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## Complete Summary

#### GUIDELINE TITLE

Antithrombotic therapy in patients with saphenous vein and internal
mammary artery bypass grafts: the Seventh ACCP Conference on
Antithrombotic and Thrombolytic Therapy.

#### BIBLIOGRAPHIC SOURCE(S)

Stein PD, Schunemann HJ, Dalen JE, Gutterman D. Antithrombotic therapy
in patients with saphenous vein and internal mammary artery bypass
grafts: the Seventh ACCP Conference on Antithrombotic and Thrombolytic
Therapy. Chest 2004 Sep;126(3 Suppl):600S-8S. \[49 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15383486)

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Stein PD, Dalen JE, Goldman
S, Theroux P. Antithrombotic therapy in patients with saphenous vein and
internal mammary artery bypass grafts. Chest 2001 Jan;119(1
Suppl):278S-282S.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Coronary artery disease: saphenous vein and internal mammary artery
(IMA) bypass grafts

#### GUIDELINE CATEGORY

Treatment

#### CLINICAL SPECIALTY

Cardiology\
Family Practice\
Internal Medicine\
Surgery

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

-   To review the literature on the effects of treatment with
    antithrombotic agents on the prevention of saphenous vein and
    internal mammary artery (IMA) bypass graft occlusion following
    coronary artery bypass grafting (CABG)

-   To provide evidence-based recommendations on the treatment of
    saphenous vein bypass grafts and internal mammary artery bypass
    grafts with antithrombotic agents for the purpose of maintaining
    graft patency

#### TARGET POPULATION

Patients who have undergone saphenous vein and internal mammary artery
(IMA) bypass graft procedures for coronary artery disease

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Treatment**

1.  Aspirin therapy

2.  Clopidogrel, as an alternative to or in addition to aspirin therapy

3.  Oral anticoagulants, including vitamin K antagonists (VKAs)

4.  Aspirin therapy in combination with oral anticoagulants

**Note**: The following medications, or combinations of medications were
considered but not recommended: dipyridamole alone or in combination
with aspirin, indobufen, ticlopidine, sulfinpyrazone.

#### MAJOR OUTCOMES CONSIDERED

-   Effectiveness of treatment on graft patency as determined by:

    -   Cardiovascular events

    -   Death

    -   Graft thrombosis

    -   Graft patency

-   Rates of bleeding complications

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

**Process of Searching for Evidence**

Defining the clinical question provided the framework for formulating
eligibility criteria that guided the search for relevant evidence. Prior
to searching for the evidence, methodological experts and librarians
reviewed each question to ensure that the librarians could derive a
comprehensive search strategy.

In specifying eligibility criteria, authors not only identified
patients, interventions, and outcomes, but also methodological criteria.
For most therapeutic studies, authors restricted eligibility to
randomized controlled trials (RCTs).

For many questions, RCTs did not provide sufficient data, and article
authors also included observational studies. This was also true when
randomized trials were not the most appropriate design to use for
addressing the research question. In particular, randomized trials are
not necessarily the best design to understand risk groups (e.g., the
baseline or expected risk of a given event for certain subpopulations).
Because there are no interventions examined in questions about
prognosis, one replaces interventions by the exposure, which is time.

**Identifying the Evidence**

To identify the relevant evidence, a team of librarians at the
University at Buffalo conducted comprehensive literature searches. For
each question the authors provided, the librarians developed sensitive
(but not specific) search strategies, including all languages, and
conducted separate searches for systematic reviews, RCTs, and, if
applicable, observational studies. The librarians searched the Cochrane
Database of Systematic Reviews, the Database of Abstracts of Reviews of
Effectiveness and Cochrane Register of Controlled Trial, the ACP Journal
Club, MEDLINE, and Embase for studies published between 1966 and June
2002 in any language. To filter MEDLINE and Embase search results for
RCT evidence, the librarians used the search strategy developed by the
Cochrane Collaboration (full strategy available in Appendix online at:
<http://www.chestjournal.org/content/vol126/3_suppl_1>).

For observational studies, they restricted their searches to human
studies. Searches were not further restricted in terms of methodology.
While increasing the probability of identifying all published studies,
this sensitive approach resulted in large number of citations for many
of the defined clinical questions. Therefore, trained research
assistants screened the citation list developed from the search and
removed any apparently irrelevant citations. These irrelevant citations
included press news, editorials, narrative reviews, single case reports,
animal studies (any nonhuman studies), and letters to the editor.
Authors included data from abstracts of recent meetings if reporting was
transparent and all necessary data for the formulation of a
recommendation were available. The guideline developers did not
explicitly use Internet sources to search for research data.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

The rating scheme framework captures the trade-off between benefits and
risks (1 or 2) (and the methodological quality of the underlying
evidence (A, B, C+, or C). See \"Rating Scheme for the Strength of the
Recommendations.\"

#### METHODS USED TO ANALYZE THE EVIDENCE

Meta-Analysis of Randomized Controlled Trials\
Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

**Summarizing Evidence**

The electronic searches also included searching for systematic reviews.
If authors were satisfied with a recent high-quality systematic review,
evidence from that review provided a foundation for the relevant
recommendation.

Pooled analyses from high-quality systematic reviews formed, wherever
possible, the evidence base of the recommendations. Pooling offers the
advantage of obtaining more precise estimates of treatment effects and
allows for a greater generalizability of results. However, pooling also
bears the risk of spurious generalization. In general, the summary
estimates of interest were the different types of outcomes conveying
benefit and downsides (i.e., risk, burden, and cost).

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus (Consensus Development Conference)

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The strength of any recommendation depends on the following two factors:
the trade-off between the benefits and the risks, burdens, and costs;
and the strength of the methodology that leads to the treatment effect.
The guideline developers grade the trade-off between benefits and risks
in the two categories: 1, in which the trade-off is clear enough that
most patients, despite differences in values, would make the same
choice; and 2, in which the trade-off is less clear, and individual
patients´ values will likely lead to different choices.

When randomized trials provide precise estimates suggesting large
treatment effects, and the risks and costs of therapy are small,
treatment for average patients with compatible values and preferences
can be confidently recommended.

If the balance between benefits and risks is in doubt, methodologically
rigorous studies providing **Grade A** evidence and recommendations may
still be weak (**Grade 2**). Uncertainty may come from less precise
estimates of benefit, harm, or costs, or from small effect sizes.

There is an independent impact of validity and consistency, and the
balance of positive and negative impacts of treatment on the strength of
recommendations. In situations in which there is doubt about the value
of the trade-off, any recommendation will be weaker, moving from **Grade
1** to **Grade 2**.

**Grade 1** recommendations can only be made when there is a relatively
clear picture of both the benefits and the risks, burdens, and costs,
and when the balance between the two clearly favors recommending or not
recommending the intervention for the typical patient with compatible
values and preferences. A number of factors can reduce the strength of a
recommendation, moving it from **Grade 1** to **Grade 2**. Uncertainty
about a recommendation to treat may be introduced if the following
conditions apply: (1) the target event that is trying to be prevented is
less important (confident recommendations are more likely to be made to
prevent death or stroke than asymptomatic deep vein thrombosis); (2) the
magnitude of risk reduction in the overall group is small; (3) the
probability of the target event is low in a particular subgroup of
patients; (4) the estimate of the treatment effect is imprecise, as
reflected in a wide confidence interval (CI) around the effect; (5)
there is substantial potential harm associated with therapy; or (6)
there is an expectation for a wide divergence in values even among
average or typical patients. Higher costs would also lead to weaker
recommendations to treat.

The more balanced the trade-off between benefits and risks, the greater
the influence of individual patient values in decision making. Virtually
all patients, if they understand the benefits and risks, will take
aspirin after experiencing a myocardial infarction (MI) or will comply
with prophylaxis to reduce the risk of thromboembolism after undergoing
hip replacement. Thus, one way of thinking about a **Grade 1**
recommendation is that variability in patient values is unlikely to
influence treatment choice in average or typical patients.

When the trade-off between benefits and risks is less clear, individual
patient values may influence treatment decisions even among patients
with average or typical preferences.

**Grade 2** recommendations are those in which variation in patient
values or individual physician values will often mandate different
treatment choices, even among average or typical patients. An
alternative, but similar, interpretation is that a **Grade 2**
recommendation suggests that clinicians conduct detailed conversations
with patients to ensure that their ultimate recommendation is consistent
with the patient\'s values.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

  ------------------------------------------------------------------------------
  **Grade of         **Clarity of     **Methodological   **Implications**
  Recommendation**   Risk/Benefit**   Strength of        
                                      Supporting         
                                      Evidence**         
  ------------------ ---------------- ------------------ -----------------------
  **1A**             Clear            Randomized         Strong recommendation;
                                      controlled trials  can apply to most
                                      (RCTs) without     patients in most
                                      important          circumstances without
                                      limitations        reservation

  **1C+**            Clear            No RCTs, but       Strong recommendation;
                                      strong RCT results can apply to most
                                      can be             patients in most
                                      unequivocally      circumstances
                                      extrapolated, or   
                                      overwhelming       
                                      evidence from      
                                      observational      
                                      studies            

  **1B**             Clear            RCTs with          Strong recommendation;
                                      important          likely to apply to most
                                      limitations        patients
                                      (inconsistent      
                                      results,           
                                      methodological     
                                      flaws\*)           

  **1C**             Clear            Observational      Intermediate-strength
                                      studies            recommendation; may
                                                         change when stronger
                                                         evidence is available

  **2A**             Unclear          RCTs without       Intermediate-strength
                                      important          recommendation; best
                                      limitations        action may differ
                                                         depending on
                                                         circumstances or
                                                         patients\' or societal
                                                         values

  **2C+**            Unclear          No RCTs, but       Weak recommendation;
                                      strong RCT results best action may differ
                                      can be             depending on
                                      unequivocally      circumstances or
                                      extrapolated, or   patients\' or societal
                                      overwhelming       values
                                      evidence from      
                                      observational      
                                      studies            

  **2B**             Unclear          RCTs with          Weak recommendation;
                                      important          alternative approaches
                                      limitations        likely to be better for
                                      (inconsistent      some patients under
                                      results,           some circumstances
                                      methodological     
                                      flaws\*)           

  **2C**             Unclear          Observational      Very weak
                                      studies            recommendation; other
                                                         alternatives may be
                                                         equally reasonable
  ------------------------------------------------------------------------------

*\*These situations include RCTs with both lack of blinding and
subjective outcomes, where the risk of bias in measurement of outcomes
is high, or RCTs with large loss to follow-up.*

#### COST ANALYSIS

While conference participants agreed that recommendations should reflect
economic considerations, incorporating costs is fraught with difficult
challenges. For most recommendations, formal economic analyses are
unavailable. Even when analyses are available, they may be
methodologically weak or biased. Furthermore, costs differ radically
across jurisdictions, and even sometimes across hospitals within
jurisdictions.

Because of these challenges, the guideline developers consider economic
factors only when the costs of one therapeutic option over another are
substantially different within major jurisdictions in which clinicians
make use of these recommendations. As a result, in jurisdictions in
which resource constraints are severe, alternative allocations may serve
the health of the public far better than some of the interventions that
are designated as **Grade 1A**. This will likely be true for all less
industrialized countries and, with the increasing promotion of expensive
drugs with marginal benefits, may be increasingly true for wealthier
nations. Furthermore, recommendations change (either in direction or
with respect to grade) only when the guideline developers believe that
costs are high in relation to benefits. Instances in which costs have
influenced recommendations are labeled in the \"values and preferences\"
statements associated with the recommendation.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The guideline authors formulated draft recommendations prior to the
conference that served as the foundation for authors to work together
and critique the recommendations. Drafts of all articles including draft
recommendations were available for review during the conference. A
representative of each article presented potentially controversial
issues in their recommendations at plenary meetings. Article authors met
to integrate feedback, to consider related recommendations in other
articles, and to revise their own guidelines accordingly. Authors
continued this process after the conference until they reached agreement
within their groups and with other author groups who had provided
critical feedback. Finally, the editors of this supplement harmonized
the articles and resolved remaining disagreements through facilitated
discussion.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The rating scheme is defined at the end of the \"Major Recommendations\"
field.

**[Prevention of Saphenous Vein Graft Occlusion Following Coronary
Artery Bypass Grafting (CABG)]{.underline}**

**Treatment with Antiplatelet Agents**

1.  For all patients with coronary artery disease, the guideline
    developers recommend aspirin, 75 to 162 mg/day, indefinitely
    (**Grade 1A**).

2.  For patients undergoing CABG, the guideline developers recommend
    aspirin, 75 to 162 mg/day, starting 6 hours after operation over
    preoperative aspirin (**Grade 1A**).

3.  In patients in whom bleeding prevents the administration of aspirin
    at 6 hours after CABG, the guideline developers recommend starting
    aspirin as soon as possible thereafter (**Grade 1C**).

> *Underlying values and preferences*: This recommendation places a
> relatively high value on avoiding cardiovascular complications and a
> relatively low value on avoiding bleeding complications.

4.  For patients undergoing CABG, the guideline developers recommend
    **against** the addition of dipyridamole to aspirin therapy (**Grade
    1A**).

5.  For patients with coronary artery disease undergoing CABG who are
    allergic to aspirin, the guideline developers recommend clopidogrel,
    300 mg, as a loading dose 6 hours after operation followed by 75
    mg/day orally (po) (**Grade 1C+**).

6.  In patients who undergo CABG for non-ST-segment elevation acute
    coronary syndrome (ACS), the guideline developers recommend
    clopidogrel, 75 mg/day, for 9 to 12 months following the procedure
    in addition to treatment with aspirin (**Grade 1A**).

> *Underlying values and preferences*: This recommendation places a
> relatively high value on avoiding myocardial infarction and a
> relatively low value on avoiding bleeding complications.

7.  For patients who received clopidogrel for ACS and are scheduled for
    coronary bypass surgery, the guideline developers recommend
    discontinuing clopidogrel for 5 days prior to the scheduled surgery
    (**Grade 2A**).

**Treatment with Oral Anticoagulants**

1.  For patients undergoing CABG who have no other indication for
    vitamin K antagonists (VKAs), the guideline developers suggest
    clinicians **not** administer VKAs (**Grade 2B**).

2.  For patients undergoing CABG in whom oral anticoagulants are
    indicated, such as those with heart valve replacement, the guideline
    developers suggest clinicians administer VKAs in addition to aspirin
    (**Grade 2C**).

**[Prevention of Internal Mammary Bypass Graft Occlusion Following
CABG]{.underline}**

**Aspirin with and without Dipyridamole**

1.  For all patients with coronary artery disease who undergo internal
    mammary artery (IMA) bypass grafting, the guideline developers
    recommend aspirin, 75 to 162 mg/day, indefinitely (**Grade 1A**).

> *Remarks*: This recommendation reflects that aspirin is indicated in
> all patients with coronary artery disease, irrespective of its effects
> on graft patency (Refer to the National Guideline Clearinghouse (NGC)
> summary of the American College of Chest Physicians (ACCP) guideline
> [Antithrombotic Therapy for Coronary Artery
> Disease](http://www.guideline.gov/summary/summary.aspx?doc_id=5897&nbr=3883)).

**VKAs**

1.  For all patients undergoing IMA bypass grafting who have no other
    indication for VKAs, the guideline developers suggest clinicians
    **not** use VKAs (**Grade 2C**).

**[Definitions]{.underline}**

  ------------------------------------------------------------------------------
  **Grade of         **Clarity of     **Methodological   **Implications**
  Recommendation**   Risk/Benefit**   Strength of        
                                      Supporting         
                                      Evidence**         
  ------------------ ---------------- ------------------ -----------------------
  **1A**             Clear            Randomized         Strong recommendation;
                                      controlled trials  can apply to most
                                      (RCTs) without     patients in most
                                      important          circumstances without
                                      limitations        reservation

  **1C+**            Clear            No RCTs, but       Strong recommendation;
                                      strong RCT results can apply to most
                                      can be             patients in most
                                      unequivocally      circumstances
                                      extrapolated, or   
                                      overwhelming       
                                      evidence from      
                                      observational      
                                      studies            

  **1B**             Clear            RCTs with          Strong recommendation;
                                      important          likely to apply to most
                                      limitations        patients
                                      (inconsistent      
                                      results,           
                                      methodological     
                                      flaws\*)           

  **1C**             Clear            Observational      Intermediate-strength
                                      studies            recommendation; may
                                                         change when stronger
                                                         evidence is available

  **2A**             Unclear          RCTs without       Intermediate-strength
                                      important          recommendation; best
                                      limitations        action may differ
                                                         depending on
                                                         circumstances or
                                                         patients\' or societal
                                                         values

  **2C+**            Unclear          No RCTs, but       Weak recommendation;
                                      strong RCT results best action may differ
                                      can be             depending on
                                      unequivocally      circumstances or
                                      extrapolated, or   patients\' or societal
                                      overwhelming       values
                                      evidence from      
                                      observational      
                                      studies            

  **2B**             Unclear          RCTs with          Weak recommendation;
                                      important          alternative approaches
                                      limitations        likely to be better for
                                      (inconsistent      some patients under
                                      results,           some circumstances
                                      methodological     
                                      flaws\*)           

  **2C**             Unclear          Observational      Very weak
                                      studies            recommendation; other
                                                         alternatives may be
                                                         equally reasonable
  ------------------------------------------------------------------------------

*\*These situations include RCTs with both lack of blinding and
subjective outcomes, where the risk of bias in measurement of outcomes
is high, or RCTs with large loss to follow-up.*

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Antithrombotic therapy has the potential for improving patency rates in
saphenous vein and internal mammary bypass grafts, and thus preventing
vein graft occlusion.

#### POTENTIAL HARMS

Bleeding is the primary complication of antithrombotic therapy in
patients with saphenous vein bypass grafts.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

**Interpreting the Recommendations**

Clinicians, third-party payers, institutional review committees, or the
courts should not construe these guidelines in any way as absolute
dictates. In general, anything other than a **Grade 1A** recommendation
indicates that the article authors acknowledge that other
interpretations of the evidence, and other clinical policies, may be
reasonable and appropriate. Even **Grade 1A** recommendations will not
apply to all circumstances and all patients. For instance, the guideline
developers have been conservative in their considerations of cost and
have seldom downgraded recommendations from **Grade 1** to **Grade 2**
on the basis of expense. As a result, in jurisdictions in which resource
constraints are severe, alternative allocations may serve the health of
the public far better than some of the interventions that are designated
as **Grade 1A**. This will likely be true for all less industrialized
countries and, with the increasing promotion of expensive drugs with
marginal benefits, may be increasingly true for wealthier nations.

Similarly, following **Grade 1A** recommendations will at times not
serve the best interests of patients with atypical values or preferences
or of those whose risks differ markedly from those of the usual patient.
For instance, consider patients who find anticoagulant therapy extremely
aversive, either because it interferes with their lifestyle (e.g.,
prevents participation in contact sports) or because of the need for
monitoring. Clinicians may reasonably conclude that following some
**Grade 1A** recommendations for anticoagulation therapy for either
group of patients will be a mistake. The same may be true for patients
with particular comorbidities (e.g., a recent gastrointestinal bleed or
a balance disorder with repeated falls) or other special circumstances
(e.g., very advanced age) that put them at unusual risk.

The guideline developers trust that these observations convey their
acknowledgment that no recommendations or clinical practice guidelines
can take into account the often compelling and unique features of
individual clinical circumstances. No clinician, and no body charged
with evaluating a clinician´s actions, should attempt to apply these
recommendations in a rote or blanket fashion.

**Limitations of Guideline Development Methods**

The limitations of these guidelines include the possibility that some
authors followed this methodology more closely than others, although the
development process was centralized and supervised by the editors.
Second, it is possible that the guideline developers missed relevant
studies despite the comprehensive searching process. Third, the
guideline developers did not centralize the methodological evaluation of
all studies to facilitate uniformity in the validity assessments of the
research incorporated into these guidelines. Fourth, if high-quality
meta-analyses were unavailable, the guideline developers did not
statistically pool primary study results using meta-analysis. Finally,
sparse data on patient preferences and values, resources, and other
costs represent additional limitations that are inherent to most
guideline development methods.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

**Guideline Implementation Strategies**

A full review of implementation strategies for practice guidelines is
provided in the companion document titled \"Antithrombotic and
Antithrombolytic Therapy: From Evidence to Application.\" The review
suggests that there are few implementation strategies that are of
unequivocal, consistent benefit, and that are clearly and consistently
worth resource investment. The following is a summary of the
recommendations (see \"Major Recommendations\" for a definition of the
recommendation grades).

To encourage uptake of guidelines, the guideline developers recommend
that appreciable resources be devoted to distribution of educational
material (**Grade 2B**).

They also suggest that:

-   Few resources be devoted to educational meetings (**Grade 2B**)

-   Few resources be devoted to educational outreach visits (**Grade
    2A**)

-   Appreciable resources be devoted to computer reminders (**Grade
    2A**)

-   Appreciable resources be devoted to patient-mediated interventions
    to encourage uptake of the guidelines (**Grade 2B**)

-   Few resources be devoted to audit and feedback (**Grade 2B**)

#### IMPLEMENTATION TOOLS

Patient Resources\
Personal Digital Assistant (PDA) Downloads\
Quick Reference Guides/Physician Guides\
Resources\
Slide Presentation\
Tool Kits

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Stein PD, Schunemann HJ, Dalen JE, Gutterman D. Antithrombotic therapy
in patients with saphenous vein and internal mammary artery bypass
grafts: the Seventh ACCP Conference on Antithrombotic and Thrombolytic
Therapy. Chest 2004 Sep;126(3 Suppl):600S-8S. \[49 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15383486)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2001 Jan (revised 2004 Sep)

#### GUIDELINE DEVELOPER(S)

American College of Chest Physicians - Medical Specialty Society

#### SOURCE(S) OF FUNDING

Funding was provided through an unrestricted educational grant by
AstraZeneca LP, Aventis Pharmaceuticals, GlaxoSmithKline, Bristol-Myer
Squibb/Sanofi-Synthelabo Partnership, and Organon Sanofi-Synthelabo LLC.

#### GUIDELINE COMMITTEE

American College of Chest Physicians Consensus Panel on Antithrombotic
and Thrombolytic Therapy

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Primary Authors*: Paul D. Stein, MD, FCCP (Chairman); Holger J.
Schünemann, MD, PhD, FCCP; James E. Dalen, MD, Master FCCP; David
Gutterman, MD, FCCP

*Committee Co-Chairs*: Jack Hirsh, MD, FCCP (Chair); Gregory W. Albers,
MD; Gordon H. Guyatt, MD, MSc; Holger J. Schünemann, MD, MSc, PhD, FCCP

*Participants*: Giancarlo Agnelli, MD; Amin Al-Ahmad, MD; Pierre
Amarenco, MD; Jack E. Ansell, MD; Shannon M. Bates, MD; Richard C.
Becker, MD; Peter B. Berger, MD; David Bergqvist, MD, PhD, FRCS; Rebecca
J. Beyth, MD, MSc; Stewart Brower, MLIS; Harry R. Buller, MD; Henry I.
Bussey, PharmD, FCCP; Christopher P. Cannon, MD, FACC; Elizabeth A.
Chalmers, MB, ChB, MD, MRCP(UK). FRCPath; Anthony K.C. Chan, MD; G.
Patrick Clagett, MD; Barry Coller, MD; Clifford W. Colwell, MD; Deborah
Cook, MD, MSc; James E. Dalen, MD, MPH, FCCP; J. Donald Easton, MD;
Michael Ezekowitz, MD; Garret A. Fitzgerald, MD; William H. Geerts, MD,
FCCP; Jeffrey S. Ginsberg, MD, FCCP; Alan S. Go, MD; Shaun D. Goodman,
MD, FACC; Ian A. Greer, MD, FRCP, FRCOG; Andreas Greinacher, MD; Jeremy
Grimshaw, MD, PhD; Cindy Grines, MD; Jonathan L. Halperin, MD; Robert A.
Harrington, MD; John Heffner, MD, MPH; John A. Heit, MD; Judith S.
Hochman, MD, FACC; Dieter Horstkotte, MD, FESC; Russell D. Hull, MBBS,
MSc, FCCP; Elaine Hylek, MD; Thomas M. Hyers, MD, FCCP; Mark R. Jackson,
MD; Alan Jacobson, MD; Roman Jaeschke, MD, MSc; Ajay Kakkar BSc, PhD;
Clive Kearon, MD, PhD, FCCP; Matthew Kraay; Michael R. Lassen, MD; Mark
N. Levine, MD, MSc; Alessandro Liberati, MD; Gregory YH Lip, MD, FESC,
FACC; Warren J. Manning, MD; M. Patricia Massicotte, MD, MSc, FRCPC,
MSc; Thomas W. Meade, MD; Venu Menon, MD, FACC; Alan D. Michelson, MD;
Nancy Miller, RN; Paul Monagle, MBBS, MSc, MD, FRACP, FRCPA, FCCP;
Heather Munger, MLS; Christopher M. O´Connor, MD; Martin O´Donnell, MD;
E. Magnus Ohman, MD, FCCP; Carlo Patrono, MD; Stephen G. Pauker, MD;
Graham F. Pineo, MD; Leon Poller, MD; Jeffrey J. Popma, MD; Martin H.
Prins, MD; Robert Raschke, MD, MS; Gary Raskob, PhD; Joel G. Ray, MD,
MSc; Gerald Roth, MD; Ralph L. Sacco, MD; Deeb N. Salem, MD, FCCP; Meyer
M. Samama, MD; Andrew Schafer; Sam Schulman, MD, PhD; Daniel Singer, MD;
Michael Sobel, MD; Paul D. Stein, MD, FCCP; Marco Tangelder, MD; Victor
F. Tapson, MD, FCCP; Philip Teal, MD; Raymond Verhaeghe, MD; David A.
Vorchheimer, MD; Theodore E. Warkentin, MD; Jeffrey Weitz, MD; Robert G.
Wilcox, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Dr. Stein received honoraria for speaking at educational events from
Aventis Pharma and Dupont Pharma. He was a consultant for Shiley several
years ago.

Dr. Schünemann has received research funding from AstraZeneca,
Boehringer Ingelheim, Pfizer, and Amgen Inc. He has received honoraria
and consultant fees from AstraZeneca, Boehringer Ingelheim, and Amgen
that were deposited into research accounts at the University of Buffalo
and McMaster University.

Dr. Dalen has received honoraria as a consultant for DuPont Pharma (now
Bristol-Myers Squibb), AstraZeneca and Sanofi-Organon.

Dr. Gutterman owns stock in Johnson & Johnson.

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Stein PD, Dalen JE, Goldman
S, Theroux P. Antithrombotic therapy in patients with saphenous vein and
internal mammary artery bypass grafts. Chest 2001 Jan;119(1
Suppl):278S-282S.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [Chest - The Cardiopulmonary and
Critical Care
Journal](http://www.chestjournal.org/content/vol126/3_suppl/).

Print copies: Available from the American College of Chest Physicians,
Products and Registration Division, 3300 Dundee Road, Northbrook IL
60062-2348.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   The Seventh ACCP Conference on Antithrombotic and Thrombolytic
    Therapy. Evidence-based guidelines. Northbrook, IL: ACCP, 2004 Sep.

-   Methodology for guideline development for the Seventh American
    College of Chest Physicians Conference on Antithrombotic and
    Thrombolytic Therapy. Northbrook, IL: ACCP, 2004 Sep.

-   Applying the grades of recommendation for antithrombotic and
    thrombolytic therapy: The Seventh ACCP Conference on Antithrombotic
    and Thrombolytic Therapy. Northbrook, IL: ACCP, 2004 Sep.

-   Hemorrhagic complications of anticoagulant treatment: The Seventh
    ACCP Conference on Antithrombotic and Thrombolytic Therapy.
    Northbrook, IL: ACCP, 2004 Sep.

-   Antithrombotic and thrombolytic therapy: from evidence to
    application: The Seventh ACCP Conference on Antithrombotic and
    Thrombolytic Therapy. Northbrook, IL: ACCP, 2004 Sep.

-   Platelet-active drugs: the relationships among dose, effectiveness,
    and side effects: The Seventh ACCP Conference on Antithrombotic and
    Thrombolytic Therapy. Northbrook, IL: ACCP, 2004 Sep.

Electronic copies: Available from the [Chest - The Cardiopulmonary and
Critical Care Journal Web
site](http://www.chestjournal.org/content/vol126/3_suppl/).

Print copies: Available from the American College of Chest Physicians
(ACCP), Products and Registration Division, 3300 Dundee Road, Northbrook
IL 60062-2348.

The following is also available:

-   Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy:
    Evidence-based guidelines; quick reference guide. Northbrook, IL:
    ACCP, 2004 Sep. Personal Digital Assistant (PDA) download available
    at [ACCP Web site](http://accp.apprisor.com/dlselect.cfm).

Additional implementation tools are also available:

-   Clinical resource: antithrombotic and thrombolytic therapy.
    Northbrook, IL. ACCP, 2004. Ordering information: Available from the
    [ACCP Web
    site](http://www.chestnet.org/education/guidelines/products.php).

#### PATIENT RESOURCES

The following is available:

-   A patient\'s guide to antithrombotic and thrombolytic therapy. In:
    Clinical resource: antithrombotic and thrombolytic therapy.
    Northbrook (IL): American College of Chest Physicians (ACCP). 2004.

Ordering information is available from the [ACCP Web
site](http://www.chestnet.org/education/guidelines/products.php).

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This summary was completed by ECRI on July 30, 2001. The information was
verified by the guideline developer on September 27, 2001. This NGC
summary was updated by ECRI on December 9, 2004. The updated information
was verified by the guideline developer on January 12, 2005.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

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Date Modified: 11/3/2008