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The Weight-based Heparin Dosing Nomogram Compared with a Standard Care Nomogram: A Randomized Controlled Trial

Robert A. Raschke, MD, MS; Brendan M. Reilly, MD; James R. Guidry, PharmD, BCPS; Joseph R. Fontana, MD; and Sandhya Srinivas, MD
[+] Article, Author, and Disclosure Information

From Good Samaritan Regional Medical Center, Phoenix, Arizona; the University of Rochester School of Medicine, Rochester, New York; St. Mary's Hospital, Rochester, New York. Requests for Reprints: Robert A. Raschke, MD, Department of Medicine, Good Samaritan Regional Medical Center, 1111 E. McDowell Road, Phoenix, AZ 85006. Acknowledgments: The authors thank Drs. Alvin Mushlin, Barbara Weber, and Michael Wagner for their review of the manuscript and Dr. Philip C. Comp and Toppy Nelson for performing anti-factor Xa assays. Grant Support: By The Palms Clinic, Phoenix, Arizona.

Copyright 2004 by the American College of Physicians

Ann Intern Med. 1993;119(9):874-881. doi:10.7326/0003-4819-119-9-199311010-00002
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Objective: To determine whether an intravenous heparin dosing nomogram based on body weight achieves therapeutic anticoagulation more rapidly than a standard care nomogram.

Design: Randomized controlled trial.

Setting: Two community teaching hospitals in Phoenix, Arizona, and Rochester, New York.

Participants: One hundred fifteen patients requiring intravenous heparin treatment for venous or arterial thromboembolism or for unstable angina.

Intervention: Patients were randomized to the weight-based nomogram (starting dose, 80 units/kg body weight bolus, 18 units/kg per hour infusion) or the standard care nomogram (starting dose, 5000-unit bolus, 1000 units per hour infusion). Activated partial thromboplastin time (APTT) values were monitored every 6 hours, and heparin dose adjustments were determined by the nomograms.

Measurements: Activated partial thromboplastin times were measured using a widely generalizable laboratory method. The primary outcomes were the time to exceed the therapeutic threshold (APTT > 1.5 times the control) and the time to achieve therapeutic range (APTT, 1.5 to 2.3 times the control). Bleeding complications and recurrent thromboembolism were also compared.

Results: Kaplan-Meier curves for the primary outcomes favored the weight-based nomogram (P < 0.001 for both). In the weight-based heparin group, 60 of 62 patients (97%) exceeded the therapeutic threshold within 24 hours, compared with 37 of 48 (77%) in the standard care group (P < 0.002). Only one major bleeding complication occurred (in a standard care patient). Recurrent thromboembolism was more frequent in the standard care group; relative risk, 5.0 (95% CI, 1.1 to 21.9).

Conclusions: The weight-based heparin nomogram is widely generalizable and has proved to be effective, safe, and superior to one based on standard practice.


Grahic Jump Location
Figure 1.
Kaplan-Meier curve for the heparin therapeutic threshold.P

The weight-based nomogram achieved an activated partial thromboplastin time above the therapeutic threshold more rapidly ( < 0.001). APT = activated partial thromboplastin time.

Grahic Jump Location
Grahic Jump Location
Figure 2.
Kaplan-Meier curve for the therapeutic range of heparin.P

The weight-based nomogram achieved an activated partial thromboplastin time within the therapeutic range (1.5 to 2.3 times the control) more rapidly ( < 0.001). APT = activated partial thromboplastin time.

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Grahic Jump Location
Figure 3.
A sample weight-based heparin order sheet. APTT = activated partial thromboplastin time.
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