quir rgicos


27> acientes m0dicos ag(dos hospitali1ados 46=) En pacientes #!dicos -ospitali+ados con en0er#edad aguda con un alto riesgo de tro#$osis6 se reco#ienda tro#$opro0ila'is anticoagulante con -eparina de $ajo peso M2BPMN6 -eparina no 0raccionada a dosis $ajas :2N.DB< $id6 2N.DB tres veces al d"a6 o 0ondaparinu' :Drado 5B<) 46A) En pacientes #!dicos -ospitali+ados con en0er#edad aguda de $ajo riesgo de tro#$osis6 se reco#ienda contra el uso de pro0ila'is 0ar#acolgica o #ec,nica :Drado 5B<) 4)G)5) En pacientes #!dicos -ospitali+ados 1ue est,n sangrando o con alto riesgo de sangrado6 se reco#ienda contra la tro#$opro0ila'is anticoagulante :Drado 5B<) 4)G)4) En pacientes #!dicos -ospitali+ados con alto riesgo de tro#$osis 1ue est,n sangrando o en alto riesgo de -e#orragia #a(or6 se sugiere la utili+acin pti#a de tro#$opro0ila'is #ec,nica con #edias de co#presin graduada :MCD<6 :Drado 4C<6 o co#presin neu#,tica inter#itente :CNI< :Drado 4C<6 en lugar de pro0ila'is no #ec,nica de tro#$osis) Cuando el riesgo de sangrado dis#inu(e6 ( si persiste el riesgo de TEV6 sugeri#os 1ue la tro#$opro0ila'is 0ar#acolgica sea sustituida por tro#$opro0ila'is #ec,nica :Drado 4B<) OOO PPP 46H) En pacientes #!dicos -ospitali+ados 1ue reci$en un curso inicial de tro#$opro0ila'is6 sugeri#os contra la a#pliacin de la duracin de la tro#$opro0ila'is #,s all, del per"odo de in#ovili+acin del paciente o de la estancia -ospitalaria aguda :Drado 4B<) !.> acientes crFticos =64) En pacientes en estado cr"tico6 sugeri#os en contra de reali+ar ecogra0"a de rutina para detectar TVP :Drado 4C<) =)A)=) En pacientes cr"ticos6 sugeri#os utili+ar 2BPM o 2N.BD co#o pro0ila'is de tro#$osis en lugar de ninguna pro0ila'is :Drado 4C<) =)A)A) En pacientes cr"ticos 1ue est,n sangrando6 o est,n en alto riesgo de -e#orragia grave6 sugieren la tro#$opro0ila'is #ec,nica con MCD :Drado 4C< o CNI :Drado 4C< -asta 1ue el riesgo de sangrado dis#inu(a6 en lugar de pro0ila'is de la tro#$osis no #ec,nica) Cuando el riesgo de sangrado dis#inu(e6 se sugiere 1ue la tro#$opro0ila'is 0ar#acolgica sea sustituida por tro#$opro0ila'is #ec,nica :Drado 4C<) OOO PPP

34,. 3ro*%oe*%o #!*o /e$o!o. 5CG . 5ed#a! de "o*pre!#'$ grad)ada. C1( . Co*pre!#'$ $e)*t#"a #$ter*#te$te 012. 0epar#$a $o &ra""#o$ada. 0BP5. 0epar#$a Ba6o Pe!o 5o e") ar. 012B7: 0epar#$a $o &ra""#o$ada a Ba6a! 7o!#!

1./ Patients With ,ancer in the 2utpatient 3etting 4.6.1. 1n outpatients with cancer who have no additional ris) factors for %&'# we suggest against routine prophyla*is with LMWH or L=>H (Grade 2B) and reco end against the prophylactic use of %/0s (Grade 1B) . 4.6.6. 1n outpatients with solid tu ors who have additional ris) factors for %&' and who are at low ris) of (leeding# we suggest prophylacticdose LMWH or L=>H over no prophyla*is (Grade 2B) . 4.4. 1n outpatients with cancer and indwelling central venous catheters# we suggest against routine prophyla*is with LMWH or L=>H (Grade 2B) and suggest against the prophylactic use of %/0s (2C) . 4./ ,hronicall" ( o!ili0ed Patients +.1. 1n chronically i o(ili:ed persons residing at ho e or at a nursing ho e# we suggest against the routine use of thro (oprophyla*is (Grade 2C) . 5./ Persons Tra6eling Long.Distance @.1.1. For long7distance travelers at increased ris) of %&' (including previous %&'# recent surgery or trau a# active alignancy# pregnancy# estrogen use# advanced age# li ited o(ility# severe o(esity# or )nown thro (ophilic disorder"# we suggest freAuent a (ulation# calf uscle e*ercise# or sitting in an aisle seat if feasi(le (Grade 2C) . @.1.6. For long7distance travelers at increased ris) of %&' (including previous %&'# recent surgery or trau a# active alignancy# pregnancy# estrogen use# advanced age# li ited o(ility# severe o(esity# or )nown thro (ophilic disorder"# we suggest use of properly fi tted# (elow7)nee ?-, providing 1+ to 30 Hg of pressure at the an)le during travel (Grade 2C) . For all other long7distance travelers# we suggest against the use of ?-, (Grade 2C) . @.1.3. For long7distance travelers# we suggest against the use of aspirin or anticoagulants to prevent %&' (Grade 2C) . 7./ Persons With 's" pto atic Thro !ophilia 7.1. 1n persons with asy pto atic thro (ophilia (ie# without a previous history of %&'"# we reco end against the long7ter daily use of echanical or phar acologic thro (oprophyla*is to prevent %&' (Grade 1C) .

..> acientes con cCncer en r0gimen am6(latorio A)4)5) En pacientes a#$ulatorios con c,ncer 1ue no tienen 0actores de riesgo adicionales de TEV6 sugeri#os contra la pro0ila'is de rutina con 2BPM o 2N.BD :Drado 4B< ( en contra del uso pro0il,ctico de /V8 :Drado 5B<) A)4)4) En pacientes a#$ulatorios con tu#ores slidos 1ue tienen 0actores adicionales de riesgo de TEV ( 1ue est,n en $ajo riesgo de -e#orragia6 sugeri#os pro0ila'is con 2BPM o 2N.BD 0rente a no-pro0ila'is :Drado 4B<) A6A) En pacientes a#$ulatorios con c,ncer ( cat!teres venosos centrales6 se sugiere en contra de la pro0ila'is de rutina con 2BPM o 2N.BD :Drado 4B<6 ( se sugiere en contra del uso pro0il,ctico de /V8 :4C<) 8.> acientes cr/nicos inmo#ili1ados B65) En las personas crnica#ente in#ovili+ados 1ue residen en el -ogar o en un -ogar de ancianos6 se aconseja en contra del uso rutinario de pro0ila'is de tro#$osis :Drado 4C<) 9.> ersonas '(e #ia2an Larga Distancia F)5)5) Para viajeros de larga distancia con alto riesgo de tro#$oe#$olis#o venoso :inclu(endo TEV anterior6 cirug"a o trau#a reciente6 neoplasia activa6 el e#$ara+o6 uso de estrgenos6 edad avan+ada6 #ovilidad li#itada6 o$esidad grave o trastorno tro#$o0"lico conocido<6 se sugiere la dea#$ulacin 0recuente6 ejercicio #uscular de la pantorrilla6 ( asiento junto al pasillo6 si es posi$le :4C<) F)5)4) Para viajeros de larga distancia con alto riesgo de tro#$oe#$olis#o venoso :inclu(endo TEV anterior6 cirug"a o trau#a reciente6 neoplasia activa6 el e#$ara+o6 uso de estrgenos6 edad avan+ada6 #ovilidad li#itada6 o$esidad grave o trastorno tro#$o0"lico conocido<6 se sugiere el uso apropiado MCD de$ajo de la rodilla 1ue proporcionen 5B a =9 ## 2g de presin en el to$illo durante el viaje :Drado 4C<) Para el resto de viajeros de larga distancia6 sugeri#os en contra del uso de MCD :Drado 4C<) F)5)=) Para viajeros de larga distancia6 sugeri#os en contra d el uso de aspirina o anticoagulantes para prevenir el TEV :Drado 4C<) :.> ersonas con trom6ofilia asintomCtica G65) En las personas con tro#$o0ilia asinto#,tica :es decir6 sin una -istoria previa de TEV<6 no se reco#ienda el uso diario a largo pla+o de tro#$opro0ila'is #ec,nica o 0ar#acolgica para prevenir el TEV :Drado 5C<)

34,. 3ro*%oe*%o #!*o /e$o!o. 5CG . 5ed#a! de "o*pre!#'$ grad)ada. C1( . Co*pre!#'$ $e)*t#"a #$ter*#te$te

012. 0epar#$a $o &ra""#o$ada. 0BP5. 0epar#$a Ba6o Pe!o 5o e") ar. 012B7: 0epar#$a $o &ra""#o$ada a Ba6a! 7o!#!

9revention of %&' in 2onorthopedic ,urgical 9atients Prevencin de TEV en pacientes 1uir rgicos no ortop!dicos 3.9 acientes sometidos a Bir(gFa =eneral7 Bir(gFa =)I7 B. -.5 Patients 7ndergoing 8eneral9 8(9 @rol/gica7 =inecol/gica7 ,ariCtrica7 Vasc(lar7 lCstica o 7rological9 reconstr(cti#a. 8"necologic9 *ariatric9 $ascular9 Plastic or =)F)5) En pacientes de cirug"a general ( a$do#inoQp!lvica con #u( $ajo riesgo de TEV :J96BRI score de ;ogers6 Reconstructi6e 3urger" JGI score Caprini 9<6 reco#enda#os no utili+ar pro0ila'is 3.@.1. For general and a(do inal7pelvic surgery 0ar#acolgica :Drado 5B< o #ec,nica :4C< espec"0ica patients at very low ris) for %&' (B 0.+CD 3ogers distinta a la dea#$ulacin preco+) score# <7D -aprini score# 0"# we reco end that no specific phar acologic (Grade 1B) or echanical (2C) =)F)4) En pacientes de cirug"a general ( a$do#ino-p!lvica con $ajo riesgo de TEV :S 56BR6 score de ;ogers G-59I prophyla*is (e used other than early a (ulation. score Caprini6 5-4<6 se sugiere pro0ila'is #ec,nica6 3.@.6. For general and a(do inal7pelvic surgery pre0eri$le#ente con co#presin neu#,tica inter#itente patients at low ris) for %&' (~1.+CD 3ogers score# 77 :CNI<6 so$re no-pro0ila'is :Drado 4C<) 10D -aprini score# 176"# we suggest echanical =)F)=) En pacientes de cirug"a general ( a$do#ino-p!lvica prophyla*is# prefera(ly with inter ittent pneu atic con riesgo #oderado de TEV :S =69R6 score de ;ogers6K co pression (19-"# over no prophyla*is (Grade 2C) . 59I puntaje Caprini =-A< 1ue no est,n en alto riesgo de 3.@.3. For general and a(do inal7pelvic surgery co#plicaciones -e#orr,gicas #a(ores6 sugieren 2BPM patients at oderate ris) for %&' (~3.0CD3ogers :4B<6 2N. :4B<6 o pro0ila'is #ec,nica6 de pre0erencia con CNI :Drado 4C<6 so$re no-pro0ila'is) score# > 10D -aprini score# 374" who are not at high =)F)A) En pacientes de cirug"a general ( a$do#ino-p!lvica ris) for a8or (leeding co plications#we suggest LMWH (2B "# L=>H (2B)# or echanical prophyla*is# con riesgo #oderado de tro#$oe#$olis#o venoso :=69RI ;ogers K 59I Caprini6 =-A< 1ue se encuentran en alto prefera(ly with 19- (Grade 2C)# over no prophyla*is. riesgo de co#plicaciones -e#orr,gicas #a(ores o 3.@.4. For general and a(do inal7pelvic surgery patients at oderate ris) for %&' (3.0CD3ogers score# a1uellos en los 1ue las consecuencias del sangrado se cree 1ue sean particular#ente graves6 sugeri#os pro0ila'is >10D -aprini score# 374" who are at high ris) for a8or #ec,nica6 de pre0erencia con CNI6 so$re no-pro0ila'is (leeding co plications or those in who the conseAue :Drado 4C<) nces of (leeding are thought to (e particularly severe# =)F)B) En pacientes de cirug"a general ( a$do#ino-p!lvica we suggest echanical prophyla*s# prefera(ly with con alto riesgo de TEV :S F69RI Caprini T B< 1ue no 19-# over no prophyla*is (Grade 2C) . est,n en alto riesgo de co#plicaciones -e#orr,gicas 3.@.+. For general and a(do inal7pelvic surgery graves6 se reco#ienda pro0ila'is 0ar#acolgica con patients at high ris) for %&' (~@.0CD-aprini score E 2BPM :Drado 5B< o 2N. :Drado 5B< so$re no+" who are not at high ris) for a8or (leeding pro0ila'is) *ugeri#os 1ue la pro0ila'is #ec,nica con co plications# we reco end phar acologic #edias el,sticas o CNI6 de$e aUadirse a la pro0ila'is prophyla*is with LMWH (Grade 1B) or L=>H (Grade 0ar#acolgica :Drado 4C<) =)F)F) En pacientes de cirug"a general ( a$do#ino-p!lvica 1B) over no prophyla*is. We suggest that echanical con alto riesgo de TEV pacientes so#etidos a cirug"a prophyla*is with elastic stoc)ings or 19- should (e a$do#inal o p!lvica por c,ncer 1ue no tienen por otro added to phar acologic prophyla*is (Grade 2C) . lado alto riesgo de -e#orragia grave6 se reco#ienda 3.@.@. For high7%&'7ris) patients undergoing duracin prolongada de pro0ila'is 0ar#acolgica con a(do inal or pelvic surgery for cancer who are not 2BPM :A se#anas< so$re una duracin #,s li#itada de otherwise at high ris) for a8or (leeding la pro0ila'is :Drado 5B<) co plications# we reco end e*tended7duration =)F)G) En pacientes de alto riesgo de TEV ( cirug"a phar acologic prophyla*is (4 wee)s" with LMWH general a$do#ino - p!lvica 1ue tienen alto riesgo de over li ited7duration prophyla*is (Grade 1B) . co#plicaciones -e#orr,gicas graves o a1uellos en 1ue 3.@.7. For high7%&'7ris) general and a(do inalpelvic las consecuencias de la -e#orragia se cree 1ue puedan surgery patients who are at high ris) for a8or ser particular#ente graves6 sugieren el uso de pro0ila'is (leeding co plications or those in who the #ec,nica6 pre0eri$le#ente con CNI so$re no-pro0ila'is6 conseAuences of (leeding are thought to (e particulary -asta 1ue el riesgo de sangrado dis#inu(a ( la pro0ila'is severe# we suggest use of echanical prophyla*is# 0ar#acolgica pueda iniciarse :Drado 4C<) prefera(ly with 19-# over no prophyla*is until the ris) of (leeding di inishes and phar acologic prophyla*is ay (e initiated (Grade 2C) .
34,. 3ro*%oe*%o #!*o /e$o!o. 5CG . 5ed#a! de "o*pre!#'$ grad)ada. C1( . Co*pre!#'$ $e)*t#"a #$ter*#te$te 012. 0epar#$a $o &ra""#o$ada. 0BP5. 0epar#$a Ba6o Pe!o 5o e") ar. 012B7: 0epar#$a $o &ra""#o$ada a Ba6a! 7o!#!

($ter*#tte$t p$e)*at#" "o*pre!!#o$ ((PC)

3.@.$. For general and a(do inal7pelvic surgery patients at high ris) for %&' (@CD -aprini score# +" in who (oth LMWH and unfractionated heparin are contraindicated or unavaila(le and who are not at high ris) for a8or (leeding co plications# we suggest low7dose aspirin (Grade 2C) # fondaparinu* (Grade 2C) # or echanical prophyla*is# prefera(ly with 19(Grade 2C) # over no prophyla*is.

=)F)H) En pacientes de cirug"a general ( a$do#ino-p!lvica con alto riesgo de TEV :FRI Caprini T B< en 1ue tanto la 2BPM co#o la -eparina no 0raccionada est!n contraindica-das o no est!n disponi$les ( 1ue no est!n en alto riesgo de co#plicaciones -e#orr,gicas graves6 se sugiere una dosis $aja de aspirina : 4C<6 0ondaparinu' :Drado 4C<6 o pro0ila'is #ec,nica6 pre0eri$le#ente con CNI :Drado 4C<6 so$re la ausencia de pro0ila'is)

=)F)L) En pacientes de cirug"a general ( a$do#ino-p!lvica 3.@... For general and a(do inal7pelvic surgery pati7 se sugiere 1ue el 0iltro de vena cava in0erior :VCI< node$e ents# we suggest that an inferior vena cava (1%-" fi lter ser utili+ado para prevencin pri#aria de VTE :4C<) should not (e used for pri ary %&' prevention (2C) =)F)59)En pacientes de cirug"a general ( a$do#ino-p!lvica 3.@.10. For general and a(do inal7pelvic surgery se sugiere 1ue la vigilancia peridica con ecogra0"a venosa patients# we suggest that periodic surveillance with de co#presin no de$e e0ectuarse :Drado 4C<) venous co pression ultrasound should not (e perfor ed (Grade 2C) . 4.0 Pacientes sometidos a ciruga cardiaca A)A)5) En pacientes de cirug"a card"aca con un curso postope- ratorio no co#plicado6 se sugiere el uso de 1./ Patients 7ndergoing ,ardiac 3urger" pro0ila'is #ec,4.4.1. For cardiac surgery patients with an unco pli nica6 de pre0erencia con pti#a aplicacin de CNI6 so$re cated postoperative course# we suggest use of echan la no-pro0ila'is :4C< o la pro0ila'is 0ar#acolgica :4C<) ical prophyla*is# prefera(ly with opti ally applied 19-# over either no prophyla*is (Grade 2C) or A)A)4) En pacientes de cirug"a card"aca cu(a estancia phar acologic prophyla*is(Grade 2C) . -ospitalaria se prolonga por una o #,s co#plicaciones 4.4.6. For cardiac surgery patients whose hospital 1uir rgicas no -e#orr,gicas6 se sugiere aUadir pro0ila'is course is prolonged (y one or ore nonhe orrhagic 0ar#acolgica con 2N. o 2BPM a la pro0ila'is #ec,nica surgical co plications# we suggest adding phar a :4C<) cologic prophyla*is with L=>H or LMWH to echanical prophyla*is (Grade 2C) . 5.0 Pacientes sometidos a ciruga torcica

4./ Patients 7ndergoing Thoracic 3urger" +.4.1. For thoracic surgery patients at oderate ris) for %&' who are not at high ris) for perioperative (leeding# we suggest L=>H (Grade 2B) # LMWH (Grade 2B) # or echanical prophyla*is with opti ally applied 19- (Grade 2C) over no prophyla*is. +.4.6. For thoracic surgery patients at high ris) for %&' who are not at high ris) for perioperative (leeding# we suggest L=>H (Grade 1B) or LMWH (1B) over no prophyla*is. 1n addition# wesuggest that echanical prophyla*is with elastic stoc)ings or 19should (e added to phar acologic prophyla*is (2C) . +.4.3. For thoracic surgery patients who are at high ris) for a8or (leeding# we suggest use of echanical prophyla*is# prefera(ly with opti ally applied 19-# over no prophyla*is until the ris) of (leeding di inish and phar acologic prophyla*is ay (e initiated (2C) . 5./ Patients 7ndergoing ,ranioto " @.4.1. For cranioto y patients# we suggest that ical prophyla*is# prefera(ly with 19-# (e used over no

B)A)5) En pacientes de cirug"a tor,cica con riesgo #oderado de TEV 1ue no est,n en alto riesgo de -e#orragia periope- ratoria6 se sugiere 2N. :Drado 4B<6 2BPM :Drado 4B<6 o pro0ila'is #ec,nica con CNI pti#a aplicada :Drado 4C< so$re la ausencia de pro0ila'is) B)A)4) En pacientes de cirug"a tor,cica en alto riesgo de TEV 1ue no est,n en alto riesgo perioperatorio de sangrado6 se sugiere 2N. :Drado 5B< o 2BPM :Drado 5B< so$re la ausencia de pro0ila'is) /de#,s6 se sugiere 1ue la pro0ila'is #ec,nica con #edias el,sticas o CNI6 de$en aUadirse a la pro0ila'is 0ar#acolgica :Drado 4C<) B)A)=) En pacientes de cirug"a tor,cica 1ue se encuentran en alto riesgo de -e#orragia #a(or6 sugeri#os el uso de pro0il-a' is #ec,nica6 pre0eri$le#ente con CNI pti#a aplicada6 so$re la ausencia de pro0ila'is -asta 1ue dis#inu(a el riesgo de sangrado ( puede iniciarse pro0ila'is 0ar#acolgica :4C<)

6.0 Pacientes sometidos a craneotoma F)A)5) Para los pacientes con craneoto#"a6 se sugiere usar pro0ila'is #ec,nica6 de pre0erencia con CNI6 so$re echan ninguna pro0ila'is :4C< o pro0ila'is 0ar#acolgica :4C<)

prophyla*is (2C) or phar acologic prophyla*is (2C) .

10

@.4.6. For cranioto y patients at very high ris) for %&' (eg# those undergoing cranioto y for alignant disease"# we suggest adding phar acologic prophyla*is to echanical prophyla*is once adeAuate he ostasis is esta(lished and the ris) of (leeding decreases (Gr 2C) . 7./ Patients 7ndergoing 3pinal 3urger" 7.4.1. For patients undergoing spinal surgery# we suggest echanical prophyla*is# prefera(ly with 19-# over no prophyla*is (Grade 2C) # unfractionated heparin (Grade 2C) # or LMWH (Grade 2C) . high ris) for %&' (including those with alignant disease or those undergoing surgery with a co (ined anterior7posterior approach"# we suggest adding phar acologic prophyla*is to echanical prophyla*is once adeAuate he ostasis is esta(lished and the ris) of (leeding decreases (Grade 2C) . 8./ Patients With Ma:or Trau a; Trau atic *rain (n:ur"9 'cute 3pinal (n:ur"9 and Trau atic 3pine (n:ur" $.4.1. For a8or trau a patients# we suggest use of L=>H (2C)# LMWH (2C) # or echanical prophyla*is# prefera(ly with 19- (2C) # over no prophyla*is.

F)A)4) En pacientes con craneoto#"a con riesgo #u( elevado de VTE :p)ej6 a1uellos so#etidos a craneoto#"a por en0er#edad #aligna<6 se sugiere aUadir pro0ila'is 0ar#acolgica a la pro0ila'is #ec,nica6 una ve+ esta$lecida una -e#ostasia adecuada ( dis#inuido el riesgo de sangrado :4 C<) G)9 Pacientes so#etidos a cirug"a espinal G)A)5) En pacientes so#etidos a cirug"a de la colu#na6 se sugiere pro0ila'is #ec,nica6 pre0eri$le#ente con CNI6 so$re no-pro0ila'is :Drado 4C<6 -eparina no 0raccionada :Drado 4C<6 o 2BPM :Drado 4C<) En alto riesgo de TEV :inclu(endo a1uellos con en0er#edad #aligna o los so#etidos a cirug"a con apro'i#acin antero-posterior co#$inada <6 se sugiere aUadir pro0ila'is 0ar#acolgica a la pro0ila'is #ec,nica6 una ve+ esta$lecida una -e#ostasia adecuada ( dis#inuido el riesgo de sangrado :Drado 4C<) 8.0 Pacientes con trauma mayor: Trauma craneoenceflico, lesin es inal aguda, y lesin es inal traumtica H)A)5) En pacientes con trau#atis#os #a(ores6 sugeri#os el uso de 2N. :4C<6 2BPM :4C<6 o pro0ila'is #ec,nica6 pre0eri$le#ente con CNI :4C<6 so$re no-pro0ila'is)

H)A)4) En pacientes con trau#atis#os #a(ores con alto riesgo de TEV :inclu(endo a1uellos con lesin espinal $.4.6. For a8or trau a patients at high ris) for %&' aguda6 lesiones cere$rales trau#,ticas6 ( cirug"a de colu#na por trau#a<6 se aconseja aUadir pro0ila'is (including those with acute spinal cord in8ury# trau atic (rain in8ury# and spinal surgery for trau a" #ec,nica a la pro0ila'is 0ar#acolgica :Drado 4C< cuando no est! contraindicad lesin de EEII) we suggest adding echanical prophyla*is to

phar acologic prophyla*is (Grade 2C) when not contraindicated (y lowere*tre ityin8ury.

H)A)=) En pacientes con trau#atis#os i#portantes en los 1ue la 2BPM ( 2N. est!n contraindicadas6 se sugiere pro0ila'is #ec,nica6 pre0eri$le#ente con CNI6 so$re no$.4.3. For a8or trau a patients in who LMWH and pro0ila'is :4C< cuando no est! contraindicada por lesin L=>H are contraindicated# we suggest echanical de EEII) *e sugiere aUadir pro0ila'is 0ar#acolgica con prophyla*is# prefera(ly with 19-# over no prophyla*is 2BPM o 2N. cuando el riesgo de sangrado dis#inu(a o (G 2C) when not contraindicated (y lower7e*tre ity la contraindicacin para la -eparina se resuelva :4C<)

in8ury. We suggest adding phar acologic prophyla*is with either LMWH or L=>H when the ris) of(leeding di inishes or the contraindication to heparin resolves (2C) . $.4.4. For a8or trau a patients# we suggest that an 1%- fi lter should not (e used for pri ary %&' prevention (Grade 2C) .

H)A)A) En pacientes con trau#atis#os #a(ores6 sugeri#os 1ue el 0iltro de VCI no de$e utili+arse para la prevencin pri#aria de VTE :Drado 4C<) H)A)B) En pacientes con trau#atis#os #a(ores6 sugeri#os 1ue la vigilancia peridica con ECV de co#presin venosano se de$e reali+ar :Drado 4C<)

$.4.+. For a8or trau a patients# we suggest that periodic surveillance with venous co pression ultrasound should not (e perfor ed (Grade 2C) . 34,. 3ro*%oe*%o #!*o /e$o!o. 5CG . 5ed#a! de "o*pre!#'$ grad)ada. C1( . Co*pre!#'$ $e)*t#"a #$ter*#te$te 012. 0epar#$a $o &ra""#o$ada. 0BP5. 0epar#$a Ba6o Pe!o 5o e") ar. 012B7: 0epar#$a $o &ra""#o$ada a Ba6a! 7o!#! ,C(. ,e$a Ca/a ($&er#or. ($ter*#tte$t p$e)*at#" "o*pre!!#o$ ((PC)

11

9revention of %&' in Frthopedic ,urgery 9atients +./ Patients 7ndergoing Ma:or 2rthopedic 3urger"; Total Hip 'rthroplast" <TH'=9 Total %nee 'rthroplast" <T%'=9 Hip Fracture 3urger" <HF3= 6.1.1. 1n patients undergoing &H0 or &/0# we reco end use of one of the following for a ini u of 10 7 14 days rather than no antithro (otic prophyla*isG low7 olecular7weight heparin (LMWH"# fondaparinu*# api*a(an# da(igatran# rivaro*a(an# low7dose unfractionated heparin (L=>H"# ad8usted7 dose %/0# aspirin (all Grade 1B) # or an inter ittent pneu atic co pression device (19-=" (Grade 1C) . 6.1.6. 1n patients undergoing HF,# we reco end use of one of the following rather than no antithro (otic prophyla*is for a ini u of 10 to 14 daysG LMWH# fondaparinu*# L=>H# ad8usted7dose %/0# aspirin (all Grade 1B) # or an 19-= (Grade 1C) . 6.6. For patients undergoing a8or orthopedic surgery (&H0# &/0# HF," and receiving LMWH as thro (o prophyla*is# we reco end starting either 16 h or ore preoperatively or 16 h or ore postoperatively rather than within 4 h or less preoperatively or 4 h or less postoperatively (Grade 1B) .

Prevencin del TEV en pacientes de cirug"a ortop!dica 2.> acientes sometidos a cir(gFa ortop0dica mayorG artro plastia total de cadera (ATB)7 artroplastia total de rodilla (AT*)7 Bir(gFa de fract(ra de cadera (B&B) 4)5)5) En pacientes so#etidos a artroplastia /TC o /T;6 se reco#ienda el uso durante un per"odo #"ni#o de 59 5A d"as 6 vs no-pro0ila'is antitro#$tica6 de uno de los siguientes: :2BPM<6 0ondaparinu'6 api'a$an6da$igat r,n6 rivaro'a$an6 :2N.< en dosis $ajas6 dosis ajustadas de /V86 aspirina :todos: Drado 5B<6 o un dispositivo de co#presin neu#,tica inter#itente :CNI< :Drado 5C<) 4)5)4) En pacientes so#etidos a C.C6 se reco#ienda el uso durante un per"odo #"ni#o de 59 - 5A d"as 6 vs nopro0ila'is antitro#$tica: 2BPM6 0ondaparinu'6 2N.6 dosis ajustadas de /V86 aspirina :todos Drado 5B<6 o CNI :Drado 5C<) 464) En pacientes so#etidos a cirug"a ortop!dica #a(or :/TC6 /T;6 C.C< tratados con 2BPM co#o pro0ila'is de tro#$osis6 se reco#ienda co#en+ar 54 -oras o #,s antes de la operacin6 o $ien 54 -oras o #,s despu!s de la operacin6 #,s 1ue A -oras o #enos antes de la cirug"a o A -oras o #enos en el postoperatorio : Drado 5B<)

4)=)5 En pacientes so#etidos a /TC6 /T;6 irrespectivaMente del uso conco#itante de un DCNI o de la duracin del trata#iento6 se sugiere el uso de 2BPM en lugar de 6.3.11n patients undergoing &H0 or &/0# irrespective los otros agentes reco#endados co#o alternativas: 0ondaparinu'6 api'a$an6 da$igatr,n6 rivaro'a$an6 of the conco itant use of an 19-= or length of treat 2N. :Drado 4B todas<6 dosis ajustadas de /V86 o ent# we suggest the use of LMWH in preference to aspirina :todos Drado4C<) the other agents we have reco ended as 4)=)4) En pacientes so#etidos a C.C6 con independencia alternatives G fondaparinu*# api*a(an# da(igatran# del uso conco#itante de un D CNI o de la duracin del rivaro*a(an# trata#iento6 se sugiere el uso de 2BPM en lugar de los L=>H (all Grade 2B) # ad8usted7dose %/0# or aspirin otros agentes reco#endados co#o alternativas: 0ondapa(all Grade 2C) . rinu'6 2N. :Drado 4B<6 dosis ajustadas de /V86 o 6.3.6. 1n patients undergoing HF,# irrespective of the aspirina :todos 4C Drado<)

conco itant use of an 19-= or length of treat ent# we suggest the use of LMWH in preference to the other agents we have reco ended as alternativesG fondaparinu*# L=>H (Grade 2B) # ad8usted7dose %/0# or aspirin (all Grade 2C) .

4)A) En pacientes so#etidos a cirug"a ortop!dica #a(or6 se sugiere e'tender la tro#$opro0ila'is en el per"odo a#$ulatorio -asta =B d"as a partir del d"a de la cirug"a en lugar de slo 59 a 5A d"as :Drado 4B<)

6.4.For patients undergoing a8or orthopedic surgery# 46B) En pacientes so#etidos a cirug"a ortop!dica #a(or6 sugiren utili+ar pro0ila'is do$le con un agente antitro#we suggest e*tending thro (oprophyla*is in the out7 $tico ( CNI durante la estancia -ospitalaria :4C<) patient period for up to 3+ days fro the day of surgery rather than for only 10 to 14 days (Grade 2B) . 46F) En pacientes so#etidos a cirug"a ortop!dica #a(or ( 6.+. 1n patients undergoing a8or orthopedic surgery# #a(or riesgo de sangrado6 sugeri#os utili+ar CNI o ninguna pro0ila'is en lugar de trata#iento 0ar#acolgico we suggest using dual prophyla*is with an antithro (otic agent and an 19-= during the hospital stay (2C). :Drado 4C<) 6.@. 1n patients undergoing a8or orthopedic surgery and increased ris) of (leeding# we suggest using an 19-= or no prophyla*is rather than phar acologic treat ent (Grade 2C) .
34,. 3ro*%oe*%o #!*o /e$o!o. 5CG . 5ed#a! de "o*pre!#'$ grad)ada. C1( . Co*pre!#'$ $e)*t#"a #$ter*#te$te 012. 0epar#$a $o &ra""#o$ada. 0BP5. 0epar#$a Ba6o Pe!o 5o e") ar. 012B7: 0epar#$a $o &ra""#o$ada a Ba6a! 7o!#! ,C(. ,e$a Ca/a ($&er#or. ($ter*#tte$t p$e)*at#" "o*pre!!#o$ ((PC)

12

6.7. 1n patients undergoing a8or orthopedic surgery and who decline or are uncooperative with in8ections or an 19-=# we reco end using api*a(an or da(igatran (alterna tively rivaro*a(an or ad8usted7 dose %/0 if api*a(an or da(igatran are unavaila(le" rather than alternative for s of prophyla*is (all Grade 1B) . 6.$. 1n patients undergoing a8or orthopedic surgery# we suggest against using 1%- fi lter place ent for pri ary prevention over no thro (oprophyla*is in patients with an increased (leeding ris) or contraindications to (oth phar acologic and echanical thro (oprophyla*is (Grade 2C) . 6... For asy pto atic patients following a8or orthopedic surgery# we reco end against =oppler (or duple*" ultrasound screening (efore hospital discharge (Grade 1B) . -./ Patients With (solated Lo>er.Leg (n:uries Distal to the %nee 3.0. We suggest no prophyla*is rather than phar acologic thro (oprophyla*is in patients with isolated lower7leg in8uries reAuiring leg i o(ili:ation (Grade 2C) . 1./ Patients 7ndergoing %nee 'rthroscop" 4.0. For patients undergoing )nee arthroscopy without a history of prior %&'# we suggest no thro (oprophyl a*is rather than prophyla*is (Grade 2B) .

46G) En pacientes so#etidos a cirug"a ortop!dica #a(or6 ( 1ue re-usan o no cooperan con las in(ecciones o CNI6 se reco#ienda utili+ar api'a$an o da$igatr,n :alternativa#ente o dosis ajustadas de /V8 si no se dispone de api'a$an o da$igatr,n< en lugar de 0or#as alternativas de pro0ila'is :todos los de Drado 5B <) 46H) En pacientes so#etidos a cirug"a ortop!dica #a(or6 sugeri#os no utili+ar 0i ltro VCI para la prevencin pri#aria 0rente a ausencia de tro#$opro0ila'is en pacientes con un #a(or riesgo de -e#orragia o contraindicaciones tanto para la tro#$opro0ila'is 0ar#acolgica co#o #ec,nica :Drado 4C<) 46L) En pacientes asinto#,ticos tras cirug"a ortop!dica #a(or6 no se reco#ienda ecogra0"a de cri$ado Doppler :o d ple'< antes del alta -ospitalaria :Drado 5B<) !.0 Pacientes con lesiones aisladas en las iernas distales a las rodillas =69) *e sugiere no-pro0ila'is en lugar de tro#$opro0ila'is 0ar#acolgica en pacientes con lesiones aisladas en la piernas 1ue re1uieren in#ovili+acin :Drado 4C<) 4.0 Pacientes sometidos a artrosco ia de rodilla A)9) En pacientes so#etidos a artroscopia de rodilla sin antecedentes de TEV previo6 se sugiere no t-ro#$opro0ila'is en lugar de la pro0ila'is :Drado 4B<)

13

9erioperative Manag ent of 0ntithro (otic &herapy +.1 (nterruption of $%'s *efore 3urger" 6.1. 1n patients who reAuire te porary interruption of a %/0 (efore surgery# we reco end stopping %/0s appro*i ately + days (efore surgery instead of stopping %/0s a shorter ti e (efore surgery (1C) . +.+ Resu ption of $%'s 'fter 3urger" 6.6. 1n patients who reAuire te porary interruption of a %/0 (efore surgery# we reco end resu ing %/0s appro*i ately 16 to 64 h aftersurgery (evening of or ne*t orning" and when there is adeAuate he ostasis instead of later resu ption of %/0s (2C) . +.1 *ridging 'nticoagulation During (nterruption of $%' Therap" 6.4. 1n patients with a echanical heart valve# atrial fi (rillation# or %&' at high ris) for thro (oe (olis # we suggest (ridging anticoagulation instead of no (ridging during interruption of %/0 therapy (2C) . 1n patients with a echanical heart valve# atrial fi (rillation# or %&' at low ris) for thro (oe (olis # we suggest no (ridging instead of (ridging anti coagulation during interruption of %/0 therapy (2C) .

Manejo perioperatorio de la Terapia antitro#$tica


2.1 Interr(pci/n de la AVK antes de la cir(gFa 465) En pacientes 1ue re1uieren interrupcin te#poral de /V8 antes de la cirug"a6 se reco#ienda detener la /V8 apro'i#ada#ente B d"as antes de la cirug"a en lugar de interru#pirla un lapso #as corto :Drado 5C<) 2.2 *ean(daci/n de AVK desp(0s de la cir(gFa 464) En los pacientes 1ue re1uieren la interrupcin te#poral de /V8 antes de la cirug"a6 se reco#ienda la reanudacin de /V8 apro'i#ada#ente 54 a 4A -oras despu!s de la cirug"a :por la noc-e o al d"a siguiente< ( cuando -a(a una -e#ostasia adecuada en lugar de una reanudacin #,s tard"a :Drado 4C<) 2.. Anticoag(laci/n p(ente d(rante la interr(pci/n del tratamiento con AVK 46A) En pacientes con una v,lvula cardiaca #ec,nica6 .i$rilacin auricular6 o TEV con alto riesgo de tro#$oe#$olis#o6 se sugiere anticoagulacin puente6 en lugar de ninguna #edicacin puente6 durante la interrupcin del trata#iento con /V8 :Drado 4C<) En pacientes con una v,lvula cardiaca #ec,nica6 .i$rilacin auricular6 o TEV con $ajo riesgo de tro#$oe#$olis#o6 sugieren no dar anticoagulacin-puente durante la interrupcin del trata#iento con /V8 :4C<) 2.8 %ane2o perioperatorio de los acientes tratados con AVK7 '(e re'(ieren procedimientos menores 46B) En los pacientes 1ue re1uieren de un procedi#iento dental #enor6 sugieren continuar /V8 con coad#inistracin de un agente oral pro -e#ost,tico6 o detener /V8 4 a = d"as antes del procedi#iento en lugar de estrategias alternativas :Drado 4C<) En pacientes 1ue re1uieren pe1ueUas intervenciones der#atolgicas ( est,n reci$iendo trata#iento con /V86 sugieren continuar /V8 en todo el curso del procedi#iento ( la opti#i+acin de la -e#ostasia local en lugar de otras estrategias :Drado 4C<) En los pacientes 1ue re1uieren cirug"a de catarata ( est,n reci$iendo trata#iento con /V86 sugieren continuar /V8 en todo el #o#ento de la cirug"a en lugar de otras estrategias :Drado 4C<)

+.4 Perioperati6e Manage ent of $%'.Treated Patients Who Re?uire Minor Procedures 6.+. 1n patients who reAuire a inor dental procedure# we suggest continuing %/0s with coad inistration of an oral prohe ostatic agent or stopping %/0s 6 to 3 days (efore the procedure instead of alternative strategies (Grade 2C) . 1n patients who reAuire inor der atologic procedures and are receiving %/0 therapy# we suggest continuing %/0s around the ti e of the procedure and opti i:ing local he ostasis instead of other strategies (Grade 2C) . 1n patients who reAuire cataract surgery and are receiving %/0 !.. acientes sometidos a (n procedimiento menor dental7 therapy# we suggest continuing %/0s around the ti e dermatol/gico7 o de "ftalmologFa of the surgery instead of other strategies (Grade 2C) . =6A) En pacientes 1ue reci$en ,cido acetilsalic"lico ://*< para la prevencin secundaria de en0er#edad cardiovascular ( se so#eten a procedi#ientos #enores -.1 Patients 7ndergoing a Minor Dental9 dentales6 o der#atolgicos6 o cirug"a de cataratas6 se Der atologic9 sugiere continuar //* en todo el curso del procedi#iento or 2phthal ologic Procedure en lugar de interru#pir el //* G a 59 d"as antes del 3.4. 1n patients who are receiving acetylsalicylic acid procedi#iento :Drado 4C<) (0,0" for the secondary prevention of cardiovascular disease and are having inor dental or der atologic procedures or cataract surgery# we suggest continuing 0,0 around the ti e of the procedure instead of stopping 0,0 7 to 10 days (efore the procedure (Grade 2C) .

14

15

3.+. 1n patients at oderate to high ris) for cardio vascular events who are receiving 0,0 therapy and reAuire noncardiac surgery# we suggest continuing 0,0 around the ti e of surgery instead of stopping 0,0 7 to 10 days (efore surgery (2C). 1n patients at low ris) for cardiovascular events who are receiving 0,0 therapy# we suggest stopping 0,0 7 to 10 days (efore surgery instead of continuation of 0,0(2C). -.5 Patients 7ndergoing ,'*8 3urger" 3.@. 1n patients who are receiving 0,0 and reAuire coronary artery (ypass graft (-0H?" surgery# we suggest continuing 0,0 around the ti e of surgery instead of stopping 0,0 7 to 10 days (efore surgery (Grade 2C) . 1n patients who are receiving dual antiplatelet drug therapy and reAuire -0H? surgery# we suggest continuing 0,0 around the ti e of surgery and stopping clopidogrel!prasugrel + days (efore surgery instead of continuing dual antiplatelet therapy around the ti e of surgery (Grade 2C) .

=6B) En pacientes con riesgo #oderado a alto de eventos cardiovasculares 1ue est,n reci$iendo trata#iento con //*6 ( re1uieren cirug"a no cardiaca6 sugieren continuar //* en todo el curso de la cirug"a6 en lugar de suspender el //* G a 59 d"as antes de la cirug"a :4C<) En pacientes con $ajo riesgo de eventos cardiovasculares 1ue est,n reci$iendo trata#iento con //*6 interru#pir el //* G a 59 d"as antes de la cirug"a en lugar de continuarlo :4C<) !.9 acientes sometidos a re#asc(lari1aci/n BA,= =6F) En pacientes 1ue est,n reci$iendo //* ( re1uieren cirug"a de revasculari+acin coronaria :C/BD<6 sugieren continuar //* en todo #o#ento perioperatorio en lugar de interru#pir el //* G- 59 d"as antes de la cirug"a :4C<) En pacientes 1ue est,n reci$iendo do$le terapia antiagregante ( re1uieren cirug"a de revasculari+acin coronaria6 se sugiere continuar el //* perioperatorio ( suspender el clopidogrel % prasugrel B d"as antes de la cirug"a en lugar de continuar la do$le antiagregacin alrededor del #o#ento de la cirug"a :Drado 4C<)

!.: acientes '(ir3rgicos con stents coronarios =6G) En pacientes con stent coronario 1ue reci$en do$le -.7 3urgical Patients With ,oronar" 3tents terapia antipla1uetaria ( re1uieren cirug"a6 reco#iendan 3.7. 1n patients with a coronary stent who are receiving posponer la cirug"a al #enos F se#anas tras la colocacin dual antiplatelet therapy and reAuire surgery# we de un stent convencional ( por lo #enos F #eses despu!s reco end deferring surgery for at least @ wee)s de la colocacin de un stent li$erador de 0,r#acos en after place ent of a (are7 etal stent and for at least @ lugar de llevar a ca$o la cirug"a dentro de estos per"odos onths after place ent of a drug7eluting stent instead de tie#po :Drado 5C<) En pacientes 1ue re1uieren of underta)ing surgery within these ti e periods cirug"a dentro de las F se#anas de la colocacin de un stent #et,lico o en los F #eses de la colocacin de un (Grade 1C) . 1n patients who reAuire surgery within @ stent li$erador de 0,r#acos6 sugeri#os continuar la wee)s of place ent of a (are7 etal stent or within terapia antipla1uetaria dual alrededor del #o#ento de la @ onths of place ent of a drug7eluting stent# we cirug"a en lugar de detener la do$le antiagregacin G a 59 suggest continuing dual antiplatelet therapy around the ti e of surgery instead of stoping dual antiplatelet d"as antes de la cirug"a :Drado 4C<)

therapy 7 to 10 days (efore surgery (Grade 2C) . 1.+ Perioperati6e 7se of ($ 7FH 4.6. 1n patients who are receiving (ridging anti coagulation with therapeutic7dose 1% >FH# we suggest stopping >FH 4 to @ h (efore surgery instead of closer to surgery (Grade 2C) . 1.- Preoperati6e (nterruption of Therapeutic. Dose *ridging LMWH 4.3. 1n patients who are receiving (ridging anti coagulation with therapeutic7dose ,- LMWH# we suggest ad inistering the last preoperative dose of LMWH appro*i ately 64 h (efore surgery instead of 16 h (efore surgery (Grade 2C) . 1.1 Postoperati6e Resu ption of Therapeutic. Dose *ridging LMWH 4.4. 1n patients who are receiving (ridging anti coagulation with therapeutic7dose ,- LMWH and are undergoing high7(leeding7ris) surgery# we suggest resu ing therapeutic7dose LMWH 4$ to 76 h after surgery instead of resu ing LMWH within 64 h after surgery (Grade 2C) .

..2 @so perioperatorio de $+& IV A64) En los pacientes 1ue reci$en anticoagulacin puente con dosis terap!uticas de -eparina IV no 0raccionada6 sugieren detener la 2N. A a F -oras antes de la cirug"a en ve+ de #,s cerca de la cirug"a :Drado 4C<) ..! Interr(pci/n preoperatoria de la $, % a dosis terap0(ticas ) p(ente A6=) En los pacientes 1ue reci$en anticoagulacin puente con dosis terap!uticas de 2BPM *C6 se sugiere la ad#inistracin de la lti#a dosis preoperatoria de 2BPM apro'i#ada#ente 4A -oras antes de la cirug"a en lugar de 54 - antes de la cirug"a :Drado 4C<) ... *ean(daci/n postoperatorio la $, % a dosis terap0(ticas ) p(ente A6A) En los pacientes 1ue reci$en anticoagulacin-puente con dosis terap!uticas de 2BPM *C ( est,n so#etidos a cirug"a de alto riesgo de sangrado6 sugeri#os reanudar la 2BPM AH a G4 - despu!s de la cirug"a en lugar de reanudarla en las 4A -oras despu!s de la cirug"a :Dr 4C<)

16

=iagnosis of =%& -./ Diagnosis of 3uspected First Lo>er @xtre it" D$T 3.1. 1n patients with a suspected fi rst lower e*tre ity =%&# we suggest that the choice of diagnostic tests process should (e guided (y the clinical assess ent of pretest pro(a(ility rather than (y perfor ing the sa e diagnostic tests in all patients (Grade 2B) . 3.6. 1n patients with a low pretest pro(a(ility of fi rst lower e*tre ity =%&# we reco end one of the following initial testsG (i" a oderately sensitive =7 di er# (ii" a highly sensitive =7di er# or (iii" co pression ultrasound (->," of the pro*i al veins rather than (i" no diagnostic testing (Grade 1B for all comparisons) # (ii" venography (Grade 1B for all comparisons), or (iii" whole7leg ultrasound (>," (Grade 2B for all comparisons). We suggest initial use of a oderately sensitive (Grade 2C) or highly sensitive (Grade 2B) =7di er rather than pro*i al ->,. 1f the =7di er is negative# we reco end no further testing over further investigation with (i" pro*i al ->,# (ii" whole7leg >,# or (iii" venography (Grade 1B for all comparisons) . 1f the pro*i al ->, is negative# we reco end no further testing co pared with (i" repeat pro*i al ->, after 1 wee)# (ii" whole7leg >,# or (iii" venography (Grade 1B for all comparisons) . 1f the =7di er is positive# we suggest further testing with ->, of the pro*i al veins ratherthan (i" whole7 leg >, (Grade 2C) or (ii" venography (Grade 1B) . 1f ->, of the pro*i al veins is positive# we suggest treating for =%& and perfor ing no further testing over perfor ing confi r atory venography (Grade 2C) 3.3. 1n patients with a oderate pretest pro(a(ility of fi rst lower e*tre ity =%&# we reco end one of the following initial testsG (i" a highly sensitive =7di er or (ii" pro*i al ->,# or (iii" whole7leg >, rather than (i" no testing (Grade 1B for all comparisons) or (ii" venography (Grade 1B for all comparisons) . We suggest initial use of a highly sensitive =7di er rather than >, (Grade 2C) .

Diagnstico de la TVP
!,0 "iagnstico de sos ec#a de rimera trom$osis %enosa rofunda de e&tremidad inferior =65) En los pacientes con sospec-a de TVP en EEII6 se sugiere 1ue la eleccin del proceso de prue$as de diagnstico de$e guiarse por la evaluacin cl"nica de la pro$a$ilidad pretest en lugar de #ediante la reali+acin de prue$as de diagnstico en todos los pacientes :Dr 4B<) =64) En pacientes con $aja pro$a$ilidad pretest de TVP en e'tre#idades in0eriores6 se reco#ienda una de las prue$as siguientes: :i< d"#ero D de #oderada sensi$ilidadl6 :ii< d"#ero D de alta sensi$ilidad 6 o :iii< ecogra0"a de co#presin :C&*< de las venas pro'i#ales en lugar de :i< ninguna prue$a de diagnstico :Drado 5B para todas las co#paraciones<6 :ii< 4B venogra0"a :Drado 5B para todas las co#paraciones<6 o :iii< ecogra0"a :&*< de toda la pierna :Drado 4B para todos las co#paraciones<) *e sugiere el uso inicial de d"#ero-D de sensi$ilidad #oderada :Drado 4C< o de alta sensi$ilidad :Drado 4B< en lugar de C&* pro'i#al) *i el d"#ero-D es negativo6 se reco#ienda no reali+ar #,s prue$as de :i< C&* pro'i#a6 :ii< &* de toda la pierna6 o :iii< venogra0"a :Drado 5B para todas las co#paraciones<) *i la C&* pro'i#al es negativa6 se reco#ienda no reali+ar #,s prue$as en co#paracin con :i< repetir C&* pro'i#al despu!s de 5 se#ana6 :ii< &* detoda la pierna6 o :iii< venogra0"a :Drado 5B para todas las co#paraciones<) *i el d"#ero D es positivo6 se sugiere la reali+acin de prue$as con C&* de las venas pro'i#ales #as $ien 1ue :i< &* de toda la pierna :Drado 4C< o :ii< venogra0"a :Drado 5B<) *i la C&* de las venas pro'i#ales es positiva6 se sugiere el trata#iento de la TVP ( la reali+acin de ninguna otra prue$a so$re la reali+acin de una venogra0"a con0ir#atoria :Drado 4C< =6=) En pacientes con una #oderada pro$a$ilidad pretest de TVP de e'tre#idades in0eriores6 se reco#ienda una de las prue$as iniciales siguientes: :i< d"#ero D de alta sensi$ilidad o :ii< C&* pro'i#ales6 o :iii< &* de toda la pierna en lugar de : i< no-test :Drado 5B para todas las co#paraciones< o :ii< venogra0"a :Drado 5B para todas las co#paraciones<) *e sugiere el uso inicial de d"#ero D de alta sensi$ilidad del en lugar de &*) :Drado 4C<)

*i el d"#ero D de alta sensi$ilidad es negativo6 se reco#ienda no reali+ar #,s prue$as #,s prue$as con :i< 1f the highly sensitive =7di er is negative# we C&* pro'i#ales6 :ii< &* de toda la pierna6 o :iii< reco end no further testing over further venogra0"a :Drado 5B para todas las co#paraciones<) investigation with (i" pro*i al ->,# (ii" wholeleg >,# *i el d"#ero D de alta sensi$ilidad es positivo6 se or (iii" venography (Grade 1B for all comparisons) . 1f reco#ienda C&* pro'i#al o &* de toda la pierna en the highly sensitive =7di er is positive# we reco end lugar de no-test :Drado 5B todas las co#paraciones< o pro*i al ->, or whole7leg >, rather than no testing venogra0"a :Drado 5B todas las co#paraciones<)

(Grade 1B for all comparisons) or venography (Grade 1B for all comparisons) .

17

8S 8 tra!o$ogra&9a. C8S :8S de "o*pre!#'$

18

1f pro*i al ->, is chosen as the initial test and is negative# we reco end (i" repeat pro*i al ->, in 1 wee) or (ii" testing with a oderate or highly sensitive =7di er assay over no further testing (Grade 1C) or venography (Grade 2B) . 1n patients with a negative pro*i al ->, (ut a positive =7di er# we reco end repeat pro*i al ->, in 1 wee) over no further testing (Grade 1B) or venography (Grade 2B) . 1n patients with (i" negative serial pro*i al ->, or (ii" a negative single pro*i al ->, and negative oderate or highly sensitive =7di er# we reco end no further testing rather than further testing with (i" whole7leg >, or (ii" venography (Grade 1B for all comparisons) . 1f whole7leg >, is negative# we reco end no further testing over (i" repeat >, in one wee)# (ii" =7di er testing# or (iii" venography (Gr 1B for all comparisons) . 1f pro*i al ->, is positive# we reco end treating for =%& rather than confi r atory venography (1B)

*i se elige C&* pro'i#al co#o prue$a inicial ( es negativa6 se reco#ienda :i< repetir C&* pro'i#al en 5 se#ana o :ii< prue$as con D-d"#ero de #oderada o alta sensi$lidad so$re no-test :Drado 5C< o venogra0"a : Drado 4B<) En los pacientes con C&* negativa pro'i#al6 pero un resultado d"#ero D positivo6 se reco#ienda repetir la C&* pro'i#al en una se#ana so$re ninguna otra prue$a :Drado 5B< o venogra0"a :Drado 4B<) En pacientes con :i< C&* pro'i#al seriadas negativas o :ii< una sola C&* negativa pro'i#al ( d"#ero-D de #oderada o alta sensi$iidad negativos6 se reco#ienda no reali+ar #,s prue$as en lugar de reali+ar #,s prue$as con :i< &* de toda la pierna o :ii< venogra0"a :Drado 5B<) *i la &* de toda la pierna es negativa6 se reco#ienda no reali+ar #,s prue$as so$re :i< repetir la &* en una se#ana6 :ii< an,lisis del d"#ero D6 o :iii< venogra0"a :Dr) 5B para todas las co#paraciones<) *i la C&* pro'i#al es positiva6 se reco#iendal tto para la tro#$osis venosa pro0unda #ejor 1ue venogra0"a de con0ir#acin :5B< *i se detecta TVP distal aislada en &* de toda la pierna6 se sugieren prue$as en serie para descartar e'tensin pro'i#al so$re trata#iento :Drado 4C<) *e reco#ienda 1ue los pacientes con C&* pro'i#ales negativos se so#etan a prue$as de d"#ero D de #oderada o alta sensi$ilidad6 &* de toda la pierna6 o repetir C&* pro'i#ales en una se#ana so$re no -acer ninguna otra prue$a :Drado 5B< o venogra0"a :Drado 4B<) En pacientes con C&* pro'i#ales negativos6 sugeri#os d"#ero-D en lugar de C&* seriadas :Drado 4B< o &* de toda la pierna :Drado 4C<) *e reco#ienda 1ue los pacientes con un solo C&* pro'i#al negativo ( d"#ero D positivo se so#etan a #,s e',#enes con C&* pro'i#al en 5 se#ana o &* de toda la pierna #ejor 1ue ninguna otra prue$a :Drado 5B para a#$as co#paraciones<)

1f isolated distal =%& is detected on wholeleg >,# we suggest serial testing to rule out pro*i al e*tension over treat ent (Grade 2C) . We reco end that patients with a negative pro*i al ->, undergo testing with a oderate 7or high7 sensitivity =7di er# whole7leg >,# or repeat pro*i al ->, in 1 wee) over no further testing (Grade 1B) or venography (Grade 2B) . 1n patients with a negative pro*i al ->,# we suggest =7di er rather than routine serial ->, (Grade 2B) or whole7leg >, (Grade 2C) . We reco end that patients with a single negative pro*i al ->, and positive =7di er undergo further testing with repeat pro*i al ->, in 1 wee) or whole7leg >, rather than no further testing (Grade 1B for both comparisons) . ;eco#enda#os 1ue en los pacientes con :i< C&* pro'i#ales negativas 6 :ii< un d"#ero-D negativo tras de We reco end that in patients with (i" negative serial C&* pro'i#ales iniciales negativos6 o :iii< &* de toda la pro*i al ->,# (ii" a negative =7di er following a pierna negativa6 no se reali+e ninguna otra prue$a en negative initial pro*i al ->,# or (iii" negative whole7 lugar de venogra0"a :Drado 5B <) leg >,# no further testing (e perfor ed rather than *i la &* pro'i#al es positiva para TVP6 se reco#ienda venography (Grade 1B) . trata#iento en lugar de venogra0"a con0ir#atoria :Drado 5B<) *i se -a detectado TVP distal aislado en &* de toda 1f pro*i al >, is positive for =%&# we reco end la pierna6 sugeri#os prue$as en serie para descartar treat ent rather than confi r atory venography e'tensin pro'i#al #ejor 1ue trata#iento :Drado 4C<) (Grade 1B) . 1f isolated distal =%& is detected on whole7leg >,# we suggest serial testing to rule out pro*i al e*tension over treat ent (Grade 2C) .

"o*pre!!#o$ ) tra!o)$d (C8S). 8S 8 tra!o$ogra&9a

19

3.@. 1n patients with suspected first lower e*tre ity =%&# we reco end against the routine use of -& venography or M31 (Grade 1C ) . 1.1$enograph" in Patients With 3uspected Recurrent D$T 4.1. 1n patients suspected of having recurrent lower e*tre ity =%&# we reco end initial evaluation with pro*i al ->, or a highly sensitive =7di er over venography# -& venography# or M31 (all Grade 1B) . 1f the highly sensitive =7di er is positive# we reco end pro*i al ->, over venography# -& venography# or M31 (Grade 1B for all com parisons) .

3,6. 4$ pa"#e$te! "o$ !o!pe":a de 3,P pr#*ar#a de e;tre*#dad #$&er#or, $o !e re"o*#e$da e )!o r)t#$ar#o de 3+C, /e$ogra&9a, o <5 (Grado 1C). ..1Venography en sospecha de TV rec(rrente A65) En pacientes con sospec-a de tro#$osis venosa pro0unda recurrente de las e'tre#idades in0eriores6 se reco#ienda evaluacin inicial con C&* pro'i#al o d"#ero D de alta sensi$ilidad #jor 1ue venogra0"a6 venogra0"a-TC o ;M :todos Drado 5B<) *i el d"#ero D de alta sensi$ilidad es positivo6 se reco#ienda C&* pro'i#al #ejor 1ue venogra0"a6 CTvenogra0"a6 o ;M :Drado 5B todas las co#paraciones <) En pacientes con sospec-a de TVP recurrente de EEII en los 1ue la C&* pro'i#al inicial es negativa :au#ento del di,#etro nor#al o residual J4 ##< 6 se sugiere al #enos una C&* pro'i#al #,s :d"a G W 5< o una prue$a con D -d"#ero de #oderada- alta sensi$ilidad :seguido por la repeticin de la C&* Md"a G W 5N si es positivo< #ejor 1ue no #,s prue$as o venogra0"a :Dr) 4 B<)

1n patients with suspected recurrent lower e*tre ity =%& in who initial pro*i al ->, is negative (nor al or residual dia eter increase of < 6 "# we suggest at least one further pro*i al ->, (day 7 1" or testing with a oderately or highly sensitive =7 di er (followed (y repeat ->, ;day 7 _ 1< if positive" rather than no further testing or venography (Gr 2B) . *e reco#ienda en los pacientes con sospec-a de TVP recurrente de e'tre#idad in0erior ( d"#ero D de alta We reco end that patients with suspected recurrent sensi$ilidad negativo o C&* pro'i#ales negativos ( negativa d"#ero D de #oderada o alta sensi$ilidad lower e*tre ity =%& and a negative highly sensitive negativo6 o C&* pro'i#ales seriados no sean so#etidos a =7di er or negative pro*i al ->, and negative ninguna otra prue$a para TVP recurrente #ejor 1ue oderately or highly sensitive =7di er or negative venogra0"a :5B< serial pro*i al ->, undergo no further testing for suspected recurrent =%& rather than venography (1B) *i la C&* de venas pro'i#ales es positiva6 reco#enda#os 1f ->, of the pro*i al veins is positive# we reco end trata#iento de la TVP ( la reali+acin de ninguna otra prue$a #ejor 1ue venogra0"a :Drado 5B < treating for =%& and perfor ing no further testing over perfor ing confi r atory venography (Grade 1B) ..2 @S de Bompresi/n en pacientes con sospecha de TV rec(rrente 1.+ ,o pression 7ltrasonograph" in Patients A64) En pacientes con sospec-a de TVP recurrente de EEII ( resultado de &* anor#al6 pero no diagnstico6 With :por eje#plo6 un au#ento en el di,#etro venoso residual 3uspected Recurrent D$T de JA6 pero K4 ## 6 se reco#ienda la reali+acin de 4.6. 1n patients with suspected recurrent lower venogra0"a6 si est, disponi$le :Drado 5B<I C&* e*tre ity =%& and a(nor al (ut nondiagnostic >, pro'i#ales seriados :Drado 4B< o prue$as de d"#ero D results (eg# an increase in residual venous dia eter of de #oderada o alta sensi$ilidad :Drado 4B<6 en B 4 (ut 5 6 "# we reco end further testing with co#paracin con otras estrategias de prue$as o venography# if availa(le (Grade 1B) D serial pro*i al trata#ientos) ->, (Grade 2B) or testing with a oderately or highly sensitive =7di er with serial pro*i al ->, as a(ove if the test is positive (Grade 2B) # as opposed to other testing strategies or treat ent.

20

1.- Pretest Pro!a!ilit" 'ssess ent in Patients With 3uspected Recurrent D$T 4.3. 1n patients with suspected recurrent ipsilateral =%& and an a(nor al >, without a prior result for co parison# we reco end further testing with venography# if availa(le (Grade 1B) or a highly sensitive =7di er (Grade 2B) over serial pro*i al ->,. 1n patients with suspected recurrent ipsilateral =%& and an a(nor al >, without prior result for co parison and a negative highly sensitive =7di er# we suggest no further testing over venography (Grade 2C) . 1n patients with suspected recurrent ipsilateral =%& and an a(nor al >, without prior result for co parison and a positive highly sensitive =7di er# we suggest venography if availa(le over e pirical treat ent of recurrence (Grade 2C) . 871VenografFa en TV relacionada con el em6ara1o 4.1 $enograph" in Pregnanc".Related D$T +.1. 1n pregnant patients suspected of having lower e*tre ity =%&# we reco end initial evaluation with pro*i al ->, over other initial tests# including a whole7leg >, (Grade 2C) # oderately sensitive =7 di er (Grade 2C) # highly sensitive =7di er (Grade 1B) # or venography (Grade 1B) .

..! H#al(aci/n de pro6a6ilidad retest en pacientes con sospecha de TV rec(rrente

8.2 @S de Bompresi/n en TV relacionada con em6ara1o

4.+ ,o pression 7ltrasonograph" in Pregnanc". Related D$T +.6. 1n pregnant patients with suspected =%& in who initial pro*i al ->, is negative# we suggest further testing with either serial pro*i al ->, (day 3 and day 7" (Grade 1B) or a sensitive =7di er done at the ti e of presentation (Grade 2B) over no further testing for =%&. We reco end that patients with an initial negative pro*i al ->, and a su(seAuent negative sensitive =7di er or negative serial pro*i al ->, undergo no further testing for =%& (Grade 1B), and that patients with positive =7di er have an additional follow7up pro*i al ->, (day 3 and day 7" rather than 8.! ro6a6ilidad pretest en TV relacionada con em6ara1o venography (Grade 1B) or whole7leg >, (Grade 2C) . 4.- Pretest Pro!a!ilit" in Pregnanc".Related D$T +.3. 1n pregnant patients with sy pto s suggestive of isolated iliac vein thro (osis (swelling of the entire leg# with or without fl an)# (uttoc)# or (ac) pain" and no evidence of =%& on standard pro*i al ->,# we suggest further testing with either =oppler >, of the iliac vein (Grade 2C) # venography (Grade 2C) # or direct M31 (Grade 2C) # rather than standard serial ->, of the pro*i al deep veins.

21

5.1 7ltrasonograph" in Patients With 7pper. @xtre it" D$T <7@D$T= @.1. 1n patients suspected of having >'=%&# we suggest initial evaluation with co (ined odality >, (co pression with either =oppler or color =oppler" over other initial tests# including highly sensitive =7di er or venography (Grade 2C) .

9.1 HcografFa en pacientes con trom6osis #enosa prof(nda de eDtremidades s(periores (@HDVT)

9.2 H#al(aci/n de pro6a6lidad pretest en pacientes con @HDVT 5.+ ,linical Pretest Pro!a!ilit" 'ssess ent in Patients With 7@D$T @.6. 1n patients with suspected >'=%& in who initial >, is negative for thro (osis despite a high clinical suspicion of =%&# we suggest further testing with a oderate or highly sensitive =7di er# serial >,# or venographic7(ased i aging (traditional# -& scan# or M31"# rather than no further testing (Grade 2C) . 1n patients with suspected >'=%& and an initial negative co (ined7 odality >, and su(seAuent negative oderate or highly sensitive =7di er or -& or M31# we reco end no further testing# rather than confi r atory venography (Grade 1C) . We suggest that patients with an initial co (ined negative odality >, and positive =7di er or those with less than co plete evaluation (y >, undergo venography rather than no further testing# unless there is an alternative e*planation for their sy pto s (Grade 2B), in which case testing to evaluate for the presence an alternative diagnosis should (e perfor ed. We suggest that patients with a positive =7di er or those with less than co plete evaluation (y >, (ut an alternative e*planation for their sy pto s undergo confi r atory testing and treat ent of this alternative e*planation rather than venography (Grade 2C) .

22

0ntithro (otic &herapy for %&' =isease +.1 (nitial 'nticoagulation for Patients With 'cute D$T of the Leg 6.1. 1n patients with acute =%& of the leg treated with %/0 therapy# we reco end initial treat ent with parenteral anticoagulation (LMWH# fondaparinu*# 1% >FH# or ,- >FH" over no such initial treat ent (1B) .

Trata#iento antitro#$tico para el TEV 2.1 Anticoag(laci/n inicial para pacientes con TV ag(da de la pierna 465) En los pacientes con TVP aguda de la pierna tratada con /V86 se reco#ienda iniciar anticoagulacin parenteral :2BPM6 0ondaparinu'6 -eparina no 0raccionada intravenosa o -eparina no 0raccionada *C< so$re la ausencia de dic-o trata#iento inicial :5B<)

2.2 Anticoag(laci/n parenteral pre#ia a reci6ir los +.+ Parenteral 'nticoagulation Prior to Receipt res(ltados de Hst(dio diagn/stico de THV 4)4)5) En los pacientes con alta sospec-a cl"nica de TEV6 of the se aconseja trata#iento anticoagulante parenteral en Results of Diagnostic Wor&.up for $T@ co#paracin con ning n trata#iento #ientras se esperan 6.6.1. 1n patients with a high clinical suspicion of acute los resultados de las prue$as diagnsticas :Drado 4C<) 4)4)4) En pacientes con sospec-a cl"nica inter#edia de %&'# we suggest treat ent with parenteral anti7 coagulants co pared with no treat ent while awaiting TEV agudo6 se aconseja el trata#iento anticoagulante parenteral en co#paracin con ning n trata#iento si los the results of diagnostic tests (Grade 2C) . resultados de las prue$as diagnsticas se espera 1ue se 6.6.6. 1n patients with an inter ediate clinical retrasen por #,s de A -oras :Drado 4C<) suspicion of acute %&'# we suggest treat ent with parenteral anticoagulants co pared with no treat ent 4)4)=) En pacientes con $aja sospec-a cl"nica de TVE no se sugiere el trata#iento con anticoagulacin parenteral if the results of diagnostic tests are e*pected to (e en espera de los resultados de las prue$as de diagnstico6 delayed for ore than 4 h(Grade 2C) . 6.6.3. 1n patients with a low clinical suspicion of acute a condicin de 1ue los resultados de las prue$as se esperen dentro de 4A -oras :Dr) 4 C<)

%&'# we suggest not treating with parenteral anticoag ulants while awaiting the results of diagnostic tests# 27! Anticoag(laci/n en pacientes con TV distal aislada provided test results are e*pected within 64 h (Gr 2C) .

+.- 'nticoagulation in Patients With (solated Distal D$T 6.3.1. 1n patients with acute isolated distal =%& of the leg and without severe sy pto s or ris) factors for e*tension# we suggest serial i aging of the deep veins for 6 wee)s over initial anticoagulation (Grade 2C) . 6.3.6. 1n patients with acute isolated distal =%& of the leg and severe sy pto s or ris) factors for e*tension (see te*t"# we suggest initial anticoagulation over serial i aging of the deep veins (Grade 2C) . 6.3.3. 1n patients with acute isolated distal =%& of the leg who are anaged with initial anticoagulation# we reco end using the sa e approach as for patients with acute pro*i al =%& (Grade 1B) . 6.3.4. 1n patients with acute isolated distal =%& of the leg who are anaged with serial i aging# we reco end no anticoagulation if the thro (us does not e*tend (Grade 1B) D we suggest anticoagulation if the thro (us e*tends (ut re ains confi ned to the distal veins (Grade 2C)D we reco end anticoagulation if the thro (us e*tends into the pro*i al veins (1B) .

23

+.1 Ti ing of (nitiation of $%' and 'ssociated Duration of Parenteral 'nticoagulant Therap" 6.4. 1n patients with acute =%& of the leg# we reco end early initiation of %/0 (eg# sa e day as parenteral therapy is started" over delayed initiation# and continuation of parenteral anticoagulation for a ini u of + days and until the 123 is 6.0 or a(ove for at least 64 h (Grade 1B) . +.4 ,hoice of (nitial 'nticoagulant Regi en in Patients With Proxi al D$T 6.+.1. 1n patients with acute =%& of the leg# we suggest LMWH or fondaparinu* over 1% >FH (Grade 2C) and over ,- >FH (Grade 2B for LMWH; Grade 2C for fondaparin !) . 6.+.6. 1n patients with acute =%& of the leg treated with LMWH# we suggest once7 over twice7daily ad inistration (Grade 2C) .

2.. Tiempo de Iniciaci/n de AVK y d(raci/n de la terapia anticoag(lante parenteral asociada

2.8 Hlecci/n de r0gimen anticoag(lante inicial en pacientes con trom6osis #enosa prof(nda proDimal

+.7 't.Ho e 6s (n.Hospital (nitial Treat ent of Patients With D$T 6.7. 1n patients with acute =%& of the leg and whose ho e circu stances are adeAuate# we reco end initial treat ent at ho e over treat in hospital (1B) . 27E Trom6/lisis Dirigida por Bat0ter en pacientes con TV ag(da 46L) En los pacientes con TVP aguda pro'i#al de la +.# ,atheter.Directed Thro !ol"sis for Patients pierna6 sugeri#os terapia anticoagulante so$re With tro#$lisis dirigida por cat!ter :CDT< :Drado 4C<) 'cute D$T 6... 1n patients with acute pro*i al =%& of the leg# we 271> Terapia trom6olFtica sist0mica para pacientes con TV ag(da suggest anticoagulant therapy alone over catheter7 4659) En los pacientes con TVP aguda pro'i#al de la directed thro (olysis (-=&" (Grade 2C) . pierna6 sugeri#os terapia anticoagulante so$re tro#$lisis sist!#ica :Drado 4C<) +.1/ 3"ste ic Thro !ol"tic Therap" for 2.11 Trom6ectomFa #enosa 'c para la TV ag(da Patients With 4)55) En pacientes con TVP aguda pro'i#al de la pierna6 'cute D$T sugeri#os terapia anticoagulante #ejor 1ue 6.10. 1n patients with acute pro*i al =%& of the leg# we suggest anticoagulant therapy alone over syste ic tro#$ecto#"a venosa 1uir rgica :Drado 4C<) thro (olysis (Grade 2C) . 2.12 Anticoag(laci/n en pacientes '(e han s(frido c(al'(ier %0todo de eliminaci/n de trom6os +.11 2perati6e $enous Thro !ecto " for 'cute 4654) En los pacientes con TVP aguda de la pierna 1ue se so#eten a la eli#inacin de tro#$os6 se reco#ienda D$T la #is#a intensidad ( duracin de trata#iento 6.11. 1n patients with acute pro*i al =%& of the leg# we suggest anticoagulant therapy alone over operative anticoagulante 1ue en pacientes co#para$les en 1ue no se procede a venous thro (ecto y (Grade 2C) . e'tirpar la tro#$osis :Drado 5B<) +.1+ 'nticoagulation in Patients Who Ha6e Had 'n" Method of Thro !us Re o6al Perfor ed 6.16. 1n patients with acute =%& of the leg who undergo thro (osis re oval# we reco end the sa e intensity and duration of anticoagulant therapy as in co para(le patients who do not undergo thro (osis re oval (Grade 1B) .

2.: Tratamiento inicial domiciliario #s hospitalario en pacientes con TV

24

25

2.1! &iltros de Vena Ba#a para el tratamiento inicial de los +.1- $ena ,a6a Filters for the (nitial Treat ent pacientes con trom6osis #enosa prof(nda of Patients With D$T 6.13.1. 1n patients with acute =%& of the leg# we reco end against the use of an 1%- fi lter in addition to anticoagulants (Grade 1B) . 6.13.6. 1n patients with acute pro*i al =%& of the leg and contraindication to anticoagulation# we reco end the use of an 1%- fi lter (Grade 1B) . 6.13.3. 1n patients with acute pro*i al =%& of the leg and an 1%- fi lter inserted as an alternative to antico7 agulation# we suggest a conventional course of antico7 agulant therapy if their ris) of (leeding resolves (2B) . 271. Deam6(laci/n preco1 en pacientes con TV ag(da

+.11 @arl" ' !ulation of Patients With 'cute D$T 6.14. 1n patients with acute =%& of the leg# we suggest early a (ulation over initial (ed rest ( 2C) .

!7> Anticoag(laci/n a largo pla1o en pacientes con TV ag(da de la pierna

-./ Long.ter 'nticoagulation in Patients With 'cute D$T of the Leg 3.0. 1n patients with acute %&' who are treated with !.1 D(raci/n del tratamiento anticoag(lante a largo pla1o anticoagulant therapy# we reco end longter therapy (see section 3.1 for reco ended duration of therapy" over stopping anticoagulant therapy after a(out 1 wee) of initial therapy (Grade 1B) . -.1 Duration of Long.ter 'nticoagulant Therap" 3.1.1. 1n patients with a pro*i al =%& of the leg provo)ed (y surgery# we reco end treat ent with anticoagulation for 3 onths over (i" treat ent of a shorter period (Grade 1B) # (ii" treat ent of a longer ti e7li ited period (eg# @ or 16 onths" (1B) # or (iii" e*tended therapy (Grad 1B re"ardless of bleedin" ris#) . 3.1.6. 1n patients with a pro*i al =%& of the leg provo)ed (y a nonsurgical transient ris) factor# we reco end treat ent with anticoagulation for 3 onths over (i" treat ent of a shorter period (Grade 1B) # (ii" treat ent of a longer ti eli ited period (eg# @ or 16 onths" (Grade 1B) # and (iii" e*tended therapy if there is a high (leeding ris) (Grade 1B) . We suggest treat ent with anticoagulation for 3 onths over e*tended therapy if there is a low or oderate (leeding ris) (Grade 2B) . 3.1.3. 1n patients with an isolated distal =%& of the leg provo)ed (y surgery or (y a nonsurgical transient ris) factor (see re ar)"# we suggest treat ent with anticoagulation for 3 onths over treat ent of a shorter period (Grade 2C), and reco end treat ent with anticoagulation for 3 onths over treat ent of a longer ti eli ited period (eg# @ or 16 onths" (Grade 1B) or e*tended therapy (Grade 1B re"ardless of bleedin" ris#) .

26

27

3.1.4. 1n patients with an unprovo)ed =%& of the leg (isolated distal ;see re ar)< or pro*i al"# we reco end treat ent with anticoagulation for at least 3 onths over treat ent of a shorter duration (Grade 1B) . 0fter 3 onths of treat ent# patients with unprovo)ed =%& of the leg should (e evaluated for the ris)7(enefi t ratio of e*tended therapy . 3.1.4.1. 1n patients with a fi rst %&' that is an unprovo)ed pro*i al =%& of the leg and who have a low or oderate (leeding ris)# we suggest e*tended anticoagulant therapy over 3 onthsof therapy ( 2B) . 3.1.4.6. 1n patients with a fi rst %&' that is an unprovo)ed pro*i al =%& of the leg and who have a high (leeding ris)# we reco end 3 onths of anticoagulant therapy over e*tended therapy (1B) . 3.1.4.3. 1n patients with a fi rst %&' that is an unprovo)ed isolated distal =%& of the leg (see re ar)"# we suggest 3 onths of anticoagulant therapy over e*tended therapy in those with a low or oderate (leeding ris) (Grade 2B) and reco end 3 onths of anticoagulant treat ent in those with a high (leeding ris) (Grade 1B) . 3.1.4.4. 1n patients with a second unprovo)ed %&'# we reco end e*tended anticoagulant therapy over 3 onths of therapy in those who have a low (leeding ris) (Grade 1B), and we suggest e*tended anticoagulant therapy in those with a oderate (leeding ris) (Grade 2B) . 3.1.4.+. 1n patients with a second unprovo)ed %&' who have a high (leeding ris)# we suggest 3 onths of anticoagulant therapy over e*tended therapy (2B) . 3.1.+. 1n patients with =%& of the leg and active cancer# if the ris) of (leeding is not high# we reco end e*tended anticoagulant therapy over 3 onths of therapy (Grade 1B) # and if there is a high (leeding ris)# we suggest e*tendedanticoagulant therapy (Grade 2B) . -.+ (ntensit" of 'nticoagulant @ffect 3.6. 1n patients with =%& of the leg who are treated with %/0# we reco end a therapeutic 123 range of 6.0 to 3.0 (target 123 of 6.+" over a lower (123 < 6" or higher (123 3.07+.0" range for all treat ent durations (Grade 1B) . -.- ,hoice of 'nticoagulant Regi en for Long. ter Therap" 3.3.1. 1n patients with =%& of the leg and no cancer# we suggest %/0 therapy over LMWH for long7ter therapy (Grade 2C) . For patients with =%& and no cancer who are not treated with %/0therapy# we suggest LMWH over da(igatran or rivaro*a(an for long7ter therapy (Grade 2C) .
!.2 Intensidad del efecto anticoag(lante =64) En los pacientes con tro#$osis venosa pro0unda de la pierna 1ue reci$en trata#iento con /V86 se reco#ienda un rango terap!utico de IN; de 469 a =69 :IN; o$jetivo de 46B< so$re un rango in0erior :IN;J 4<6 o superior :IN; =)9-B)9< para todas las duraciones de trata#iento :Drado 5B<)

!.! Hlecci/n de r0gimen anticoag(lante para terapia a largo pla1o

28

3.3.6. 1n patients with =%& of the leg and cancer# we suggest LMWH over %/0 therapy (Grade 2B) . 1n patients with =%& and cancer who are not treated with LMWH# we suggest %/0 over da(igatran or rivaro*a(an for long7ter therapy(Grade 2B) . -.1 ,hoice of 'nticoagulant Regi en for @xtended Therap" 3.4. 1n patients with =%& of the leg who receive e*tended therapy# we suggest treat ent with the sa e anticoagulant chosen for the fi rst 3 onths (Grade 2C) -.4 Treat ent of Patients With 's" pto atic D$T of the Leg 3.+. 1n patients who are incidentally found to have asy pto atic =%& of the leg# we suggest the sa e initial and long7ter anticoagulation as for co para(le patients with sy pto atic =%& (2B) . 1.1 ,o pression 3toc&ings and *andages to Pre6ent PT3 4.1. 1n patients with acute sy pto atic =%& of the leg# we suggest the use of co pression stoc)ings (2B) .
!.. Hlecci/n de r0gimen anticoag(lante para tto prolongado =6A) En los pacientes con TVP de la pierna 1ue reci$en trata#iento prolongado6 se aconseja el trata#iento con el #is#o anticoagulante los pri#eros = #eses :Drado 4C< !.8 Tratamiento de los pacientes con TV asintomCtica de la pierna

..1 %edias de compresi/n y #enda2es para pre#enir TS A65) En los pacientes con TVP aguda sinto#,tica de la pierna6 se sugiere el uso de #edias de co#presin :4B<) ..2 Tratamiento fFsico de pacientes con TS

1.+ Ph"sical Treat ent of Patients With PT3 4.6.1. 1n patients with 9&, of the leg# we suggest a trial of co pression stoc)ings (Grade 2C) . 4.6.6. 1n patients with severe 9&, of the leg that is not adeAuately relieved (y co pression stoc)ings# we suggest a trial of an inter ittent co pression device ..! Tratamiento farmacol/gico de pacientes con TS (Grade 2B) . 1.- Phar acologic Treat ent of Patients With PT3 4.3. 1n patients with 9&, of the leg# we suggest that venoactive edications (eg# rutosides# defi (rotide# and hidros in" not (e used (Grade 2C) .

29

4.1 (nitial 'nticoagulation for Patients With 'cute Pul onar" @ !olis <P@= +.1. 1n patients with acute 9'# we reco end initial treat ent with parenteral anticoagulation (LMWH# fondaparinu*# 1% >FH# or ,- >FH" over no such initial treat ent (Grade 1B) . 4.+ Parenteral 'nticoagulation Prior to Receipt of the Results of Diagnostic Wor&.up for P@ +.6.1. 1n patients with a high clinical suspicion of acute 9'# we suggest treat ent with parenteral anticoagu7 lants co pared with no treat ent while awaiting the results of diagnostic tests (Grade 2C) . +.@.6.1. 1n patients with acute 9'# when a thro (olytic agent is used# we suggest short infusion ti es (eg# a 67h infusion" over prolonged infusion ti es (eg# a 647h infusion" (Grade 2C) . +.@.6.6. 1n patients with acute 9' when a thro (olytic agent is used# we suggest ad inistration through a peripheral vein over a pul onary artery catheter (2C) 4.7 ,atheter.*ased Thro !us Re o6al for the (nitial Treat ent of Patients With P@ +.7. 1n patients with acute 9' associated with ypotension and who have (i" contraindications to thro (olysis# (ii" failed thro (olysis# or (iii" shoc) that is li)ely to cause death (efore syste ic thro (olysis can ta)e effect (eg# within hours"# if appropriate e*pertise and resources are availa(le# we suggest catheter7assisted thro (us re oval over no such intervention (Grade 2C) . 4.8 3urgical @ !olecto " for the (nitial Treat ent of Patients With P@ +.$. 1n patients with acute 9' associated with hypo tension# we suggest surgical pul onary e (olecto y over no such intervention if they have (i" contraindi cations to thro (olysis# (ii" failed thro (olysis or catheter7assisted e (olecto y# or (iii" shoc) that is li)ely to cause death (efore thro (olysis can ta)e effect (eg# within hours"# provided surgical e*pertise and resources are availa(le (Grade 2C) . 4.#. $ena ,a6a Filters for the (nitial Treat ent of Patients With P@ +...1. 1n patients with acute 9' who are treated with anticoagulants# we reco end against the use of an 1%fi lter (Grade 1B) . +...6. 1n patients with acute 9' and contraindication to anticoagulation# we reco end the use of an 1%- fi lter (Grade 1B) . +...3. 1n patients with acute 9' and an 1%- filter inserted as an alternative to anticoagulation# we suggest a conventional course of anticoagulant therapy if their ris) of (leeding resolves (Grade 2B) . 5./ Long.ter Treat ent of Patients With P@

8.1 Anticoag(laci/n inicial en pacientes con Hm6olia p(lmonar (H )


B65) En pacientes con EP agudo6 se reco#ienda iniciar nticoagulacin parenteral :2BPM6 0ondaparinu'6 2N. iv6 o -eparina no 0raccionada *C< so$re ausencia de dic-o trata#iento inicial :Drado 5B<)

8.2 Anticoag(laci/n parenteral con anterioridad al reci6o de *es(ltados de Hst(dio diagn/stico para H
B)4)5) En pacientes con alta sospec-a cl"nica de TEP6 se sugiere el trata#iento con anticoagulantes parenterales6 en co#paracin con ning n trata#iento6 #ientras llegan los resultados de las prue$as diagnsticas :Drado 4C< 5.6.'.(. )n los acientes con )P agudo, cuando se utili*a un agente trom$oltico, se sugieren cortos tiem os de infusin + e,, infusin '-#- %s tiem os de infusin rolongada + e,, infusin '4-#- +grado '.-. 5.6.'.'. )n acientes con )P agudo cuando se utili*a un agente trom$oltico, sugieren administracin a tra%/s de %ena erif/rica %s or cat/ter de arteria ulmonar +'.-

5,0 )liminacin de trom$os $asada en cat/tera ara el tto inicial de los acientes con )P 5,0. )n acientes con )P agudo asociados con #i otensin y 1ue tienen: i- contraindicaciones ara la trom$lisis, iitrom$olisis fallida, o +iii- s#oc2 1ue ueda causar la muerte antes 1ue la trom$olisis sist/mica ueda actuar + e,, en #oras-, si #ay e& eriencia adecuada y #ay recursos dis oni$les, sugerimos eliminacin de trom$os con ayuda de cat/ter so$re no tal inter%encin +3r '.-. 5,8 )m$olectoma 1uir4rgica ara el tratamiento inicial de acientes con P) 5,8. )n acientes con )P agudo asociado con #i otensin, sugerimos em$olectoma 1uir4rgica so$re no tal inter%encin si tienen: +i- contraindicacin a la trom$olisis, +ii- trom$olisis o em$olectoma asistida con cat/ter fallidas, o +iii- s#oc2 1ue ueda causar la muerte antes de 1ue la trom$lisis ueda actuar + e,, en cuestin de #oras-, siem re y cuando la e& eriencia 1uir4rgica y los recursos est/n dis oni$les +3rado '.-.
5,5. 6iltros de 7ena .a%a ara el tratamiento inicial de los acientes con )P B)L)5) En pacientes con EP agudo tratados con anticoagulantes6 no se reco#ienda el uso de 0iltro VCI :5B<) B)L)4) En pacientes con EP agudo ( contraindicacin de anticoagulacin6 se reco#ienda uso de 0iltro VCI :5B<) B)L)=) En pacientes con EP ( 0iltro de VCI insertado co#o alternativa a la anticoagulacin6 se aconseja un curso convencional de terapia anticoagulante6 si el riesgo de sangrado est, controlado :Drado 4B<) 6.0 Tratamiento a largo la*o de los acientes con P) F65) En pacientes con EP provocado por la cirug"a6 se reco#ienda trata#iento con anticoagulacin durante = #eses so$re: :i< trata#iento por un per"odo #,s corto :Drado 5B<6 :ii< trata#iento por un per"odo #,s largo :por eje#plo6 F 54 #eses< :Drado 5B <6 o :iii< trata#iento e'tendido :Drado 5B independiente#ente del riesgo de sangrado<)

30

@.1. 1n patients with 9' provo)ed (y surgery# we reco end treat ent with anticoagulation for 3 onths over (i" treat ent of a shorter period (Grade 1B) # (ii" treat ent of a longer ti eli ited period (eg# @ or 16 onths" (Grade 1B) # or (iii" e*tended therapy (Grade 1B re"ardless of bleedin" ris#) .

31

@.6. 1n patients with 9' provo)ed (y a nonsurgical transient ris) factor# we reco end treat ent with anticoagulation for 3 onths over (i" treat ent of a shorter period (Grade 1B) # (ii" treat ent of a longer ti e7 li ited period (eg# @ or 16 onths" (Grade 1B) # and (iii" e*tended therapy if there is a high (leeding ris) (Grade 1B) . We suggest treat ent with anticoagulation for 3 onths over e*tended therapy if there is a low or oderate (leeding ris) (Grade 2B) . @.3. 1n patients with an unprovo)ed 9'# we reco end treat ent with anticoagulation for at least 3 onths over treat ent of a shorter duration (Grade 1B) . 0fter 3 onths of treat ent# patients with unprovo)ed 9' should (e evaluated for the ris)7(enefi t ratio of e*tended therapy. @.3.1. 1n patients with a fi rst %&' that is an unprovo)ed 9' and who have a low or oderate (leeding ris)# we suggest e*tended anticoagulant therapy over 3 onths of therapy (Grade 2B) . @.3.6. 1n patients with a fi rst %&' that is an unprovo)ed 9' and who have a high (leeding ris)# we reco end 3 onths of anticoagulant therapy over e*tended therapy (Grade 1B) . @.3.3. 1n patients with a second unprovo)ed %&'# we reco end e*tended anticoagulant therapy over 3 onths of therapy in those who have a low (leeding ris) (Grade 1B) # and we suggest e*tended anticoagulant therapy in those with a oderate (leeding ris) (Grade 2B) . @.3.4. 1n patients with a second unprovo)ed %&' who have a high (leeding ris)# we suggest 3 onths of therapy over e*tended therapy (Grade 2B) . @.4. 1n patients with 9' and active cancer# if there is a low or oderate (leeding ris)# we reco end e*tended anticoagulant therapy over 3 onths of therapy (Grade 1B) # and if there is a high (leeding ris)# we suggest e*tended anticoagulant therapy ( 2B) . @.+. 1n patients with 9' who are treated with %/0# we reco end a therapeutic 123 range of 6.0 to 3.0 (target 123 of 6.+" over a lower (123 , 6" or higher (123 3.07+.0" range for all treat ent durations (1B) . @.@. 1n patients with 9' and no cancer# we suggest %/0 therapy over LMWH for long7ter therapy (2C) For patients with 9' and no cancer who are not treated with %/0 therapy# we suggest LMWH over da(igatran or rivaro*a(anfor long7ter therapy (2C) . @.7. 1n patients with 9' and cancer# we suggest LMWH over %/0 therapy (Grade 2B) . 1n patients with 9' and cancer who are not treated with LMWH# we suggest %/0 over da(igatran or rivaro*a(an for long7 ter therapy (Grade 2C) . @.$. 1n patients with 9' who receive e*tended therapy# we suggest treat ent with the sa e anticoagulant chosen for the fi rst 3 onths(Grade 2C) . @... 1n patients who are incidentally found to have asy pto atic 9'# we suggest the sa e initial and long7 ter anticoagulation as for co para(le patients with sy pto atic 9'(Grade 2B) .

F64) En pacientes con EP provocadas por un 0actor de riesgo transitorio no 1uir rgico6 se reco#ienda anticoagulacin durante = #eses so$re: :i< trata#iento por un per"odo #,s corto :Drado 5B<6 :ii< trata#iento por un per"odo #,s largo de tie#po :p ej6 F a 54 #eses< :Drado 5B<6 ( :iii< trata#iento e'tendido si -a( un riesgo alto de -e#orragia :Drado 5B<) *e sugiere anticoagulacin durante = #eses so$re trata#iento e'tendidodo6 si -a( un riesgo de -e#orragia $ajo o #oderado :Drado 4B<) F6=) En pacientes con PE sin provocacin6 reco#iendan trata#iento anticoagulante por lo #enos durante = #eses so$re trata#iento de una duracin #,s corta :Drado 5B<) Despu!s de = #eses de trata#iento6 los pacientes con EP sin provocacin de$en ser evaluados para la relacin riesgo-$ene0icio de la terapia prolongada) F)=)5) En pacientes con un pri#er TEV 1ue es un PE no provocado ( 1ue tienen un $ajo o #oderado riesgo de sangrado6 sugeri#os anticoagulante prolongado so$re trata#iento de = #eses :Drado 4B<) F)=)4) En pacientes con un pri#er TEV 1ue es un PE no provocado ( 1ue tienen un riesgo de -e#orragia alto6 se reco#ienda = #eses de trata#iento anticoagulante so$re un trata#iento #,s prolongado :Drado 5B<) F)=)=) En pacientes con un segundo TEV no provocado6 se reco#ienda terapia anticoagulante prolongada6 so$re = #eses de trata#iento en a1uellos 1ue tienen un $ajo riesgo -e#orr,gico :Drado 5B<6 ( se sugiere el trata#iento anticoagulante prolongado en pacientes con riesgo de -e#orragia #oderada :Drado 4B<) F)=)A) En pacientes con un segundo TEV no provocado 1ue tienen un alto riesgo de -e#orragia6 se sugieren = #eses de trata#iento so$re una terapia prolongada :4B<) F6A) En pacientes con EP ( c,ncer activo6 si -a( riesgo de sangrado $ajo o #oderado6 se reco#ienda trata#iento anticoagulante prolongado so$re = #eses de trata#iento :Drado 5B<6 ( si -a( un alto riesgo de -e#orragia6 se sugiere t$ terapia anticoagulante prolongada :4B< ) F6B) En pacientes con EP en tto con /V86 se reco#ienda un rango terap!utico de IN; de 469 a =69 :IN; o$jetivo de 46B< so$re un rango in0erior :IN;J 4< o superior :IN; =69-B69< para todas las duraciones del tto :5B< ) F6F) En pacientes con EP ( no-c,ncer 6 sugieren tto con /V8 so$re 2BPM para terapia a largo pla+o :4C<) En pacientes con EP sin c,ncer no tratados con /V86 sugieren 2BPM so$re da$igatr,n o rivaro'a$an para terapia a largo pla+o :4C<) F6G) En pacientes con EP ( c,ncer6 sugieren 2BPM so$re /V8 :Drado 4B<) En pacientes con EP ( c,ncer 1ue no reci$en 2BPM6 sugieren /V8 so$re da$igatr,n o rivaro'a$an para tto a largo pla+o :Drado 4C<) F6H) En pacientes con EP 1ue reci$en tto prolongado6 se aconseja tto con el anticoagulante elegido para los = pri#eros #eses :Drado 4C<) F6L) En pacientes en 1ue se encuentra incidental#ente un PE asinto#,tico6 se sugiere la #is#a anticoagulacin inicial (a largo pla+o6 1ue para los pacientes co#para$les con EP sinto#,tica :Drado 4B<)

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7.1 Pul onar" Thro !oendarterecto "9 'nticoagulant Therap"9 and $ena ,a6a Filter for the Treat of ,hronic Thro !oe !olic Pul onar" H"pertension<,TPH= 7.1.1. 1n patients with -&9H# we reco end e*tended anticoagulation over stopping therapy (Grade 1B) . 7.1.6. 1n selected patients with -&9H# such as those with central disease under the care of an e*perienced thro (oendarterecto y tea # we suggest pul onary thro (oendarterecto y over no pul onary thro (oendarterecto y (Grade 2C) .

7,1 3ro*%oe$dartere"to*9a p) *o$ar, 3erap#a a$t#"oag) a$ te, = &# tro de /e$a "a/a para e tto de a 0#perte$!#'$ p) *o$ar tro*%oe*%' #"a "r'$#"a (0P3C) G)5)5) En pacientes con 2PTC6 se reco#ienda anticoagula -cin prolongada so$re interru#pir el tto :Drado 5B<) G)5)4) En pacientes seleccionados con 2PTC6 tales co#o a1uellos con en0er#edad central $ajo el cuidado de un e1uipo con e'periencia de tro#$oendarterecto#"a6 sugieren tro#$oendarterecto#"a pul#onar so$re notro#$oendar -terecto#"a pul#onar :Drado 4C<)

8.( Tratamiento de los acientes con T7 su erficial H)5)5) En pacientes con tro#$osis venosa super0icial de la e'tre#idad in0erior de al #enos B c# de longitud6 se 8.1 Treat ent of Patients With 3uperficial $ein sugiere el uso de una dosis pro0il,ctica de 2BPM o 0ondaparinu' durante AB d"as so$re no- anticoagulacin Thro !os :grado 4B<) $.1.1. 1n patients with superfi cial vein thro (osis of H)5)4) En pacientes con TV super0icial tratados con the lower li ( of at least + c in length# we suggest the anticoagulacin6 sugeri#os 0ondaparinu' 46B #g al d"a use of a prophylactic dose of fondaparinu* or LMWH so$re dosis pro0il,ctica de 2BPM :4C<)

for 4+ days over no anticoagulation (Grade 2B) . $.1.6. 1n patients with superficial vein thro (osis who are treated with anticoagulation# we suggest fondaparinu* 6.+ g daily over a prophylactic dose of LMWH (2C) . #.1 'cute 'nticoagulation for Patients With 7@D$T ..1.1. 1n patients with >'=%& that involves the a*illary or ore pro*i al veins# we reco end acute treat ent with parenteral anticoagulation (LMWH# fondaparinu*# 1% >FH# or ,- >FH" over no such acute treat ent (Grade 1B) .

5.( 8nticoagulacin aguda ara acientes con 9)"7T L)5)5) En pacientes con &EDVT 1ue involucra a las venas a'ilares o #,s pro'i#ales6 se reco#ienda tto agudo con anticoagulacin parenteral :2BPM6 0ondaparinu'6 -eparina no 0raccionada intravenosa o -eparina no 0raccionada *C< so$re ausencia de dic-o trata#iento agudo :Drado 5B<) L)5)4) En pacientes con &EDVT aguda 1ue co#pro#ete las venas a'ilares o #,s pro'i#ales6 sugeri#os 2BPM o 0ondaparinu' so$re 2N. iv:Drado 4C< ( so$re 2N. sc :Drado 4B<)

5.' Tratamiento trom$oltico ara el tratamiento inicial de ..1.6. 1n patients with acute >'=%& that involves the acientes con 9)"7T a*illary or ore pro*i al veins# we suggest LMWH or L)4)5) En pacientes con &EDVT aguda 1ue co#pro#ete fondaparinu* over 1% >FH (Grade 2C) and over ,las venas a'ilares o #,s pro'i#ales6 se sugiere terapia >FH (Grade 2B) . anticoagulante sola6 so$re tro#$lisis :Drado 4C<) L)4)4) En pacientes con &EDVT 1ue se so#eten a tro#$olisis6 se reco#ienda la #is#a intensidad ( #.+ Thro !ol"tic Therap" for the (nitial duracin de la terapia anticoagulante 1ue en pacientes Treat ent of Patients With 7@D$T si#ilares 1ue no se so#eten a tro#$olisis :Drado 5B<) ..6.1. 1n patients with acute >'=%& that involves the a*illary or ore pro*i al veins# we suggest anticoagu lant therapy alone over thro (olysis (Grade 2C) . E7! Anticoag(laci/n a largo pla1o en pacientes con @HDVT ..6.6. 1n patients with >'=%& who undergo L)=)5) En la #a(or"a de los pacientes con &EDVT thro (olysis# we reco end the sa e intensity and asociada duration of anticoagulant therapy as in si ilar con un cat!ter venoso central6 sugeri#os 1ue no se 1uite patients who do not undergo thro (olysis (Grade 1B) . el cat!ter si es 0uncional ( -a( una necesidad continua de el cateter :Drado 4C<) L)=)4) En los pacientes con &EDVT 1ue involucra a las #.- Long.ter 'nticoagulation for Patients venas a'ilares o #,s pro'i#ales6 se sugiere una duracin With 7@D$T #"ni#a de la anticoagulacin de = #eses so$re un ..3.1. 1n ost patients with >'=%& that is associated per"odo #,s corto :Drado 4B<) with a central venous catheter# we suggest that the L)=)=) En pacientes 1ue tienen &EDVT est, asociada con catheter not (e re oved if it is functional and there is un cat!ter venoso central6 1ue se retira6 se reco#ienda = an ongoing need for the catheter (Grade 2C) . #eses de anticoagulacin so$re un per"odo #,s largo de ..3.6. 1n patients with >'=%& that involves the la terapia en pacientes sin c,ncer :Drado 5B<6 ( lo #is#o a*illary or ore pro*i al veins#we suggest a ini u en los pacientes con c,ncer :4C<) duration of anticoagulation of 3 onths over a shorter period (Grade 2B) . ..3.3. 1n patients who have >'=%& that is associated

33

with a central venous catheter that is re oved# we reco end 3 onths of anticoagulation over a longer duration of therapy in patients with no cancer (Grade 1B) # and we suggest this in patients with cancer (2C) .

847,3: )ppere;tre*#t= 7,3

34

..3.4. 1n patients who have >'=%& that is associated with a central venous catheter that is not re oved# we reco end that anticoagulation is continued as long as the central venous catheter re ains over stopping after 3 onths of treat ent in patients with cancer (Grade 1C) # and we suggest this in patients with no cancer (Grade 2C) . ..3.+. 1n patients who have >'=%& that is not associated with a central venous catheter or with cancer# we reco end 3 onths of anticoagulation over a longer duration of therapy (Grade 1B) . #.1 Pre6ention of PT3 of the 'r ..4. 1n patients with acute sy pto atic >'=%&# we suggest against the use of co pression sleeves or venoactive edications (Grade 2C) . #.4 Treat ent of Patients With PT3 of the 'r ..+.1. 1n patients who have 9&, of the ar # we suggest a trial of co pression (andages or sleeves to reduce sy pto s (Grade 2C) . ..+.6. 1n patients with 9&, of the ar # we suggest against treat ent with venoactive edications (Grade 2C) . 1/./ Patients With 3planchnic $ein Thro !osis 10.1. 1n patients with sy pto atic splanchnic vein thro (osis (portal# esenteric# and!or splenic vein thro (oses"# we reco end anticoagulation over no anticoagulation (Grade 1B) . 10.6. 1n patients with incidentally detected splanchnic vein thro (osis (portal# esenteric# and!or splenic vein thro (oses"# we suggest no anticoagulation over anticoagulation (Grade 2C) .

L)=)A) En pacientes 1ue tienen &EDVT asociada con un cat!ter venoso central 1ue no se 1uita6 se reco#ienda 1ue la anticoagulacin se #antenga #ientras el cat!ter venoso central se #antiene so$re interru#pirla a los = #eses de trata#iento en pacientes con c,ncer :Drado 5C<6 ( lo #is#o en los pacientes sin c,ncer : Drado 4C<) 9.3.5. 4$ pa"#e$te! >)e t#e$e$ 847,3 $o a!o"#ada "o$ )$ "at?ter /e$o!o "e$tra o "o$ "$"er, !e re"o*#e$da 3 *e!e! de a$t#"oag) a"#'$ !o%re )$a *a=or d)ra"#'$ de a terap#a (Grado 1B). 5.4 Pre%encin de la PT: del $ra*o L6A) En los pacientes con &EDVT sinto#,tica aguda6 se aconseja en contra del uso de #angas de co#presin o #edica#entos venoactivos :Drado 4C<) 5.5 Tratamiento de los acientes con PT: del $ra*o L)B)5) En pacientes con *TP del $ra+o6 sugeri#os una prue$a de vendajes de co#presin o #angas para reducir los s"nto#as :Drado 4C<) L)B)4) En los pacientes con *PT del $ra+o6 sugeri#os contra el trata#iento con #edica#entos venoactivos :Drado 4C<) (0.0 Pacientes con trom$osis %enosa es lcnica 5965) En pacientes con tro#$osis venosa sinto#,tica espl,cnica :#esent!rico portal6 ( % o tro#$osis de vena espl!nica<6 se reco#ienda la anticoagulacin so$re no anticoagulacin :Drado 5B<) 5964) En pacientes con tro#$osis de la vena espl,cnica detectado incidental#ente :tro#$osis de vena porta6 #esent!ricas6 ( % o espl!nica<6 sugeri#os no anticoagular6 so$re anticoagulacin :Drado 4C<)

((.0 Pacientes con trom$osis de la %ena #e tica 5565) En pacientes con tro#$osis sinto#,ticade la vena 11./ Patients With Hepatic $ein Thro !osis -ep,tica6 se sugiere anticoagulacin so$re no11.1. 1n patients with sy pto atic hepatic vein anticoagulacin :Drado 4C<) thro (osis# we suggest anticoagulation over no 5564) En pacientes con tro#$osis de la vena -ep,tica anticoagulation (Grade 2C) . detectada incidental#ente6 sugeri#os no anticoagular 6 11.6. 1n patients with incidentally detected hepatic vein so$re anticoagulacin :Drado 4C<)

thro (osis# we suggest no anticoagulation over anticoagulation (Grade 2C) .


P3S: po!tt:ro*%ot#" !=$dro*e

35

&reat ent and 9revention of Heparin71nduced &hro (ocytopenia +.1 Platelet ,ount Monitoring ,o !ined With the 1Ts 3core for Patients Recei6ing HeparinALMWH 6.1.1. For patients receiving heparin in who clinician consider the ris) of heparininduced thro (ocytopenia (H1&" to (e 5 1C# we suggest that platelet count onitoring (e perfor ed every 6 or 3 days fro day 4 to day 14 (or until heparin is stopped# whichever occurs first" (Grade 2C) . 6.1.6. For patients receiving heparin in who clinician consider the ris) of H1& to (e < 1C#we suggest that platelet counts not (e onitored (Grade 2C) .

Trata#iento ( Prevencin de Tro#$ocitopenia inducida por -eparina 2.1 Seg(imiento del rec(ento de pla'(etas en com6inaci/n con el .Ts score en pacientes '(e reci6en heparina I $, % 4)5)5) En pacientes 1ue reci$en -eparina en los 1ue los #!dicos consideren 1ue el riesgo de TI2 es K 5R6 se sugiere #onitori+ar las pla1uetas cada 4 = d"as a partir de d"a A al d"a 5A :o -asta 1ue la -eparina se suspenda6 lo 1ue ocurra pri#ero< :Drado 4C<) 4)5)4) Para los pacientes 1ue reci$en -eparina6 en los 1ue los #!dicos consideran 1ue el riesgo de TI2 en J5R6 se sugiere no #onitori+ar el recuento de pla1uetas :4C<)

-.1 Discontinuation of Heparin or (nitiation of $%'s 6s Treat ent With )onheparin 'nticoagulants 3.1. 1n patients with H1& co plicated (y thro (osis (H1&&"# we reco end the use of nonheparin anti coagulants# in particular lepirudin# argatro(an# and danaparoid# over the further use of heparin or LMWH !.2 Selecci/n de +on)heparin anticoag(lantes en pacientes or initiation!continuation ofa %/0 (Grade 1C) con $ITT =)4)5) En pacientes con 2ITT ( 0uncin renal nor#al6 se -.+ ,hoice of )onheparin 'nticoagulants in sugiere el uso de argatro$an o lepirudina o danaparoid so$re otros non--eparin anticoagulantes :4C<) Patients =)4)4) En pacientes con 2ITT e insu0iciencia renal6 With H(TT sugeri#os el uso de argatro$an so$re otros non--eparin 3.6.1. 1n patients with H1&& who have nor al renal anticoagulantes :Drado 4C<) function# we suggest the use of argatro(an or lepirudin or danaparoid over other nonheparin anticoagulants (Grade 2C) . !.! Transf(siones de pla'(etas 3.6.6. 1n patients with H1&& and renal insufficiency we =)= En pacientes con 2IT ( tro#$ocitopenia severa6 suggest the use of argatro(an over other nonheparin sugeri#os -acer trans0usiones de pla1uetas slo si se anticoagulants (Grade 2C) . presenta sangrado) o durante la ejecucin de un procedi#iento invasivo con alto riesgo de sangrado :4C<) -.- Platelet Transfusions 3.3 1n patients with H1& and severe thro (ocytopenia# !.. Bomien1o de AVK antes de la rec(peraci/n de pla'(etas =)A)5) En los pacientes con 0uerte sospec-a de 2IT6 o we suggest giving platelet transfusions only if (leeding con0ir#ada6 no se reco#ienda iniciar /V8 -asta 1ue las or during the perfor ance of an invasive procedure pla1uetas 1ue se -an recuperado sustancial#ente :es with a high ris) of (leeding (Grade 2C) . decir6 general#ente por lo #enos a 5B9)< vs utili+ar /V8
con un recuento $ajo de pla1uetas6 ad#inistra la /V8 a dosis $ajas inicial#ente :#,'i#o6 B #g de 7ar0arina o F -.1 3tarting $%'s *efore Platelet Reco6er" 3.4.1. 1n patients with strongly suspected or confir ed #g 0enprocu#on< vs el uso de dosis #,s altas :5C<) =)A)4) /de#,s6 sugeri#os 1ue si (a se -a$"a iniciado una H1&# we reco end against starting %/0 until platelets have su(stantially recovered (ie# usually to at /V8 cuando un paciente es diagnosticado de 2IT6 de$e least 1+0 x 10. !L"over starting %/0 at a lower platelet ad#inistrarse vita#ina 8 :Drado 4C<)

!.1 S(spensi/n de la heparina o iniciaci/n de AVK #s tratamiento con anticoag(lantes +on)heparin =65) En los pacientes con TI2 co#plicada con tro#$osis :2ITT<6 reco#enda#os el uso de anticoagulantes non-eparin6 en particular lepirudin6 argatro$an6 ( danaparoide6 so$re la continuacin del uso de -eparina o 2BPM6 o la iniciacin%continuacin de /V8 :Drado 5C<)

count and that the %/0 (e initially given in low doses ( a*i u # + g of warfarin or @ g phenprocou on" over using higher doses (Grade 1C) . 3.4.6. We further suggest that if a %/0 has already (een started when a patient is diagnosed with H1&# vita in / should (e ad inistered (Grade 2C) .

36

-.4 Discontinuation of Thro !in (nhi!itor 'fter a Mini u of 4 Da"s of 26erlap With $%'s 3.+. 1n patients with confi r ed H1&# we reco end that that the %/0 (e overlapped with a nonheparin anticoagulant for a ini u of + days and until the 123 is within the target range over shorter periods of overlap and that the 123 (e rechec)ed after the anti coagulant effect of the nonheparin anticoagulant has resolved (Grade 1C) . 1.1 Discontinuation of Heparin or (nitiation of $%'s 6s Treat ent With )onheparin 'nticoagulants 4.1. 1n patients with isolated H1& (H1& without thro (osis"# we reco end the use of lepirudin or argatro(an or danaparoid over the further use of heparin or LMWH or initiation!continuation of a %/0 (Grade 1C) .

!.8 Interr(pci/n del inhi6idor de la trom6ina desp(0s de (n mFnimo de 8 dFas de coincidencia con las AVK =6B) En los pacientes con 2IT con0i r#ada6 se reco#ienda 1ue la /V8 se superponga con un non-eparin anticoagulante durante un #"ni#o de B d"as6 ( -asta 1ue el IN; est, dentro del rango o$jetivo vs per"odos #,s cortos de superposicin6 ( 1ue el IN; sea revisado de nuevo despu!s de 1ue el e0ecto anticoagulante del anti coagulante non--eparin se -a(a resuelto :Drado 5C<) ..1 S(spensi/n de la heparina o iniciaci/n de AVK #s tratamiento con anticoag(lantes +on)heparin A65) En los pacientes con 2IT aislado :2IT sin tro#$osis<6 se reco#ienda el uso de lepirudina o argatro$an o danaparoid so$re continuar con -eparina o 2BPM o iniciacin % continuacin de /V8 :Drado 5C<) ..2 Hlecci/n de anticoag(lantes)+onheparin en pacientes con $IT aislada A64) En los pacientes con 2IT aislado :2ITsin tro#$osis< 1ue tienen una 0uncin renal nor#al6 se sugiere el uso de argatro$an o lepirudina o danaparoid so$re otros anticoagulantes non--eparin :Drado 4C<)

1.+ ,hoice of )onheparin 'nticoagulants in Patients With (solated H(T 4.6. 1n patients with isolated H1& (H1& without 8.1 acientes '(e re'(ieren cir(gFa cardFaca (rgente thro (osis" who have nor al renal function# we B)5)5) En pacientes con 2IT aguda :2IT tro#$ocitosuggest the use of argatro(an or lepirudin or danaparoid over other nonheparin anticoagulants (2C) p!nica6 anticuerpos-positivo< o 2IT su$aguda :pla1uetas recuperadas6 pero todav"a con 2IT anticuerpos-positivo< 1ue re1uieren cirug"a cardiaca urgente6 sugieren el uso 4.1 Patients Who Re?uire 7rgent ,ardiac de $ivalirudina #,s anticoagulantes-non-eparin so$re -eparina #,s antiagregantes pla1uetarios :Drado 4C<) 3urger" B)5)4) En pacientes con 2IT aguda 1ue re1uieren cirug"a +.1.1. 1n patients with acute H1& (thro (ocytopenic# card"aca no urgente6 reco#enda#os retrasar la cirug"a H1& anti(ody positive" or su(acute H1& (platelets recovered (ut still H1& anti(ody positive" who reAuire :si es posi$le< -asta 1ue tiene la 2IT resuelta ( los 2ITanticuerpos son negativos :Drado 4C<) urgent cardiac surgery# we suggest use of (ivalirudin over other nonheparin anticoagulants and over heparin plus antiplatelet agents (Grade 2C) . 8.2 acientes '(e re'(ieren Inter#encionismo coronario +.1.6. 1n patients with acute H1& who reAuire non7 perc(tCneo (rgente urgent cardiac surgery# we reco end delaying the B64) En los pacientes con 2IT aguda o 2IT su$aguda 1ue surgery (if possi(le" until H1& has resolved and H1& re1uieren intervenciones coronarias percut,neas6 se anti(odies are negative (see section @.1" (Grade 2C) . sugiere el uso de $ivalirudina :4B Drado< o argatro$ano
:Drado 4C< so$re otros anticoagulantes-non-eparin

4.+ Patients Who Re?uire 7rgent Percutaneous ,oronar" (nter6entions +.6. 1n patients with acute H1& or su(acute H1& who reAuire percutaneous coronary interventions# we suggest the use of (ivalirudin (Grade 2B) anticoagulants. 4.- Patients Who Re?uire Renal Replace ent Therap" +.3.1. 1n patients with acute or su(acute H1& who

8.! acientes '(e re'(ieren terapia de reempla1o renal B)=)5) En los pacientes con 2IT aguda o su$aguda 1ue re1uieren terapia de ree#pla+o renal6 sugieren el uso de argatro$an o danaparoid so$re otros anticoagulantes non--eparin :Drado 4C<) B)=)4) En pacientes con antecedentes de 2IT6 1ue re1uieren iniciar terapia de ree#pla+o renal o de cat!ter cerrado6 se sugiere el uso de citrato regional so$re el uso de -eparina o 2BPM :Drado 4C<)

37

reAuire renal replace ent therapy# we suggest the use of argatro(an or danaparoid over other nonheparin anticoagulants (Grade 2C) . +.3.6. 1n patients with a past history of H1& who reAuire ongoing renal replace ent therapy or catheter loc)ing# we suggest the use of regional citrate over the use of heparin

38

4.1 Pregnant Patients +.4. 1n pregnant patients with acute or su(acute H1&# we suggest danaparoid over other nonheparin anti 7coagulants (2C) . We suggest the use of lepirudin or fondaparinu* only if danaparoid is not availa(le (2C) . 5.1 Patients With a Histor" of H(T Who Re?uire ,ardiac 3urger" @.1.1. 1n patients with a history of H1& in who heparin anti(odies have (een shown to (e a(sent who reAuire cardiac surgery# we suggest the use of heparin (short7ter use only" over nonheparin anticoagulants (Grade 2C), or LMWH (Grade 2C) . @.1.6. 1n patients with a history of H1& in who heparin anti(odies are still present who reAuire cardiac surgery# we suggest the use of nonheparin anticoagulants (see +.1.1" over heparin or LMWH (Grade 2C) . 5.+ Patients Who Re?uire P,( @.6. 1n patients with a history of H1& in who heparin anti(odies have (een shown to (e a(sent who reAuire cardiac catheteri:ation or percutaneous coronary interventions# the reco ended treat ent is the sa e as +.6. 5.- Patients Who Re?uire Proph"laxis or Treat ent of Thro !osis @.3. 1n patients with a past history of H1& who have acute thro (osis (not related to H1&" and nor al renal function# we suggest the use of fondaparinu* at full therapeutic doses until transition to a %/0 can (e achieved (Grade 2C) .

8.. acientes em6ara1adas B6A) En pacientes e#$ara+adas con 2IT aguda o su$aguda6 sugeri#os danaparoid so$re otros anticoagulantes non--eparin :Drado 4C<) *ugeri#os el uso de lepirudina o 0ondaparinu' slo si danaparoid no est, disponi$le :Drado 4C<) 9.1 acientes con antecedentes de TI$ '(e re'(ieren cir(gFa Bardiaca F)5)5) En pacientes con antecedentes de TI2 en los 1ue los anticuerpos--eparina est,n ausentes6 ( 1ue re1uieren cirug"a cardiaca6 se sugiere el uso de -eparina :uso a corto pla+o sola#ente< so$re anticoagulantes non--eparin :Drado 4C<) F)5)4) En pacientes con antecedentes de TI2 en los 1ue los anticuerpos -eparina est,n presentes ( 1ue re1uieren cirug"a cardiaca6 se sugiere el uso de non-eparinanticoagulantes :ver B)5)5< #ejor 1ue la -eparina o la 2BPM :Drado 4C<) 9.2 acientes '(e re'(ieren BI F64) En pacientes con antecedentes de TI2 en los 1ue los anticuerpos--eparina -an de#ostrado estar ausentes 1ue re1uieren un cateteris#o card"aco o intervenciones coronarias percut,neas6 el trata#iento reco#endado es el #is#o 1ue en B64) 9.! acientes '(e re'(ieren profilaDis o tratamiento de Trom6osis F6=) En los pacientes con antecedentes de 2IT6 1ue tienen tro#$osis aguda :no relacionada con 2IT< ( 0uncin renal nor#al6 se sugiere el uso de 0ondaparinu' a dosis terap!uticas co#pletas -asta 1ue pueda lograrse transicin a una /V8 :Drado 4C<)

39

0ntithro (otic &herapy for 0trial Fi(rillation +.1 Patients With )onrheu atic 'trial Fi!rillation <'F= 6.1.$. For patients with 0F# including those with paro*ys al 0F# who are at low ris) of stro)e (eg# -H0=, 2 ;congestive heart failure# hypertension# age > 7+ years# dia(etes ellitus# prior stro)e or transient ische ic attac)< score 0"# we suggest no therapy rather than antithro (otic therapy (Grade 2B). For patients who do choose antithro (otic therapy# we suggest aspirin (7+ g to 36+ g once daily" rather than oral anticoagulation (Grade 2B) or co (ination therapy with aspirin and clopidogrel (2B)

Trata#iento antitro#$tico para la 0i$rilacin auricular

2.1 acientes con &A no re(mCtica


4)5)H) En pacientes con ./6 inclu(endo a1uellos con ./ paro'"stica6 1ue se encuentran en $ajo riesgo de accidente cere$rovascular :por ej6 puntuacin C2/D*4 MI card"aca congestiva6 -ipertensin6 edad K GB aUos6 dia$etes #ellitus6 antecedentes de ictus o ata1ue is1u!#ico transitorioN de 96 se sugiere no-terapia en lugar de terapia antitro#$tica :Drado 4B<) Para los pacientes 1ue eligen terapia antitro#$tica6 sugieren aspirina :GB #g a =4B #g una ve+ al d"a< en lugar de anticoagulantes orales :Drado 4B<6 o co#$inacin de terapia con aspirina ( clopidogrel :Drado 4B<)

4)5)L) Para los pacientes con ./6 inclu(endo a1uellos con ./ paro'"stica6 1ue tienen un riesgo inter#edio de 6.1... For patients with 0F# including those with accidente cere$rovascular :por eje#plo6 C2/D* 4 de 5<6 paro*ys al 0F# who are at low ris) of stro)e (eg# -H0=, 2 ;congestive heart failure# hypertension# age 5 se reco#ienda anticoagulacin oral6 #ejor 1ue ning n trata#iento :Drado 5B<) *ugeri#os anticoagulacin oral 7+ years# dia(etes ellitus# prior stro)e or transient en lugar de aspirina :GB #g a =4B #g una ve+ al d"a< ische ic attac)< score 5 0"# we suggest no therapy :Drado 4B< o terapia de co#$inacin con aspirina ( rather than antithro (otic therapy (Grade 2B) . For clopidogrel :Drado 4B<) Para los pacientes 1ue no son patients who do choose antithro (otic therapy# we adecuados o deciden no to#ar anticoagulantes orales :por suggest aspirin (7+ g to 36+ g once daily" rather ra+ones distintas de las preocupaciones de -e#orragia than oral anticoagulation (Grade 2B) or co (ination #a(or<6 se sugiere la co#$inacin de aspirina ( therapy with aspirin and clopidogrel (Grade 2B) . For clopidogrel en lugar de aspirina :GB #g a =4B #g una ve+ patients who are unsuita(le for or choose not to ta)e al d"a< :Drado 4B<)

an oral anticoagulant (for reasons other than concerns a(out a8or (leeding"# we suggest co (ination 4)5)59) Para los pacientes con ./6 inclu(endo a1uellos con therapy with aspirin and clopidogrel rather than ./ paro'"stica6 1ue est,n en alto riesgo de accidente aspirin (7+ g to 36+ g once daily"(Grade 2B) . cere$rovascular :Por eje#plo6 C2/D* 4 de 4<6 se reco#ienda anticoagulacin oral #ejor 1ue ning n trata#iento :Drado 5/<6 aspirina :GB #g a =4B #g una 6.1.10. For patients with 0F# including those with ve+ al d"a< :Drado 5B<6 o una co#$inacin de aspirina ( paro*ys al 0F# who are at high ris) of stro)e (eg# clopidogrel :Drado 5B<) Para los pacientes 1ue no son -H0=, 2 score 5 6"# we reco end oral anticoagul adecuados o eligen no to#ar un anticoagulante oral :por ation rather than no therapy (Grade 1$) # aspirin (7+ g to 36+ g once daily" (Grade 1B) # or co (ination ra+ones distintas a las preocupaciones so$re sangrado therapy with aspirin and clopidogrel (Grade 1B) . For i#portante<6 se reco#ienda la terapia de co#$inacin con aspirina ( clopidogrel en lugar de aspirina :GB #g a patients who are unsuita(le for or choose not to ta)e an oral anticoagulant (for reasons other than concerns =4B #g una ve+ al d"a< :Drado 5B<) a(out a8or (leeding"# we reco end co (ination 4)5)55) Para los pacientes con ./6 inclu(endo ./ therapy with aspirin and clopidogrel rather than paro'"stica6 con reco#endaciones a 0avor de la aspirin (7+ g to 36+ g once daily" (Grade 1B) . anticoagulacin oral :incluidos los 4)5)L6 4)5)596 ( 6.1.11. For patients with 0F# including those with paro*ys al 0F# for reco endations in favor of oral anticoagulation (including 6.1..# 6.1.10# and e*cluding 6.6# 3.1# 3.6# 3.3"# we suggest da(igatran 1+0 g twice daily rather than ad8usted7dose %/0 therapy (target 123 range# 6.073.0" (Grade 2B) .
e'clu(endo 4)46 =)56 =)46 =)=<6 sugeri#os da$igatr,n 5B9 #g dos veces al d"a en lugar de dosis ajustadas de trata#iento con /V8 :IN; rango6 469-=69< :Drado 4B<) V$servaciones: El da$igatr,n se eli#ina principal#ente por el riUn) No se -a estudiado ( est, contraindicado en pacientes con insu0iciencia renal grave :aclara#iento de creatinina esti#ado de =9 #l % #in o #enos<) >os #!dicos de$en ser conscientes de 1ue no e'iste un ant"doto de da$igatr,n)

40

+.+ Patients With 'F and Mitral 3tenosis 6.6. For patients with 0F and itral stenosis# we reco end ad8usted7dose %/0 therapy (target 123 range# 6.073.0" rather than no therapy# aspirin (7+ g to 36+ g once daily"# or co (ination therapy with aspirin and clopidogrel (all Grade 1B) . For patients with 0F and itral stenosis who are unsuita(le for or choose not to ta)e ad8usted7dose %/0 therapy (for reasons other than concerns a(out a8or (leeding"# we reco end co (ination therapy with aspirin and clopidogrel rather than aspirin (7+ g to 36+ g once daily" alone (Grade 1B) . -.1 Patients With 'F and 3ta!le ,oronar" 'rter" Disease 3.1. For patients with 0F and sta(le coronary artery disease (eg# no acute coronary syndro e within the previous year" and who choose oral anticoagulation# we suggest ad8usted7dose %/0 therapy alone (target international nor ali:ed ratio ;123< range# 6.073.0" rather than the co (ination of ad8usted7dose %/0 therapy and aspirin (Grade 2C) .

2.2 acientes con fi6rilaci/n a(ric(lar y estenosis mitral 464) En pacientes con estenosis #itral ( ./6 reco#iendan trata#iento con dosis ajustadas de /V8 :o$jetivo IN; de 469 a =69< en ve+ de no-trata#iento6 aspirina :GB #g a =4B #g una ve+ al d"a<6 o una co#$inacin de aspirina ( clopidogrel :Drado 5B<) Para los pacientes con 0i$rilacin auricular ( estenosis #itral 1ue no son adecuados o deciden no to#ar dosis ajustadas de /V8 :por ra+ones 1ue no sean la preocupacin por -e#orragia #a(or<6 reco#iendan terapia de co#$inacin con aspirina ( clopidogrel en lugar de aspirina :GB #g a =4B #g una ve+ al d"a< sola :Drado 5B<)
!.1 acientes con &A y enfermedad arterial coronaria esta6le =65) En pacientes con ./ ( en0er#edad coronaria esta$le :por eje#plo6 ausencia de s"ndro#e coronario agudo en el aUo anterior< ( 1ue optan por anticoagulacin por v"a oral6 sugieren dosis ajustadas de /V8 unica#ente :IN; rango6 469-=69< #ejor 1ue la co#$inacin de dosis ajustadas de /V8 ( aspirina :Drado 4C<)

!.2 acientes con &A y colocaci/n de (n Stent intracoronario -.+ Patients With 'F and Place ent of an =64) En pacientes con ./ con alto riesgo de accidente cere$rovascular :por eje#plo6 C2/D* 4 de 4 o #,s< (ntracoronar" durante el pri#er #es despu!s de la colocacin de un 3tent stent convencional6 o = a F #eses despu!s de la colocacin 3.6. For patients with 0F at high ris) of stro)e (eg# de un stent li$erador de 0,r#aco6 sugiern triple terapia -H0=, 2 score of 6 or greater" during the fi rst onth :por eje#plo6 trata#iento con /V86 aspirina ( after place ent of a (are7 etal stent or the fi rst 3 to @ clopidogrel< en lugar de terapia antipla1uetaria dual onths after place ent of a drug7eluting stent# we :por eje#plo6 p aspirina ( clopidogrel< :Drado 4C<) suggest triple therapy (eg# %/0 therapy# aspirin# and Despu!s de este per"odo inicial de triple terapia6 sugieren clopidogrel" rather than dual antiplatelet therapy (eg# una /V8 :IN; 4)9-=)9<6 ade#,s de un solo antiagregante aspirin and clopidogrel" (Grade 2C) . 0fter this initial pla1uetario #ejor 1ue una /V8 sola :Drado 4C<) 54 period of triple therapy# we suggest a %/0 (123 6.07 #eses despu!s de la colocacin de un stent 3.0" plus a single antiplatelet drug rather than %/0 intracoronario6 se sugiere terapia antitro#$tica co#o alone (Grade 2C) . 0t 16 onths after intracoronary para los pacientes con ./ ( en0er#edad coronaria esta$le stent place ent# antithro (otic therapy is suggested :ver seccin =)5<)

as for patients with 0F and sta(le coronary artery disease (see section 3.1". For patients with 0F at low to inter ediate ris) of stro)e (eg# -H0=, 6 score of 0 or 1" during the fi rst 16 onths after place ent of an intracoronary stent ((are etal or drug eluting"# we suggest dual antiplatelet therapy rather than triple therapy (?rade 6-" . 0t 16 onths after intracoronary stent place ent# antithro (otic therapy is suggested as for patients with 0F and sta(le coronary artery disease (see section 3.1".

En pacientes con ./ en riesgo $ajo a inter#edio de accidente cere$rovascular :por eje#plo6 C2/D* 4 de 9 5< durante los pri#eros 54 #eses despu!s de la colocacin de un stent intracoronario :de #etal desnudo o li$erador de 0,r#acos<6 sugieren terapia antipla1uetaria dual en lugar de terapia triple :Drado 4C<) / los 54 #eses despu!s de la colocacin de stent intracoronario6 se sugiere terapia antitro#$tica igua@l a la de los pacientes con ./ ( en0er#edad arterial coronaria esta$le :ver seccin =)5<)

41

-.- Patients With 'F and ',3 Who Do )ot 7ndergo (ntracoronar" 3tent Place ent 3.3. For patients with 0F at inter ediate to high ris) of stro)e (eg# -H0=, 2 score of 1 or greater" who e*perience an acute coronary syndro e and do not undergo intracoronary stent place ent# we suggest for the fi rst 16 onths# ad8usted7dose %/0 therapy (123 6.073.0" plus single antiplatelet therapy rather than dual antiplatelet therapy (eg# aspirin and clopidogrel" or triple therapy (eg# warfarin# aspirin# and clopidogrel (Grade 2C) . 0fter the first 16 onths# antithro (otic therapy is suggested as for patients with 0F and sta(le coronary artery disease (see section 3.1". For patients with 0F at low ris) of stro)e (eg# -H0=, 2 score of 0"# we suggest dual antiplatelet therapy (eg# aspirin and clopidogrel" rather than ad8usted7dose %/0 therapy (123 6.073.0" plus single antiplatelet therapy or triple therapy (eg# warfarin# aspirin# and clopidogrel" (Grade 2C) . 0fter the fi rst 16 onths# antithro (otic therapy is suggested as for patients with 0F and sta(le coronary artery disease (see section 3.1". -.1 Patients With 'F Managed !" a Rh"th ,ontrol 3trateg" 3.4. For patients with 0F (eing anaged with a rhyth control strategy (phar acologic or catheter a(lation"# we suggest that antithro (otic therapy decisions follow the general ris)7(ased reco endatio for patients with 0F in section 6.1# regardless of the apparent persistence of nor al sinus rhyth (2C) .

!.! acientes con &A y ABS '(e no sometidos a colocaci/n de stent intracoronario
=6=) Para los pacientes con ./ en riesgo inter#edio ( alto de accidente cere$rovascular :por eje#plo6 C2/D* 4 de 5 #,s< 1ue su0ren un s"ndro#e coronario agudo ( no se so#eten a la colocacin de un stent intracoronario6 sugeri#os para los pri#eros 54 #eses6 trata#iento con dosis ajustadas de /V8 :IN; 4)9-=)9<6 #,s terapia antipla1uetaria nica en lugar de do$le antiagregacin :por eje#plo6 aspirina ( clopidogrel<6 o terapia triple :por eje#plo6 7ar0arina6 aspirina ( clopidogrel< :Drado 4C<) Despu!s de los pri#eros 54 #eses6 se sugiere terapia antitro#$tica co#o en los pacientes con ./ ( en0er#edad coronaria esta$le :ver seccin =)5<) Para los pacientes con ./ con $ajo riesgo de accidente cere$rovascular :por eje#plo6 C2/D* 4 de 9<6 sugeri#os do$le antiagregacin :por ej) aspirina ( clopidogrel< 6 en lugar de dosis ajustadas de trata#iento con /V8 :IN; 4)9-=)9< #,s trata#iento antipla1uetario solo o triple terapia :Por eje#plo6 7ar0arina6 aspirina ( clopidogrel< :Drado 4C<) Despu!s de los pri#eros 54 #eses6 se sugiere terapia antitro#$tica co#o para los pacientes con ./ ( en0er#edad arterial coronaria esta$le :ver seccin =)5<)

!.. acientes con &A mane2ados con estrategia de control del ritmo
=6A) En pacientes con ./ con estrategia de control del rit#o :0ar#acolgico o a$lacin con cat!ter<6 sugeri#os 1ue las decisiones so$re la terapia antitro#$tica sigan las reco#endacione generales $asadas en el riesgo de los pacientes con ./ en la seccin 4656 independiente#ente de la aparente persistencia de rit#o sinusal nor#al :4C<)

!.8 acientes con &l(tter a(ric(lar


=6B) En pacientes con .lutter auricular6 sugeri#os 1ue las decisiones so$re la terapia antitro#$tica sigan las #is#as reco#endaciones 1ue para ./ $asadas en riesgo)

-.4 Patients With 'trial Flutter 3.+. For patients with atrial fl utter# we suggest that ..1 acientes sometidos a cardio#ersi/n electi#a de la &A antithro (otic therapy decisions follow the sa e ris)7 A)5)5) En pacientes con ./ de #,s de AH -oras o de (ased reco endations as for 0F. duracin desconocida so#etidos a cardioversin electiva 0ar#acolgica o el!ctrica6 se reco#ienda anticoagulacin 1.1 Patients 7ndergoing @lecti6e ,ardio6ersion terap!utica :trata#iento con dosis ajustadas de /V86 para o$jetivo de IN; 4)9-=)96 2BPM a dosis co#pletas de of 'F trata#iento de tro#$oe#$olis#o venoso6 da$igatr,n< 4.1.1. For patients with 0F of greater than 4$ h or durante al #enos = se#anas antes de la cardioversin o un)nown duration undergoing elective electrical or un en0o1ue guiado por ecocardiogra0"a transeso0,gica phar acologic cardioversion# we reco end therap :ETE< con anticoagulacin a$reviada antes de la eutic anticoagulation (ad8usted7dose %/0 therapy# cardioversin en lugar de no-anticoagulacin :Drado 5B<) target 123 range 6.073.0# low7 olecular7weight *e reco#ienda anticoagulacin terap!utica durante al heparin at full venous thro (oe (olis treat ent #enos A se#anas despu!s de la cardioversin con !'ito a doses# or da(igatran" for at least 3 wee)s (efore cardio rit#o sinusal #ejor 1ue no-nticoagulacin6 con version or a transesophageal echocardio graphy (&''" independencia del riesgo $asal de /CV :Drado 5B<) 7 guided approach with a((reviated anticoagulation (efore cardioversion rather than no anticoagulation (1B) . We reco end therapeutic anticoagulation for at least 4 wee)s after successful cardioversion to sinus

42

rhyth rather than no anticoagulation# regardless of the (aseline ris) of stro)e (Grade 1B)

43

=ecisions a(out anticoagulation (eyond 4 wee)s should (e ade in accordance with our ris)7(ased reco endations for long7ter antithro (otic therapy in section 6.1. 4.1.6. For patients with 0F of docu ented duration of 4$ h or less undergoing elective cardioversion (electrical or phar acologic"# we suggest starting anticoagulation at presentation (low7 olecular7weight heparin or unfractionated heparin at full venous thro (oe (olis treat ent doses" and proceeding to cardioversion rather than delaying cardioversion for 3 wee)s of therapeutic anticoagulation or a &''7 guided approach (Grade 2C) . 0fter successful cardio version to sinus rhyth # we reco end therapeutic anticoagulation for at least 4 wee)s rather than no anticoagulation# regardless of (aseline stro)e ris) (2C) =ecisions a(out long7ter anticoagulation after cardioversion should (e ade in accordance with our ris)7(ased reco endations for long7ter antithro (otic therapy in section 6.1. 1.+ Patients 7ndergoing 7rgent ,ardio6ersion for He od"na icall" 7nsta!le 'F 4.6. For patients with 0F and he odyna ic insta(ility undergoing urgent cardioversion (electrical or phar acologic"# we suggest that therapeutic7dose parenteral anticoagulation (e started (efore cardioversion# if possi(le (Grade 2C) # (ut that initiation of anticoagulation ust not delay any e ergency intervention (Grade 2C) . 0fter successful cardioversion to sinus rhyth # we suggest therapeutic anticoagulation for at least 4 wee)s after successful cardioversion to sinus rhyth rather than no anticoag ulation# regardless of (aseline stro)e ris) (Grade 2C) . =ecisions a(out anticoagulation (eyond 4 wee)s should (e ade in accordance with our ris)7(ased reco endations for long7ter antithro (otic therapy in section 6.1. 1.- Patients 7ndergoing @lecti6e or 7rgent ,ardio6ersion for 'trial Flutter 4.3. For patients with atrial flutter undergoing elective or urgent phar acologic or electrical cardioversion# we suggest that the sa e approach to thro (oprophyla*is (e used as for patients with atrial fi (rillation undergoingcardioversion.

>as decisiones so$re anticoagulacin #,s all, de A se#anas de$e -acerse de acuerdo con las reco#enda -ciones de terapia antitro#$tica $asadas en riesgo a largo pla+o de la seccin 4)5) A)5)4) En pacientes con ./ de duracin docu#entada de AH -oras o #enos so#etidos a cardioversin electiva :el!ctrica o 0ar#acolgica<6 sugeri#os anticoagulacin a partir de la presentacin :-eparina de $ajo peso #olecular o -eparina no 0raccionada en dosis co#pletas de trata#iento de tro#$oe#$olis#o venoso< ( proceder a la cardioversin en lugar de retrasar la cardioversin durante = se#anas de anticoagulacin terap!utica o un en0o1ue guiado por ETE :Drado 4C<) Tras el !'ito de la cardioversin rit#o sinusal6 se reco#ienda anticoagula -cin terap!utica durante al #enos A se#anas en lugar de no anticoagulacin6 con independencia del riesgo $asal de accidente cere$rovascular :4C< >as decisiones so$re anticoagulacin a largo pla+o despu!s de la cardioversin de$en to#arse de acuerdo con nuestras reco#endaciones $asadas en el riesgo a largo pla+o la terapia antitro#$tica en la seccin 4)5)

..2 acientes sometidos a cardio#ersi/n de emergencia por &A h$emodinCmicamente inesta6le A64) En pacientes con ./ e inesta$ilidad -e#odin,#ica candidatos a cardioversin urgente :el!ctrica o 0ar#acolgica<6 se sugiere 1ue las dosis terap!uticas de anticoagulacin parenteral se inicien antes de la cardioversin6 si es posi$le :Drado 4C<6 pero 1ue el inicio de la anticoagulacin no de$e retrasar la intervencin de e#ergencia :Drado 4C <) Despu!s de una cardioversin con !'ito a rit#o sinusal6 se aconseja la anticoagulacin terap!utica durante al #enos A se#anas despu!s del !'ito cardioversin a rit#o sinusal en lugar de no anticoagular6 independiente#ente del riesgo $asal de /CV :Drado 4C<) >as decisiones so$re anticoagulacin #,s all, de A se#anas de$e -acerse de acuerdo con nuestras reco#endaciones so$re terapia antitro#$tica a largo pla+o $asadas en el riesgo de la seccin 4)5 ) ..! acientes sometidos a cardio#ersi/n electi#a o de (rgencia para fl(tter a(ric(lar A6=) En pacientes con .lutter auricular candidatos a cardioversinlectiva o urgente 0ar#acolgica o el!ctrica6 sugeri#os el #is#o en0o1ue de tro#$opro0ila'is usado para los pacientes con ./ so#etidos a cardioversin)

44

0ntithro (otic and &hro (olytic &herapy for %alvular =isease +./ Patients With Rheu atic Mitral $al6e Disease 6.0.1. 1n patients with rheu atic itral valve disease and nor al sinus rhyth with a left atrial dia eter <++ we suggest not using antiplatelet or %/0 ther apy (Grade 2C) . 6.0.6. 1n patients with rheu atic itral valve disease and nor al sinus rhyth with a left atrial dia eter 5++ # we suggest %/0 therapy (target 123# 6.+D range# 6.073.0" over no %/0 therapy or antiplatelet (Grade 2C) .

Terapia /ntitro#$tica ( Tro#$ol"tica para la En0er#edad Valvular 2.> acientes con enfermedades re(mCticas de la VCl#(la %itral 4)9)5) En pacientes con en0er#edades reu#,tica de la v,lvula #itral ( rit#o sinusal nor#al6 con di,#etro de aur"cula i+1uierda J BB ##6 sugeri#os no utili+ar trata#iento antiagregante o con /V8 :Drado 4C<)
4)9)4) En pacientes con en0er#edades reu#,ticas de la v,lvula #itral ( rit#o sinusal nor#al6 con un di,#etro de aur"cula i+1uierda K BB ##6 se sugiere trata#iento con /V8 :IN; o$jetivo de 46B6 rango6 469-=69< so$re no trata#iento con /V86 o antiagregante pla1uetario :4C< )

4)9)=) En pacientes con valvulopat"a #itral reu#,tica co#plicada por la presencia de tro#$o auricular i+16 se 6.0.3. For patients with rheu atic itral valve disease reco#ienda trata#iento con /V8 :IN; o$jetivo de 46B6 co plicated (y the presence of left atrial thro (us# we rango6 469-=69< so$re no - trata#iento con /V8 :5/<) reco end %/0 therapy (target 123# 6.+D range# 6.07

3.0" over no %/0 therapy (Grade 1$) . 6.0.4. For patients with rheu atic itral valve disease co plicated singly or in co (ination (y the presence of atrial fi (rillation or previous syste ic e (olis # we reco end %/0 therapy (target 123# 6.+D range# 6.073.0" over no %/0 therapy (Grade 1$) .

4)9)A) En pacientes con valvulopat"a #itral reu#,tica co#plicadada6 por separado o en co#$inacin6 con .i$rilacin auricular o E#$olia sist!#ica previa6 se reco#ienda trata#iento con /V8 :IN; o$jetivo de 46B6 rango de 469 a =69< vs no - trata#iento con /V8 :5/<)

+.1 Patients With Rheu atic Mitral $al6e Disease 7ndergoing Percutaneous Mitral *alloon $al6oto " <PM*$= 6.1.1. For patients (eing considered for 9MH% with preprocedural &'' showing left atrial thro (us# we 4)5)4) Para pacientes 1ue est,n siendo considerados para reco end postpone ent of 9MH% and that %/0 PMBV6 con una ETE pre-procedi#iento 1ue #uestre therapy (target 123# 3.0D range# 6.+73.+" (e tro#$o auricular i+1uierdo6 si el tro#$o auricular ad inistered until thro (us resolution is docu ented i+1uierdo no se resuelve con el trata#iento con /V86 (y repeat &'' over no %/0 therapy (Grade 1$) . reco#enda#os no llevar a ca$o la PMBV :grado 5/<) 6.1.6. For patients (eing considered for 9MH% with 9.2 acientes con &" y ane(risma del sept(m preprocedural &'' showing left atrial thro (us# if intera(ric(lar the left atrial thro (us does not resolve with %/0 therapy# we reco end that 9MH% not (e perfor ed F)4)4) En los pacientes con ictus criptog!nico ( .VP6 o aneuris#a del septo auricular6 se reco#ienda aspirina (Grade 1$) . :B9-599 #g % d"a< vs no - aspirina :grado 5/<) 5.+ Patients With PF2 and 'trial 3eptal F)4)5) En pacientes asinto#,ticos con 0ora#en oval per#ea$le :.VP< o aneuris#a del septu# interauricular6 'neur"s @.6.6. 1n patients with cryptogenic stro)e and 9FF or sugeri#os en contra de la terapia antitro#$tica :4C<) atrial septal aneurys # we reco end aspirin (+07100 g!d" over no aspirin (Grade 1$) . @.6.1. 1n patients with asy pto atic patent fora en ovale (9FF" or atrial septal aneurys # we suggest against antithro (otic therapy (Grade 2C) . PM*$B Percutaneous Mitral *alloon $al6oto " BC $al6uloto Da Mitral PercutEnea con *alFn.

2.1 acientes con enfermedad re(mCtica de la #Cl#(la mitral sometidos a #al#(lotomFa mitral perc(tCnea con 6al/n ( %,V) 4)5)5) Para pacientes 1ue est,n siendo considerados para PMBV6 con una ETE pre-procedi#iento 1ue #uestre tro#$o auricular i+1uierdo6 se reco#ienda apla+ar la PMBV ( terapia con /V8 :IN;6 =)96 rango de 4)B a =)B< -asta 1ue la resolucin del tro#$o se docu#enta en ETE repetida6 vs no - trata#iento con /V8 :Drado 5/<)

45

T@@ B Transesophageal @chocardiograph"G BC @T@; @cocardiografDa TransesofEgica. PF2 B Patent Fora en 26ale F2P

@.6.3. 1n patients with cryptogenic stro)e and 9FF or atrial septal aneurys # who e*perience recurrent events despite aspirin therapy# we suggest treat ent with %/0 therapy (target 123# 6.+D range# 6.073.0" and consideration of device closure over aspirin therapy (Grade 2C) . @.6.4. 1n patients with cryptogenic stro)e and 9FF# with evidence of =%&# we reco end %/0 therapy for 3 onths (target 123# 6.+D range# 6.073.0" (Grade 1B) and consideration of device closure over no %/0 therapy or aspirin therapy (Grade 2C) .

F)4)=) En pacientes con ictus criptog!nico ( .VP o aneuris#a del septo auricular6 1ue e'peri#entan eventos recurrentes a pesar de terapia con aspirina6 se sugiere trata#iento con /V8 :IN; o$jetivo de 46B6 rango6 469=69< ( considerar colocar un dispositivo de cierre vs terapia con aspirina :Drado 4C<) F)4)A) En pacientes con ictus criptog!nico ( .VP6 con evidencia de tro#$osis venosa pro0unda6 se reco#ienda terapia con /V8 durante = #eses :IN; o$jetivo de 46B6 rango de 469 a =69< :Drado 5B< ( considerar colocar un dispositivo de cierre6 vs no - trata#iento /V8 o terapia con aspirina :4C<)

7.1 Role of 'nticoagulants and 'ntiplatelet 'gents in Patients With )ati6e $al6e @ndocarditis 7.1.1. 1n patients with infective endocarditis (1'"# we reco end against routine anticoagulant therapy# unless a separate indication e*ists (Grade 1C) . 7.1.6. 1n patients with 1'# we reco end against routine antiplatelet therapy# unless a separate indication e*ists (Grade 1B) .

7.1 Pape de o! a$t#"oag) a$te! = a$t#agrega$te! p a>)e@ tar#o! e$ pa"#e$te! "o$ e$do"ard#t#! de / /) a $at#/a G)5)5) En pacientes con endocarditis in0ecciosa :EI<6 no se reco#ienda el trata#iento anticoagulante de rutina6 a #enos 1ue e'ista una indicacin por separado :Dr 5C<)
G)5)4) En pacientes con endocarditis in0ecciosa6 no se reco#ienda la terapia antipla1uetaria de rutina6 a #enos 1ue e'ista una indicacin por separado :Drado 5B<)

7.2 Pape de o! a$t#"oag) a$te! e$ pa"#e$te! "o$ 4$do"ard#t#! !o%re / /) a prot?!#"a G64) En pacientes tratados con /V8 por v,lvula prot!sica6 7.+ Role of 'nticoagulants in Patients With 1ue desarrollan EI6 sugeri#os interru#pir la /V8 en el Prosthetic #o#ento de la presentacin inicial -asta 1ue 1uede claro $al6e @ndocarditis 1ue no ser,n necesarios procedi#ientos invasivos ( el 7.6. 1n patients on %/0 for a prosthetic valve who paciente se -a(a esta$ili+ado6 sin signos de a0ectacin del develop 1'# we suggest %/0 (e discontinued at the *NC) Cuando el paciente se considere esta$le6 sin ti e of initial presentation until it is clear that invasive contraindicaciones o co#plicaciones neurol- gicas6 procedures will not (e reAuired and the patient has sugeri#os reinstauracin del trata#iento con /V8 sta(ili:ed without signs of -2, involve ent. When the :Drado 4C<) patient is dee ed sta(le without contraindications or neurologic co plications# we suggest reinstitution of 7.3 Pa"#e$te! "o$ e$do"ard#t#! tro*%'t#"a $o %a"ter#a$a %/0 therapy (Grade 2C) . G6=) En los pacientes con endocarditis tro#$tica no $acteriana ( e#$olia sist!#ica o pul#onar6 se sugiere trata#iento con dosis co#pletas de 2N. o 2BPM IV sc6 so$re ausencia de anticoagulacin :Drado 4C<) 7.- Patients With )on!acterial Thro !otic @ndocarditis 7.3. 1n patients with non(acterial thro (otic endocarditis and syste ic or pul onary e (oli# we suggest treat ent with full7dose 1% >FH or ,LMWH over no anticoagulation (Grade 2C) . 8.+ 'ntithro !otic Therap" in the First Months 'fter 3urger" $.6.1. 1n patients with aortic (ioprosthetic valves# who are in sinus rhyth and have no other indication for %/0 therapy# we suggest aspirin (+07100 g!d" over %/0 therapy in the fi rst 3 onths (Grade 2C) . 8.2 3rata*#e$to a$t#tro*%'t#"o e$ o! pr#*ero! 3 *e!e! de!p)?! de a "#r)g9a H)4)5) En pacientes con $ioprtesis v,lvular artica6 1ue est,n en rit#o sinusal ( no tienen ninguna otra indicacin para el trata#iento con /V86 se sugiere aspirina :B9-599 #g % d< #ejor 1ue terapia con /V8 en los = pri#eros #eses :Drado 4C<)
H)4)4) En pacientes con $ioprtesis artica transcat!ter6 se sugiere aspirina :B9-599 #g % d"a< ( clopidogrel :GB #g % d< so$re trata#iento con /V8 ( so$re no - trata#iento antipla1uetario en los pri#eros = #eses :Dr) 4 C<)

46

$.6.6. 1n patients with transcatheter aortic (ioprosthetic valves# we suggest aspirin (+07100 g!d" plus clopidogrel (7+ g!d" over %/0 therapy and over no antiplatelet therapy in the fi rst 3 onths (Gr 2C) .

47

$.6.3. 1n patients with a (ioprosthetic valve in the itral position# we suggest %/0 therapy (target 123# 6.+D range# 6.073.0" over no %/0 therapy for the fi rst 3 onths after valve insertion (Grade 2C) . 8.- Long.ter 'ntithro !otic Therap" for Patients With *ioprosthetic $al6es $.3. 1n patients with (ioprosthetic valves in nor al sinus rhyth # we suggest aspirin therapy over no aspirin therapy after 3 onths postoperative (Gr 2C) . #.1 @arl" Postoperati6e *ridging to (nter ediateA Long.ter Therap" <Postoperati6e Da" / to 4= ..1. 1n patients with echanical heart valves# we suggest (ridging with unfractionated heparin (>FH# prophylactic dose" or LMWH (prophylactic or therapeutic dose" over 1% therapeutic >FH until sta(le on %/0 therapy (Grade 2C) . #.+ Long.ter 'ntithro !otic Therap" for Patients With Mechanical $al6es ..6. 1n patients with echanical heart valves# we reco end %/0 therapy over no %/0 therapy for long7ter anage ent (Grade 1B) .

H)4)=) En pacientes con $ioprtesis valvular en la posicin #itral6 se sugiere trata#iento con /V8 :IN; o$jetivo de 46B6 rango6 4)9-=)9< so$re no - terapia con /V8 por un lapso de = #eses tras la insercin de la v,lvula :4C<)

;7! Tratamiento antitrom6/tico a largo pla1o en los pacientes con 6iopr/tesis H6=) En pacientes con $ioprtesis valvulares en rit#o sinusal nor#al6 se sugiere terapia con aspirina 0rente a ausencia de terapia con aspirina en los = #eses postoperatorios :4 C<) E71 Tratamiento p(ente en el postoperatorio inmediato hacia terapia a intermedio I largo pla1o (dFas > a 8 .".) L65) En pacientes con v,lvulas card"acas #ec,nicas6 sugeri#os terapia puente con dosis pro0il,cticas de -eparina no 0raccionada :2N.<6 o 2BPM :dosis pro0il,ctica o terap!utica<6 so$re 2N. IV terap!utica -asta 1ue esta$ili+ar el trata#iento con /V8 :4C<) E72 Tratamiento antitrom6/tico a largo pla1o en pacientes con #Cl#(las mecCnicas L64) En pacientes con v,lvulas card"acas #ec,nicas6 se reco#ienda terapia con /V8 0rente a no-trata#iento con /V8 para el #anejo a largo pla+o :Drado 5B<)

E.! Intensidad de la terapia con AVK para pacientes con r/tesis mecCnica de la #Cl#(la a/rtica L)=)5) En pacientes con v,lvula artica #ec,nica6 sugieren #.- (ntensit" of $%' Therap" for Patients With terapia con /V8 con una #eta de 46B :rango6 469-=69< Mechanical 'ortic $al6e Prostheses so$re o$jetivos #,s $ajos :Drado 4C<) ..3.1. 1n patients with a echanical aortic valve# we L)=)4) En pacientes con una v,lvula artica #ec,nica6 se suggest %/0 therapy with a target of 6.+ (range# 6.07 reco#ienda terapia con /V8 con una #eta de 46B :rango 3.0" over lower targets (Grade 2C) . 469 a =69< so$re #etas #,s altas :Drado 5B<) ..3.6. 1n patients with a echanical aortic valve# we E.. Intensidad de la terapia con AVK en pacientes con reco end %/0 therapy with a target of 6.+ (range pr/tesis mecCnicas de #Cl#(la mitral 6.073.0" over higher targets (Grade 1B) . L6A) En pacientes con una v,lvula #ec,nica #itral6 #.1 (ntensit" of $%' Therap" for Patients With sugieren la terapia con /V8 con una #eta de =69 :rango6 46B-=6B< so$re o$jetivos in0eriores de IN; :Drado 4C<) Mechanical Mitral $al6e Prostheses ..4. 1n patients with a echanical itral valve# we E.8 Intensidad de la terapia con AVK en pacientes con suggest %/0 therapy with a target of 3.0 (range# 6.+7 do6le VCl#(la mecCnica o factores de riesgo adicionales 3.+" over lower 123 targets (Grade 2C) . L6B) En pacientes con v,lvulas card"acas #ec,nicas6 tanto artica co#o #itral6 sugeri#os o$jetivo de IN; =69 #.4 (ntensit" of $%' Therap" in Patients With :rango de 4)B a =)B< so$re IN; de 46B :rango 469-=69< :Drado 4C<) Dou!le Mechanical $al6e or With 'dditional Ris& Factors ..+. 1n patients with echanical heart valves in (oth the aortic and itral position# we suggest target 123 3.0 (range 6.+73.+" over target 123 6.+ (range 6.073.0" (Grade 2C) .

48

#.5 'ntiplaelet 'gent in 'ddition to $%' Therap" for Patients With Mechanical 'ortic or Mitral $al6e Prostheses

..@. 1n patients with a echanical itral or aortic valve at low ris) of (leeding# we suggest adding over not adding an antiplatelet agent such as low7dose aspirin (+07100 g!d" to the %/0 therapy (Grade 1B) . E.: Antiagregante pla'(etario en #e1 de terapia con AVK Re ar&s; Ca tion sho ld be sed in patients at L6G) En pacientes con v,lvula #ec,nica artica o #itral increased bleedin" ris#, s ch as histor% of G& bleedin". se reco#ienda /V8 so$re agentes antipla1uetarios :5B<) #.7 'ntiplatelet 'gent Therap" (nstead of $%' Therap" ..7. For patients with echanical aortic or itral valves we reco end %/0 over antiplatelet agents (Grade 1B) .

E.9 Agentes antipla'(etares7 ademCs de AVK7 en pacientes con pr/tesis mecCnica a/rtica o mitral L6F) En pacientes con v,lvula #ec,nica #itral o artica6 con $ajo riesgo de sangrado6 se sugiere aUadir6 vs noaUadir6 un agente antipla1uetario co#o la aspirina a dosis $ajas :B9-599 #g % d<6 a la terapia con /V8 :5B<) A%!er/a"#o$e!: Se de%e te$er pre"a)"#'$ e$ pa"#e$te! "o$ r#e!go a to de !a$grado, ("o*o a$te"ede$te de !a$grado G()

1/.1 'ntithro !otic Therap" 'fter Mitral $al6e Repair 10.1. 1n patients undergoing itral valve repair with a 1>.2 acientes sometidos a reparaci/n de la #Cl#(la a/rtica prosthetic (and in nor al sinus rhyth # we suggest 5964) En pacientes so#etidos a reparacin de v) artica6 the use of antiplatelet therapy for the fi rst 3 onths sugieren aspirina B9 a 599 #g % d so$re /V8 :4C< over %/0 therapy (Grade 2C) . 1/.+ Patients 7ndergoing 'ortic $al6e Repair 10.6. 1n patients undergoing aortic valve repair# we suggest aspirin at +0 to 100 g!d over %/0 therapy (Grade 2C) .

1>71 Tratamiento antitrom6/tico desp(0s de reparaci/n de la #Cl#(la mitral 5965) En pacientes so#etidos a reparacin de la v,lvula #itral con una $anda prot!sica6 en rit#o sinusal nor#al6 se sugiere el uso de terapia antipla1uetaria por un lapso de = #eses so$re el trata#iento con /V8 :Drado 4C<)

11.1 Patients With Right.3ided Prosthetic $al6e 11.2 acientes con trom6osis #. prot0sica lado i1'(ierdo Thro !osis 11.1. For patients with right7sided prosthetic valve lado i+1uierdo ( thro (osis (9%&"# in the a(sence of contraindications 55)4)5) En pacientes con TVP en el 4 tro#$o de ,rea grande :K 96H c# <6 se sugiere cirug"a we suggest ad inistration of fi (rinolytic therapy over preco+ 0rente a trata#iento 0i$rinol"tico :Drado 4C<) surgical intervention (Grade 2C) . *i -a( contraindicaciones para la operacin6 se sugiere el uso de terapia 0i$rinol"tica :Drado 4C<) 11.+ Patients With Left.3ided Prosthetic $al6e Thro !osis 55)4)4) En pacientes con TVP en el lado i+1uierdo ( tro#$o de ,rea pe1ueUa :J 96H c#4<6 se sugiere la 11.6.1. For patients with left7sided 9%& and large thro (us area ( 5 0.$ c 6 "# we suggest early surgery ad#inistracin de terapia 0i$rinol"tica 0rente a la cirug"a) En tro#$os #u( pe1ueUos6 no o$structivos se sugiere over fi (rinolytic therapy (Grade 2C) . 1f contraindi I 2N. iv aco#paUada por ecocardiogra0"as Doppler cations to surgery e*ist# we suggest the use of seriadas para docu#entar la resolucin o #ejora del fi(rinolytic therapy (Grade 2C) . tro#$o6 0rente a otras alternativas :Drado 4C<) 11.6.6. For patients with left7sided 9%& and s all thro (us area ( , 0.$ c 2 "# we suggest ad inistration of fi (rinolytic therapy over surgery. For very s all# nono(structive thro (us we suggest 1% >FH acco panied (y serial =oppler echocardiography to docu ent thro (us resolution or i prove ent over other alternatives (Grade 2C) . (P,3): pro!t:et#" /a /e t:ro*%o!#! .B (3,P): tro*%o!#! / /) a prot?!#"a

11.1 acientes con trom6osis de #Cl#(la prot0sica del lado derecho 5565) En pacientes con tro#$osis v,lvula prot!sica :TVP< del lado derec-o6 en ausencia de contraindicaciones6 se sugiere la ad#inistracin de terapia 0i$rinol"tica6 so$re intervencin 1uir rgica :Drado 4C<)

49

0ntithro (otic and &hro (olytic &herapy for 1sche ic ,tro)e +.1 ($ Reco !inant Tissue Plas inogen 'cti6ator <r.tP'= for Patients With 'cute (sche ic 3tro&e 6.1.1. 1n patients with acute ische ic stro)e in who treat ent can (e initiated within 3 h of sy pto onset# we reco end 1% r7t90 over no 1% r7t90 (1$). 6.1.6. 1n patients with acute ische ic stro)e in who treat ent can (e initiated within 4.+ (ut not within 3 h of sy pto onset# we suggest 1% r7t90 over no 1% r7 t90 (Grade 2C). 6.1.3. 1n patients with acute ische ic stro)e in who treat ent cannot (e initiated within 4.+ h of sy pto onset# we reco end against 1%r7t90 (Grade 1B). +.+ (ntraarterial Thro !ol"sis in Patients With 'cute (sche ic 3tro&e 6.6.1. 1n patients with acute ische ic stro)e due to pro*i al cere(ral artery occlusions who do not eet eligi(ility criteria for treat ent with 1% r7t90# we suggest intraarterial (10" r7t90 initiated within @ h of sy pto onset over no 10 r7t90 (Grade 2C). 6.6.6. 1n patients with acute ische ic stro)e we suggest 1% r7t90 over the co (ination 1%!10 r7t90 (?rade 6-". +.- Mechanical Thro !ecto " in Patients With 'cute (sche ic 3tro&e 6.3. 1n patients with acute ische ic stro)e# we suggest against the use of echanical thro (ecto y (2C).

Trata#iento /ntitro#$tico ( Tro#$ol"tico para el ictus is1u!#ico 2.1. Acti#ador Tis(lar *ecom6inante del lasmin/) geno(r)t A) en pacientes con ict(s is'(0mico ag(do 4)5)5) En pacientes con ictus is1u!#ico agudo en los 1ue el trata#iento puede iniciarse en #enos de = - de la aparicin de los s"nto#as6 se reco#ienda r-tP/ iv 0rente a no r-tP/ iv :5/<) 4)5)4) En pacientes con ictus is1u!#ico agudo en los 1ue el trata#iento puede ser iniciado en A6B -oras6 pero no dentro de las = - de la aparicin de los s"nto#as6 se sugiere r-tP/ iv 0rente a no r-tP/ iv :Drado 4C<) 4)5)=) En pacientes con ictus is1u!#ico agudo en los 1ue el trata#iento no puede iniciarse en las A6B -oras de inicio de los s"nto#as6 reco#iendan en contra del r-tP/ iv :5B<) 272 Trom6olisis intraarterial en pacientes con ict(s is'(0mico ag(do 4)4)5) En pacientes con ictus is1u!#ico agudo6 de$ido a oclusiones pro'i#ales de las arterias cere$rales6 1ue no cu#plan con los criterios de elegi$ilidad para trata#iento con r-tP/ iv6 sugieren r-tP/ intraarterial :I/< iniciado dentro de las F - de inicio de los s"nto#as) .rente a r-tP/ I/ :4C<) 4)4)4) En pacientes con /CV is1u!#ico agudo sugieren rtP/ iv so$re la co#$inacin r-tP/ iv%ia :Drado 4C<) 27! Trom6ectomFa mecCnica en pacientes con ict(s is'(0mico ag(do 46=) En pacientes con /CV is1u!#ico agudo6 sugieren en contra del uso de tro#$ecto#"a #ec,nica :Drado 4C< 2.. Aspirina en pacientes con ict(s is'(0mico ag(do
46A) En pacientes con /CV is1u!#ico agudo o accidente is1u!#ico transitorio :/IT<6 se reco#ienda terapia preco+ :dentro de AH -oras< con aspirina a dosis de 5F9 a =4B #g6 0rente a no trata#iento con aspirina :grado 5/<)

+.1 'spirin in Patients With 'cute (sche ic 3tro&e 6.4. 1n patients with acute ische ic stro)e or transient 278 Anticoag(laci/n en pacientes con ict(s is'(0mico ische ic attac) (&10"# we reco end early (within 4$ ag(do 46B) En pacientes con /CV agudo is1u!#ico o /IT6 se h" aspirin therapy at a dose of 1@0 to 36+ g over no reco#ienda terapia te#prana :dentro de AH -oras< con aspirin therapy (Grade 1$). aspirina6 con una dosis inicial de 5F9 a =4B #g6 durante la anticoagulacin terap!utica parenteral :grado 5/<) +.4 'nticoagulation in Patients With 'cute =)5 Prevencin del TEV en pacientes con ictus is1u!#ico (sche ic 3tro&e =)5)5) En pacientes con ictus is1u!#ico agudo ( 6.+. 1n patients with acute ische ic stro)e or &10# we #ovilidad restringida6 sugeri#os dosis pro0il,cticas sc de reco end early (within 4$ h" aspirin therapy with an 2N. o 2BPM o dispositivos de co#presin neu#,tica initial dose of 1@0 to 36+ g over therapeutic inter#itente #ejor 1ue la ausencia de pro0ila'is :Drado parenteral anticoagulation (Grade 1$). 4B<) -.1 $T@ Pre6ention in Patients With (sche ic 3tro&e 3.1.1. 1n patients with acute ische ic stro)e and restricted o(ility# we suggest prophylacticdose ,>FH or LMWH or inter ittent pneu atic co pression devices over no prophyla*is (Grade 2B).

50

51

3.1.6. 1n patients with acute ische ic stro)e and restricted o(ility# we suggest prophylactic7dose LMWH over prophylactic7dose >FH (Grade 2B). 3.1.3. 1n patients with acute stro)e and restricted o(ility# we suggest against elastic co pression stoc)ings (Grade 2B). -.+ $T@ Pre6ention in Patients With He orrhagic 3tro&e 3.6.1. 1n patients with acute pri ary intracere(ral he orrhage and restricted o(ility# we suggest prophylactic7dose ,- heparin (>FH or LMWH" started (etween days 6 and 4 or inter ittent pneu atic co pression devices over no prophyla*is (Grade 2C). 3.6.6. 1n patients with acute pri ary intracere(ral he orrhage and restricted o(ility# we suggest prophylactic7dose LMWH over prophylactic7dose >FH (Grade 2B). 3.6.3. 1n patients with pri ary intracere(ral he orrhage and restricted o(ility# we suggest against elastic co pression stoc)ings (Grade 2B). 1.1 'ntithro !otic Therap" for the 3econdar" Pre6ention of )oncardioe !olic 3tro&e 4.1.1. 1n patients with a history of noncardioe (olic ische ic stro)e or &10# we reco end long7ter treat ent with aspirin (7+7100 g once daily"# clopidogrel (7+ g once daily"# aspirin!e*tended7 release dipyrida ole (6+ g!600 g (id"# or cilosta:ol (100 g (id" over no antiplatelet therapy (Grade 1$)# oral anticoagulants (Grade 1B)# the co (ination of clopidogrel plus aspirin (Grade 1B)# or triflusal (2B). 4.1.6. Ff the reco ended antiplatelet regi ens# we suggest clopidogrel or aspirin!e*tended release dipyrida ole over aspirin (Gr 2B) or cilosta:ol (2C).

=)5)4) En pacientes con ictus is1u!#ico agudo ( #ovilidad restringida6 sugieren dosis pro0il,cticas de 2BPM so$re dosis pro0il,cticas de 2N. :Drado 4B<) =)5)=) En los pacientes con /CV agudo ( #ovilidad restringid6 se sugieren #edias de co#presin el,stica :4B<

!.2 re#enci/n del THV en pacientes con ict(s hemorrCgico =)4)5) En pacientes con -e#orragia pri#aria aguda intracere$ral ( #ovilidad restringida6 se sugiere iniciar dosis pro0il,cticas de -eparina *C :2N. o 2BPM< entre los d"as 4 ( A o dispositivos de co#presin neu#,tica inter#itente so$re ausencia de pro0ila'is :Drado 4C<) =)4)4) En pacientes con -e#orragia aguda intracere$ral pri#aria ( #ovilidad restringida6 se sugieren dosis pro0il,cticas de 2BPM so$re dosis pro0il,ctica de 2N. :Drado 4B<) =)4)=) En pacientes con -e#orragia aguda intracere$ral pri#aria ( #ovilidad restringida6 sugeri#os en contra de las #edias de co#presin el,sticas :Drado 4B<) ..1 Tratamiento antitrom6/tico para la pre#enci/n sec(ndaria del ict(s no cardioem6/lico A)5)5) En pacientes con una -istoria de ictus is1u!#ico no cardioe#$lico o /IT6 se reco#ienda trata#iento a largo pla+o con aspirina :GB-599 #g una ve+ al d"a<6 clopidogrel :GB #g una ve+ al d"a<6 aspirina % dipirida#ol de li$eracin prolongada :4B #g%499 #g $id<6 o cilosta+ol :599 #g veces al d"a<6 so$re no - trata#iento anticoagulante :grado 5/<6 anticoagulantes orales :Drado 5B<6 co#$inacin de clopidogrel #,s aspirina :Drado 5B<6 o tri0lusal :4B<)
A)5)4) De los reg"#enes antipla1uetarios reco#endados6 se sugiere de clopidogrel o aspirina % dipirida#ol de li$eracin e'tendida so$re aspirina :Dr) 4B< o cilosta+ol :4C<)

1.+ 'ntithro !otic Therap" for the 3econdar" Pre6ention of ,ardioe !olic 3tro&e 4.6.1. 1n patients with a history of ische ic stro)e or &10 and 0F# including paro*ys al 0F# we reco end oral anticoagulation over no antithro 7 A)4)4) En pacientes con antecedentes de ictus is1u!#ico o (otic therapy (Grade 1$)# aspirin (Grade 1B)# or /IT ( .i$rilacin auricular6 inclu(endo la ./ co (ination therapy with aspirin and clopidogrel (1B) paro'"stica6 se sugiere anticoagulacin oral con 5B9 #g de da$igatr,n $id so$re dosis ajustadas de trata#iento con 4.6.6. 1n patients with a history of ische ic stro)e or /V8 :rango #eta6 4)9-=)9< :Drado 4B<) &10 and atrial fi (rillation# including paro*ys al 0F# we suggest oral anticoagulation with da(igatran 1+0 g (id over ad8usted7dose %/0 therapy (target range# 6.073.0" (Grade 2B).

..2 Tratamiento antitrom6/tico para la pre#enci/n sec(ndaria del ict(s cardioem6/lico A)4)5) En pacientes con antecedentes de ictus is1u!#ico o /IT ( ./6 inclu(endo) ./ paro'"stica6 se reco#ienda anticoagulacin oral 0rente a no - trata#iento antitro#$tico :grado 5/<6 aspirina :Drado 5B<6 o terapia co#$inada con aspirina ( clopidogrel :5B<

52

4.6.3. 1n patients with a history of ische ic stro)e or &10 and atrial fi (rillation# including paro*ys al 0F# who are unsuita(le for or choose not to ta)e an oral anticoagulant (for reasons other than concerns a(out a8or (leeding"# we reco end co (ination therapy with aspirin and clopidogrel over aspirin (Grade 1B). Re ar&s; 'atients sho ld be treated (ie, brid"ed) (ith aspirin ntil anticoa" lation has reached a therape tic le)el. *ral anticoa" lation sho ld "enerall% be initiated (ithin 1 to 2 (ee#s after stro#e onset. +arlier anticoa" , lation can be considered for patients at lo( ris# of bleedin" complications (e", those (ith a small infarct b rden and no e)idence of hemorrha"e on brain ima"in"). -ela%in" anticoa" lation sho ld be considered for patients at hi"h ris# of hemorrha"ic complications (e", those (ith e!tensi)e infarct b rden or e)idence of si"nifi cant hemorrha"ic transformation on brain ima"in"). -abi"atran is e!creted primaril% b% the #idne%. &t has not been st died and is contraindicated in patients (ith se)ere renal impairment (estimated creatinine clearance of ./ mL0min or less). 1.- 'ntithro !otic Therap" for 3tro&e Pre6ention in Patients With a Histor" of (ntracere!ral He orrhage <(,H= 4.3. 1n patients with a history of a sy pto atic pri ary 1-H# we suggest against the long7ter use of antithro (otic therapy for the prevention of ische ic stro)e (Grade 2C). Re ar&s; 'atients (ho mi"ht benefi t from antithrombotic therap% are those at relati)el% lo( ris# of rec rrent &CH (e", (ith deep hemorrha"es) and relati)el% hi"h ris# (1 23 per %ear) of thromboembolic e)ents (e", (ith mechanical heart )al)es or CH$-4 2 (Con"esti)e heart fail re, H%pertension, $"e . 25, -iabetes mellit s, 4tro#e or 6&$) score . 7 points).

A)4)=) En pacientes con antecedentes de ictus is1u!#ico o /IT ( 0i$rilacin auricular6 inclu(endo la ./ paro'"stica6 1ue no son adecuados para6 o se elige no to#ar un anticoa gulante oral :por ra+ones distintas a la preocupacin acerca de -e#orragia #a(or<6 se reco#ienda trata#iento co#$inado con aspirina ( clopidogrel vs aspirina :5B<) "6ser#acionesG Los pacientes de6en ser tratados (es decir 4p(enteados5) con aspirina hasta '(e la anticoag(laci/n ha llegado a s( ni#el terap0(tico. La anticoag(laci/n oral en general7 se de6e iniciar de 1 a 2 semanas desp(0s de la aparici/n del ABV. @na anticoag(laci/n preco1 p(ede ser considerada en pacientes con 6a2o riesgo de complicaciones hemorrCgicas (por e2emplo7 a'(ellos con infarto pe'(eJo y sin e#idencia de hemorragia en imagen cere6ral). *etrasar la anticoag(laci/n de6e ser considerado para pacientes con alto riesgo de complicaciones hemorrCgicas (por e2emplo7 a'(ellos con infarto eDtenso o e#idencia significati#a de transformaci/n hemorrCgica en las imCgenes del cere6ro). Hl da6igatrCn se elimina principalmente por el riJ/n. +o se ha est(diado y estC contraindicado en pacientes con ins(ficiencia renal gra#e (aclaramiento de creatinina estimado de !> mL I min o menos). 4.! Tratamiento antitrom6/tico para pre#enci/n del ict(s

en pacientes con antecedente de hemorragia intracere6ral ($IB) A6=) En pacientes con -istoria de 2IC pri#aria sinto#,tica sugeri#os en contra del uso a largo pla+o de trata#iento antitro#$tico para prevencin de /CV is1u!#ico :Drado 4C<) "6ser#aci/nesG los pacientes '(e podrFan 6eneficiarse de terapia antitrom6/tica son los '(e estCn en riesgo relati#amente 6a2o de $IB rec(rrente (p. e2.7 con hemorragias prof(ndas) y (n riesgo relati#amente alto (K :L por aJo) de e#entos trom6oem6olicos (p.e2.7 con #Cl#(las cardFacas mecCnicas o B$ADS2 (ins(ficiencia cardFaca congesti#a7 hipertensi/n7 edad K :87 dia6etes mellit(s7 accidente cere6ro#asc(lar o AIT) score K . p(ntos).

8.1 Anticoag(laci/n en pacientes con trom6osis sintomCtica de senos #enosos cere6rales B65) En pacientes con tro#$osis de senos venosos cere$rales6 sugieren anticoagulacin 0rente a ning n 4.1 'nticoagulation for Patients With trata#iento anticoagulante durante las 0ases aguda ( 3" pto atic ,ere!ral $enous 3inus Thro !osis crnica :4C<) +.1. 1n patients with cere(ral venous sinus thro (osis# "6ser#acionesG Los pacientes con historia de $BI7 '(e podrFan 6eneficiarse de terapia antitrom6/tica son los '(e we suggest anticoagulation over no anticoagulant estCn en relati#amente 6a2o riesgo de $IB rec(rrente (p. e2.7 therapy during the acute and chronic phases (2C). con hemorragias prof(ndas) y relati#amente alto riesgo (K Re ar&s; 'atients (ith a histor% of &CH (ho mi"ht :L por aJo) de e#entos trom6oem6/licos cardiacas (p. e2.7 benefi t from antithrombotic therap% are those at relati)el% con #Cl#(las mecCnicas del cora1/n o p(nt(aci/n B$ADS2 lo( ris# of rec rrent &CH (e", (ith deep hemorrha"es) K . p(ntos). and relati)el% hi"h ris# (. 23 per %ear) of cardiac thromboembolic e)ents (e", (ith mechanical heart )al)es or CH$-42 score . 7 points).

53

&he 9ri ary and ,econdary 9revention of -ardiovascular =isease +./ Pri ar" Pre6ention of ,ardio6ascular Disease 6.1. For persons aged +0 years or older without sy pto7 atic cardiovascular disease# we suggest low7dose aspirin 7+ to 100 g daily over no aspirin therapy (2B) .
-.1 ,hoice of Long.ter 'ntithro !otic Therap" in Patients With @sta!lished ,oronar" 'rter" Disease <,'D=

Prevencin pri#aria ( secundaria de en0er#edades cardiovasculares


2.> re#enci/n rimaria de Hnfermedades Bardio#asc(lares 465) En personas #a(ores de B9 aUos sin en0er#edad cardiovascular sinto#,tica6 sugeri#os dosis $ajas de aspirina GB a 599 #g al d"a 0rente a no-aspirina :4B<)

3.1.173.1.+. For patients with esta(lished coronary artery disease (-0="# defi ned as patients 17year post7 acute coronary syndro e (0-," # with prior revasculari:ation# coronary stenoses 5 +0C (y coronary angiogra # and!or evidence for cardiac ische ia on diagnostic testing# (including patients after the fi rst year post70-, and!or with prior coronary artery (ypass graft ;-0H?< surgery"G 8 We reco end long7ter single antiplatelet therapy with aspirin 7+ to 100 g daily or clopidogrel 7+ g daily over no antiplatelet therapy (Grade 1$) . 8 We suggest single over dual antiplatelet therapy with aspirin plus clopidogrel (Grade 2B) . -.+ ,hoice of 'ntithro !otic Therap" Follo>ing ',3 3.6.173.6.+. For patients in the fi rst year after an 0-, who have not undergone percutaneous coronary intervention (9-1"G

!.1 Hlecci/n de tratamiento antitrom6/tico a largo pla1o en pacientes con enfermedad arterial coronaria (HAB) =)5)5-=)5)B) En pacientes con en0er#edad arterial coronaria esta$lecida :C/D<6 Mdefinida como acientes ( a;o ost -sndrome coronario agudo +:.8-, re%asculari*acin re%ia, estenosis coronarias< 50= or coronariografa, y > o e%idencia de is1uemia en los test diagnsticos +incluyendo los acientes ( a;o des u/s de :.8 y > o con $y ass coronario re%io, .8?3N:
X *e reco#ienda terapia antipla1uetaria a largo pla+o con aspirina sola GB a 599 #g al d"a o clopidogrel GB #g al d"a 0rente a no - trata#iento anticoagulante :grado 5/<) X *ugieren antiagregacin nica vs do$le con aspirina ( clopidogrel :Drado 4B<)

!.2 Hlecci/n del tratamiento antitrom6/tico tras SBA =)4)5-=)4)B) Para pacientes en el 5er aUo despu!s de un *C/ 1ue no -an sido so#etidos a ICP :intervencin coronaria percut,nea <:

X *e reco#ienda terapia antipla1uetaria dual :ticagrelor L9 #g dos veces al d"a #,s aspirina en dosis $ajas GB-599 #g al d"a o clopidogrel GB #g al d"a #,s aspirina en dosis $ajas GB-599 #g al d"a< 0rente a terapia antipla1uetaria nica :5B<) X *ugieren ticagrelor L9 #g%d #,s aspirina a dosis $ajas 8 We reco end dual antiplatelet therapy (ticagrelor so$re clopidogrel GB #g d"a #,s aspirina dosis $aja :4B< .0 g twice daily plus low7dose aspirin 7+7100 g Para pacientes en el 5er aUo despu!s de un *C/ 1ue -an daily or clopidogrel 7+ g daily plus low7dose aspirin sido so#etidos una ICP con colocacin de stent: 7+7100 g daily" over single antiplatelet therapy (1B) . X *e reco#ienda terapia antipla1uetaria dual :ticagrelor 8 We suggest ticagrelor .0 g daily plus lowdose L9 #g dos veces al d"a #,s aspirina en dosis $ajas GB-599 aspirin over clopidogrel 7+ g daily plus low7dose #g al d"a6 clopidogrel GB #g al d"a #,s aspirina a dosis aspirin (Grade 2B) . $aja6 o prasugrel 59 #g al d"a #,s dosis $ajas de aspirina For patients in the fi rst year after an 0-, who have 0rente terapia antiagregante nica< :Drado 5B<) X *ugieren ticagrelor L9 #g dos veces al d"a #,s aspirina undergone 9-1 with stent place entG 8 We reco end dual antiplatelet therapy (ticagrelor en dosis $ajas so$re clopidogrel GB #g al d"a #,s dosis $aja de aspirina :Drado 4B<) .0 g twice daily plus low7dose aspirin 7+7100 g

daily# clopidogrel 7+ g daily plus low7dose aspirin# or prasugrel 10 g daily plus low7dose aspirin over single antiplatelet therapy" (Grade 1B) . 8 We suggest ticagrelor .0 g twice daily plus low7 dose aspirin o6er clopidogrel 7+ g daily plus low7 dose aspirin (Grade 2B) . For patients with 0-, who undergo 9-1 with stent place ent# we refer to sections 4.3.1 to 4.3.+ for reco endations concerning ini u and prolonged duration of treat ent. 3.6.@73.6.7. For patients with anterior M1 and left

En pacientes con *C/ so#etidos a ICP con colocacin de stent6 re#iten a las secciones A)=)5 a A)=)B para las reco#endaciones relativas a la duracin #"ni#a o prolongada de trata#iento) 3)4)F-=)4)G) En pacientes con I/M anterior ( tro#$o ventricular i+1 :VI< 6 o con alto riesgo de tro#$o VI :0raccin de e(eccin J A9R6 dis1uinesia anteroapical de la pared<6 1ue no se so#eten a colocacin de stents:

54

ventricular (L%" thro (us# or at high ris) for L% thro (us (e8ection fraction , 40C# anteroapical wall otion a(nor ality"# who do not undergo stentingG

Coro$ar= +rter= 7#!ea!e (C+7) .B 4$&er*edad +rter#a Coro$ar#a (4+C). +")te Coro$ar= S=$dro*e (+CS) .B S9$dro*e Coro$ar#o +g)do (SC+). pPr")ta$eo)! Coro$ar= ($ter/e$t#o$ (PC() .B (CP ($ter/e$"#'$ Coro$ar#a Per")t$ea

55

8 We reco end warfarin (123 6.073.0" plus low7dose aspirin 7+ to 100 g daily over single antiplatelet therapy or dual antiplatelet therapy for the fi rst 3 onths (Grade 1B) . &hereafter# we reco end discontinuation of warfarin and continuation of dual antiplatelet therapy for up to 16 onths as per the 0-, reco endations (see reco endations 3.6.173.6.+". 0fter 16 onths# single antiplatelet therapy is reco ended as per the esta(lished -0= reco endations (see reco enda tions 3.1.173.1.+". For patients with anterior M1 and L% thro (us# or at high ris) for L% thro (us (e8ection fraction < 40C# anteroapical wall otion a(nor ality"# who undergo (are7 etal stent (HM," place entG 8 We suggest triple therapy (warfarin ;123 6.073.0<# low7dose aspirin# clopidogrel 7+ g daily" for 1 onth over dual antiplatelet therapy (Grade 2C) . 8 We suggest warfarin (123 6.073.0" and single antiplatelet therapy for the second and third onth post7HM, over alternative regi ens and alternative ti e fra es for warfarin use (Grade 2C) . &hereafter# we reco end discontinuation of warfarin and use of dual antiplatelet therapy for up to 16 onths as per the 0-, reco endations (see reco endations 3.6.173.6.+". 0fter 16 onths# antiplatelet therapy is reco ended as per the esta(lished -0= reco endations (see reco endations 3.1.173.1.+". For patients with anterior M1 and L% thro (us# or at high ris) for L% thro (us (e8ection fraction , 40C# anteroapical wall otion a(nor ality" who undergo drug7eluting stent (='," place entG 8 We suggest triple therapy (warfarin 123 6.073.0# low7 dose aspirin# clopidogrel 7+ g daily" for 37 @ onths over alternative regi ens and alternative durations of warfarin therapy (2C) . &hereafter# we reco end discontinuation of warfarin and continuation of dual antiplatelet ther apy for up to 16 onths as per the 0-, reco endations (see reco endations 3.6.17 3.6.+". 0fter 16 onths# antiplatelet therapy is reco ended as per the esta(lished -0= reco endations (see reco endations 3.1.173.1.+". 1./ 'ntithro !otic Therap" Follo>ing @lecti6e P,( 4.1.174.3.+. For patients who have undergone elective 9-1 with place ent of HM,G 8 For the fi rst onth# we reco end dual anti platelet therapy with aspirin 7+ to 36+ g daily and clopidogrel 7+ g daily over single antiplatelet therapy (Grade 1$) .

X *e reco#ienda 7ar0arina :IN; 4)9-=)9<6 #,s una dosis $aja de aspirina GB a 599 #g al d"a 0rente a terapia antipla1ue- taria nica o terapia antipla1uetaria dual6 durante los pri#eros = #eses :Drado 5B<) / partir de entonces6 se reco#ienda la suspensin de la 7ar0arina ( la continuacin de terapia antipla1uetaria dual -asta 54 #eses seg n las reco#endaciones para el *C/ :v!anse reco#endaciones =)4)5-=)4)B<) Despu!s de 54 #eses6 el trata#iento antipla1uetario solo se reco#ienda de acuerdo con las reco#endaciones esta$lecidas para la E/C :ver reco#) =)5)5-=)5)B<) En pacientes con in0arto de #iocardio anterior ( tro#$osis del VI6 o en alto riesgo de tro#$os en VI :0raccin de e(eccin J A9R6 anor#alidad del #ovi#iento de la pared anteroapical< 1ue se so#eten a colocacin de stent #et,lico convencional: X *ugieren triple terapia :7ar0arina MIN; 4)9-=)9N6 dosis $ajas de aspirina6 clopidogrel GB #g al d"a< durante un #es 0rente a terapia antipla1uetaria dual :Drado 4C<) X *ugieren 7ar0arina :IN; 4)9-=)9< ( terapia antipla1uetaria nica durante el segundo ( tercer #es post stent 0rente a trata#ientos alternativos ( #arcos te#porales alternativos para el uso de 7ar0arina : 4C<) / partir de entonces6 se reco#ienda la suspensin de la 7ar0arina ( el uso de terapia antipla1uetaria dual -asta 54 #eses seg n las reco#endaciones del *C/ :v!anse reco#endaciones =)4)5-=)4)B<) Despu!s de 54 #eses6 se reco#ienda trata#iento antipla1uetario de acuerdo con las reco#endaciones esta$lecidas para la E/C :v!anse las reco#endaciones =)5)5-=)5)B<) En pacientes con in0arto de #iocardio ( tro#$osis anterior del VI6 o en alto riesgo de tro#$o VI :.) de e(eccin6 A9R6 dis1uinesia anteroapical< 1ue se so#eten a colocacin de stent li$erador de 0,r#aco :DE*<: X *ugeri#os triple terapia :7ar0arina IN; 469-=696 dosis $ajas de aspirina6 clopidogrel GB #g al d"a< durante = a F #eses 0rente a otros reg"#enes ( duraciones alternativas de 7ar0arina :Drado 4C<) Posterior#ente6 se reco#ienda la suspensin de la 7ar0arina ( continuacin de terapia dual antipla1uetaria durante -asta 54 #eses co#o la reco#endada en el *C/ :V!anse las reco#endaciones =)4)5-=)4)B<) Despu!s de 54 #eses6 se reco#ienda trata#iento antipla1uetario co#o el reco#endado en la E/C :v!anse las reco#endaciones =)5)5-=)5)B<)

..> Tratamiento antitrom6/tico tras IB electi#a A)5)5-A)=)B) Para los pacientes 1ue -an su0rido ICP electiva con la colocacin de BM* :stent<: X Para el pri#er #es6 se reco#ienda terapia dual antipla1ue-taria con aspirina GB a =4B #g al d"a ( clopidogrel GB #g al d"a 0rente a antipla1uetario en #onoterapia :grado 5/<)

56

8 For the su(seAuent 11 onths# we suggest dual antiplatelet therapy with co (ination of low7dose aspirin 7+ to 100 g daily and clopidogrel 7+ g daily over single antiplatelet therapy (Grade 2C) . 8 0fter 16 onths# we reco end single antiplatelet therapy over continuation of dual antiplatelet therapy (Grade 1B) . For patients who have undergone elective 9-1 with place ent of =',G 8 For the fi rst 3 to @ onths# we reco end dual antiplatelet therapy with aspirin 7+ to 36+ g daily and clopidogrel 7+ g daily over single antiplatelet therapy (Grade 1$) . 8 0fter 3 to @ onths# we suggest continuation of dual antiplatelet therapy with lowdose aspirin 7+ to 100 g and clopidogrel (7+ g daily" until 16 onths over single antiplatelet therapy (Grade 2C) . 8 0fter 16 onths# we reco end single antiplatelet ther apy over continuation of dual antiplatelet therapy (1B) . ,ingle antiplatelet therapy thereafter is reco ended as per the esta(lished -0= (see 3.1.173.1.+". For patients who have undergone elective HM, or =', stent place entG 8 We reco end using low7dose aspirin 7+ to 100 g daily and clopidogrel 7+ g daily alone rather than cilosta:ol in addition to these drugs (Grade 1B) . 8 We suggest aspirin 7+ to 100 g daily or clopidogrel 7+ g daily as part of dual antiplatelet therapy rather than the use of either drug with cilosta:ol (Grade 1B) . 8 We suggest cilosta:ol 100 g twice daily as su(stitute for either low7dose aspirin 7+ to 100 g daily or clopidogrel 7+ g daily as part of a dual antiplatelet regi en in patients with an allergy or intolerance of either drug class (Grade 2C) . For patients with -0= undergoing elective 9-1 (ut no stent place entG 8 We suggest for the fi rst onth dual antiplatelet ther apy with aspirin 7+ to 36+ g daily and clopidogrel 7+ g daily over single antiplatelet therapy (Grade 2C) . ,ingle antiplatelet therapy thereafter is reco ended as per the esta(lished -0= (see 3.1.173.1.+". 4./ 'ntithro !otic Therap" in Patients With 3"stolic L$ D"sfunction +.17+.3. For patients with systolic L% dysfunction without esta(lished -0= and no L% thro (us# we suggest not to use antiplatelet therapy or warfarin (2C) For patients with systolic L% dysfunction without esta(lished -0= with identifi ed acute L% thro (us (eg# &a)otsu(o cardio yopathy"# we suggest oderate 7intensity warfarin (123 6.073.0" for at least 3 onths (Grade 2C) . For patients with systolic L% dysfunction and esta(lished -0=# reco endations are as per the esta(lished -0= reco endations (see reco endations 3.1.173.1.+".

X Para los siguientes 55 #eses6 sugieren do$le antiagregacin con la co#$inacin de dosis $ajas de aspirina GB a 599 #g al d"a ( clopidogrel GB #g al d"a 0rente a trata#iento con un solo antiagregante pla1uetario :Drado 4C<) X Despu!s de 54 #eses6 se reco#ienda terapia antipla1uetaria nica 0rente a do$le antiagregacin :Drado 5B<) En pacientes 1ue -an sido so#etidos a ICP electiva con la colocacin de DE*: X por un lapso de = a F #eses6 se reco#ienda do$le antiagre gacin con aspirina GB a =4B #g%d ( clopidogrel GB #g al d"a vs #onoterapia antipla1uetaria :grado 5/<) X Despu!s de = a F #eses6 se sugiere la continuacin de do$le antiagregacin con $ajas dosis de aspirina GB a 599 #g ( clopidogrel :GB #g al d"a< -asta los 54 #eses6 #ejor 1ue #onoterapia antipla1uetaria :Drado 4C<) X Despu!s de 54 #eses6 se reco#ienda terapia con un solo antipla1uetario 0rente a la continuacin de do$le trata#iento antipla1uetario :Drado 5B<) Posterior#ente se reco#ienda un nico antiagregante pla1uetario de acuerdo con las reco#endaciones esta$lecidas para la E/C :vre reco#end =)5)5-=)5)B< En pacientes con colocacin electiva de stent BM* o DE*: X ;eco#enda#os el uso de dosis $ajas de aspirina GB a 599 #g al d"a ( clopidogrel GB #g al d"a #ejor 1ue cilosta+ol en adicin a estos 0,r#acos :Drado 5B<) X *e aconseja aspirina GB a 599 #g al d"a o clopidogrel GB #g al d"a co#o parte de la do$le antiagregacin en lugar de la utili+acin de cual1uiera de las dos drogas con cilosta+ol :Drado 5B<) X *ugeri#os cilosta+ol 599 #g dos veces al d"a co#o sustituto de la aspirina a $aja dosis : GB a 599 #g al d"a< o del clopidogrel GB #g al d"a co#o parte de un r!gi#en de do$le antiagregacin en pacientes con alergia o intolerancia a cual1uiera de los 0,r#acos de esta clase :Drado 4C<) Para los pacientes con en0er#edad arterial coronaria so#etidos a ICP electiva sin colocacin de stent: X *ugeri#os do$le antiagregacin durante el pri#er #es con aspirina GB a =4B #g al d"a ( clopidogrel GB #g %d"a 0rente a un solo antiagregante pla1uetario :Drado 4C<) Posterior#ente se reco#ienda un nico antiagregante pla1uetario de acuerdo con las reco#endaciones esta$lecidas para la E/C :Ver reco# =)5)5-=)5)B<) 5.0 Tratamiento antitrom$tico en acientes con disfuncin sistlica del %entrculo i*1uierdo B)5 - B)=) En pacientes con dis0uncin sistlica del VI sin E/C esta$lecida ( sin tro#$o VI6 se sugiere no utili+ar terapia antipla1uetaria o 7ar0arina :Drado 4C<) En pacientes con dis0uncin sistlica del VI6 sin E/C esta$lecida6 con tro#$o VI agudo identi0icado :p)ej) cardio- #iopat"a Ta@otsu$o<6 sugeri#os 7ar0arina de intensidad #oderada :IN; 4)9-=)9< durante al #enos = #eses :4C<) En pacientes con dis0uncin sistlica del VI6 ( E/C esta$lecida6 las reco#endaciones son co#o las reco#endaciones esta$lecidas para la E/C :v!anse las reco#endaciones =)5)5-=)5)B<)

57

0ntithro (otic &herapy in 9eripheral 0rtery =isease +./ Pri ar" Pre6ention of ,ardio6ascular @6ents in Patients >ith 's" pto atic P'D 6.1. For persons with asy pto atic peripheral arterial disease (90="# we suggest aspirin 7+ to 100 g daily over no aspirin therapy (Grade 2B) . -./ 3econdar" Pre6ention of ,ardio6ascular @6ents in Patients >ith 3" pto atic P'D 3.173.4. For secondary prevention patients with sy pto atic 90=# we reco end one of the two following antithro (otic regi ens to (e continued long ter over no antithro (otic treat entG aspirin 7+ to 100 g daily or clopidogrel 7+ g daily (all Grade 1$) . We suggest not to use dual antiplatelet therapy with aspirin plus clopidogrel (Grade 2B) . We reco end not to use an antiplatelet agent with oderate7intensity warfarin (Grade 1B) . 1./ 'ntithro !otic Therap" for the Manage ent of Patients >ith ,laudication 4.174.4. For patients with inter ittent claudication refractory to e*ercise therapy (and s o)ing cessation"# we suggest the use of cilosta:ol in addition to reviously reco ended antithro (otic therapies (aspirin 7+7 100 g daily or clopidogrel 7+ g daily" (Grade 2C) D we suggest against the use of pento*ifylline# heparinoids# or prostanoids (Grade 2C) . 4./ Patients With ,ritical Li ! (sche ia +.1. For patients with sy pto atic 90= and critical leg ische ia!rest pain who are not candidates for vascular intervention# we suggest the use of prostanoids in addition to previously reco ended antithro (otic therapies (aspirin 7+7100 g daily or clopidogrel 7+ g daily"(Grade 2C) .

Trata#iento antitro#$tico en la En0er#edad /rterial Peri0!rica 27> pre#enci/n primaria de e#entos cardio#asc(lares en pacientes con enfermedad arterial perif0rica asintomCtica 465) En personas con en0er#edad arterial peri0!rica asinto#,tica :P/D<6 sugieren aspirina GB a 599 #g al d"a 0rente a ning n trata#iento con aspirina :grado 4B<) !.> re#enci/n sec(ndaria de e#entos cardio#asc(lares en pacientes con HA sintomCtica =)5 a =)A) Para prevencin secundaria en pacientes con E/P sinto#,tica6 se reco#ienda uno de los dos siguientes reg"#enes antitro#$ticos para continuar a largo pla+o 0rente a ausencia de trata#iento antitro#$tico: aspirina GB a 599 #g al d"a o clopidogrel GB #g al d"a :todos los grados 5/<) *e reco#ienda no utili+ar la terapia antipla1uetaria dual con aspirina #,s clopidogrel :Drado 4B<) *e reco#ienda no utili+ar un nico agente antipla1uetario 6 7ar0arina de intensidad #oderada :Drado 5B<) ..> Tratamiento antitrom6/tico para el mane2o de los pacientes con Bla(dicaci/n A)5-A)A) Para los pacientes con claudicacin inter#itente re0ractario a la terapia de ejercicio :( dejar de 0u#ar<6 se sugiere el uso de cilosta+ol6 ade#,s de los trata#ientos antitro#$ticos previa#ente reco#endados :aspirina GB599 #g al d"a o clopidogrel GB #g al d"a< :Drado 4C<6 sugeri#os en contra del uso de la pento'i0ilina6 -eparinoides o prostanoides :Drado 4C<) 8.> acientes con is'(emia crFtica B65) Para los pacientes con E/P sinto#,tica e is1ue#ia cr"tica de la pierna % dolor en reposo 1ue no son candidatos para intervencin vascular6 se sugiere el uso de prostanoides6 ade#,s del trata#iento antitro#$tico previa#ente reco#en-dado :aspirina GB-599 #g al d"a o clopidogrel GB #g al d"a< :Drado 4C< ) 9.> Is'(emia ag(da de las eDtremidades

F)5 - F)=) En pacientes con is1ue#ia aguda de las e'tre#ida-des de$ido a e#$olia arterial o tro#$osis6 sugeri#os la anticoagulacin sist!#ica in#ediata con 5./ 'cute Li ! (sche ia -eparina no 0raccionada so$re no-anticoagulacin @.17@.3. 1n patients with acute li ( ische ia due to :Drado 4C<I sugeri#os terapia de reper0usin :cirug"a o arterial e (oli or thro (osis# we suggest i ediate syste ic anticoagulation with unfractionated heparin tro#$lisis I/< so$re no - terapia de reper0usin :Drado 4C<I reco#enda#os la cirug"a so$re la tro#$olisis I/ over no anticoagulation (Grade 2C) D we suggest :Drado 5B<) En pacientes reperfusion therapy (surgery or 10 thro (olysis" over so#etidos a tro#$olisis I/6 sugeri#os no reperfusion therapy (Grade 2C) D we reco end activador tisular del plas#ingeno reco#$inante :rt-P/< surgery over 10 thro (olysis (Grade 1B) . 1n patients o uro1uinasa so$re la estrepto1uinasa :Drado 4C<)

undergoing 10 thro (olysis# we suggest reco (inant tissue7type plas inogen activator (rt790" or uro)inase over strepto)inase (Grade 2C) .

Per#p:era +rter= 7#!ea!e P+7 .B 4+P 4$&er*edad +rter#a Per#&?r#"a

58

7./ @ndo6ascular Re6asculari0ation in Patients With 3" pto atic P'D 7.1. For patients undergoing peripheral artery percutaneous translu inal angioplasty with or without stenting# we reco end longter aspirin (7+7 100 g!day" or clopidogrel (7+ g!day" (Grade 1$) . For patients undergoing peripheral artery percutaneous translu inal angioplasty with stenting# we suggest single rather than dual antiplatelet therapy (Grade 2C) . 8./ 'ntithro !otic Therap" Follo>ing Peripheral 'rter" *"pass 8raft 3urger" $.17$.4. We reco end one of the following antithro (otic regi ens to (e continued longter following peripheral artery (ypass graft surgery over no antithro (otic treat entG aspirin 7+ to 100 g daily or clopidogrel 7+ g daily (all Grade 1$) . We reco end single antiplatelet therapy over antiplatelet therapy and warfarin (Grade 1B) . 1n patients undergoing (elow7)nee (ypass graft surgery with prosthetic grafts# we suggest clopidogrel 7+ g!d plus aspirin (7+7100 g!d" over aspirin alone for 1 year (Grade 2C) . For all other patients# we suggest single over dual antiplatelet therapy (Grade 2B) .

:.> *e#asc(lari1aci/n endo#asc(lar en pacientes con HA sintomCtica


G65) En pacientes so#etidos a angioplastia translu#inal percut,nea arterial peri0!rica con o sin colocacin de stent6 se reco#ienda aspirina a largo pla+o :GB-599 #g % d"a< o clopidogrel :GB #g % d"a< :grado 5/<) En pacientes so#etidos a angioplastia translu#inal percut,nea arterial peri0!rica con colocacin de stent6 sugeri#os terapia antipla1uetaria nica 0rente a dual :Drado 4C<)

;.> Tratamiento antitrom6/tico Tras la cir(gFa de in2erto de deri#aci/n arterial perif0rica H)5-H)A) ;eco#enda#os 1ue se siga uno de los siguientes reg"#enes antitro#$ticos a largo pla+o tras cirug"a $(pass arterial peri0!rico con injerto: aspirina GB a 599 #g al d"a o clopidogrel GB #g al d"a :todos los grados 5/<) *e reco#ienda la terapia antipla1uetaria nica 0rente a la terapia antipla1uetaria ( la 7ar0arina :Drado 5B<) En los pacientes so#etidos a cirug"a de injerto de $(pass de$ajo de la rodilla con injerto prtesico6 sugeri#os clopidogrel GB #g % d #,s aspirina :GB-599 #g % d"a< so$re aspirina sola durante 5 aUo :Drado 4C<) Para todos los de#,s pacientes6 sugeri#os la terapia antipla1uetaria nica so$re la do$le :Drado 4B<) E.> acientes con estenosis carotFdea

L65) En pacientes con estenosis carot"dea asinto#,tica6 sugieren aspirina GB a 599 #g al d"a so$re no- aspirina #./ Patients With ,arotid 'rter" 3tenosis :4B<) ..1. For patients with asy pto atic carotid stenosis# L)4-L)=) En pacientes con estenosis carot"dea sinto#,tica we suggest aspirin 7+ to 100 g daily over no aspirin :inclu(endo la endarterecto#"a carot"dea reciente<6 se therapy (Grade 2B) . reco#ienda terapia antipla1uetaria a largo pla+o con clopidogrel :GB #g una ve+ al d"a< o aspirine'tended ..67..3. 1n patients with sy pto atic carotid stenosis release (including recent carotid endarterecto y"# we dipirida#ol :4B #g%499 #g $id< o aspirina :GB-599 #g reco end long7ter antiplatelet therapy with una ve+ al d"a< so$re ausencia de trata#iento clopidogrel (7+ g once daily" or aspirine*tended7 anticoagulante :grado 5/<) *ugeri#os clopidogrel :GB #g release dipyrida ole (6+ g!600 g (id" or aspirin una ve+ al d"a< o aspirina e'tendedrelease dipirida#ol :4B (7+7100 g once daily" over no antiplatelet therapy (Grade 1$) . We suggest either clopidogrel (7+ g once #g%499 #g dos veces%d< so$re la aspirina :GB-599 #g< :Drado4B<) daily" or aspirin7e*tendedrelease dipyrida ole (6+

g!600

g (id" over aspirin (7+7100

g" (Grade 2B) .

YYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYY Traduccin: ZC Vergara 59

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