Chapter 9Chapter 9

Medications that Affect Medications that Affect CoagulationCoagulation

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Objective 1Objective 1

Define terms related to blood coagulation and Define terms related to blood coagulation and medications that affect coagulation.medications that affect coagulation.

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Objective 1Objective 1

AnticoagulantsAnticoagulants Agents that inhibit blood clottingAgents that inhibit blood clotting

Coagulation (clotting) factorsCoagulation (clotting) factors A series of twelve factors essential to normal blood clottingA series of twelve factors essential to normal blood clotting

CoagulantsCoagulants Agents that promote, accelerate, or make possible blood coagulationAgents that promote, accelerate, or make possible blood coagulation

HemostaticsHemostatics Agents that enhance clot formation and reduce bleedingAgents that enhance clot formation and reduce bleeding

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Objective 1Objective 1

ParenteralParenteral Administration route other than the alimentary canal (e.g., Administration route other than the alimentary canal (e.g.,

intramuscular, intravenous, subcutaneous)intramuscular, intravenous, subcutaneous) Platelet aggregationPlatelet aggregation

Clumping together of platelets; part of a sequential Clumping together of platelets; part of a sequential mechanism leading to blood clot (thrombus) formationmechanism leading to blood clot (thrombus) formation

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Objective 1Objective 1

SystemicSystemic Pertaining to or affecting the body as a wholePertaining to or affecting the body as a whole

Thrombolytics (fibrinolytics)Thrombolytics (fibrinolytics) Agents that dissolve blood clotsAgents that dissolve blood clots

ThrombosisThrombosis Abnormal formation or presence of a blood clot within a Abnormal formation or presence of a blood clot within a

blood vesselblood vessel

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Objective 2Objective 2

Describe the physiology of blood clot Describe the physiology of blood clot formation.formation.

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Objective 2. Physiology of ClottingObjective 2. Physiology of Clotting

Blood naturally hasBlood naturally has CoagulantsCoagulants AnticoagulantsAnticoagulants

Blood must flow smoothlyBlood must flow smoothly But not from a damaged vesselBut not from a damaged vessel

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Objective 2. Physiology of ClottingObjective 2. Physiology of Clotting

Natural coagulantsNatural coagulants For small vessels onlyFor small vessels only

• Example: paper cut on fingerExample: paper cut on finger

Prevents some blood lossPrevents some blood loss

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Objective 2. Physiology of ClottingObjective 2. Physiology of Clotting

Natural anticoagulantsNatural anticoagulants Prevent undesired clotting in undamaged vesselsPrevent undesired clotting in undamaged vessels Interfere with clotting sequenceInterfere with clotting sequence

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Objective 2. Physiology of ClottingObjective 2. Physiology of Clotting

Physiology of clotting is aPhysiology of clotting is a Cascade in 3 stagesCascade in 3 stages

Stage 1: thromboplastinStage 1: thromboplastin Stage 2: thrombinStage 2: thrombin Stage 3: fibrinStage 3: fibrin

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Objective 2. Physiology of ClottingObjective 2. Physiology of Clotting

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Objective 2. Physiology of ClottingObjective 2. Physiology of Clotting

Stage 1: 2 mechanismsStage 1: 2 mechanisms Extrinsic — initiated byExtrinsic — initiated by

• Factors outside bloodFactors outside blood

Intrinsic — initiated byIntrinsic — initiated by• Factors contained in bloodFactors contained in blood

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Objective 2. Physiology of ClottingObjective 2. Physiology of Clotting

Stage 1: extrinsicStage 1: extrinsic Damaged tissue releasesDamaged tissue releases Factor III (t. thromboplastin)Factor III (t. thromboplastin) Plus factor VIII and CaPlus factor VIII and Ca++ = = Activated factor X, plus factor V plus CaActivated factor X, plus factor V plus Ca++ = thromboplastin = thromboplastin

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Objective 2. Physiology of ClottingObjective 2. Physiology of Clotting

Stage 1: intrinsicStage 1: intrinsic Damaged vessel releasesDamaged vessel releases Factor XII activates factor XIFactor XII activates factor XI Activates factor IXActivates factor IX Factor VIII and CaFactor VIII and Ca++ = = Activated factor X, plus factor V plus CaActivated factor X, plus factor V plus Ca++ = thromboplastin = thromboplastin

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Objective 2. Physiology of ClottingObjective 2. Physiology of Clotting

So, Stage 1 is the formation of: So, Stage 1 is the formation of: ThromboplastinThromboplastin

(Prothrombin activator)(Prothrombin activator) Two pathways to achieve itTwo pathways to achieve it

IntrinsicIntrinsic ExtrinsicExtrinsic

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Objective 2. Physiology of ClottingObjective 2. Physiology of Clotting

Stage 2: Stage 2: Thromboplastin convertsThromboplastin converts

Prothrombin (factor II)Prothrombin (factor II) into thrombininto thrombin

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Objective 2. Physiology of ClottingObjective 2. Physiology of Clotting

Stage 3: Stage 3: Thrombin convertsThrombin converts

Fibrinogen (factor I)Fibrinogen (factor I) into fibrininto fibrin

Fibrin is a mesh of protein threads; a net to form Fibrin is a mesh of protein threads; a net to form clot.clot.

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Objective 2. Physiology of ClottingObjective 2. Physiology of Clotting

A cascade requires many substancesA cascade requires many substances In the correct amountIn the correct amount At the correct time At the correct time

Remove 1 substance = no cascade = no clotRemove 1 substance = no cascade = no clot

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Objective 2. Physiology of ClottingObjective 2. Physiology of Clotting

Calcium (CaCalcium (Ca++) is required at all stages to enable ) is required at all stages to enable critical steps.critical steps.

Vitamin K is also required to synthesize several Vitamin K is also required to synthesize several factors.factors.

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Objective 2. Physiology of ClottingObjective 2. Physiology of Clotting

Clotting in an intact vesselClotting in an intact vessel ThrombosisThrombosis

Arterial requires surgeryArterial requires surgery Venous usually treated medicallyVenous usually treated medically

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Objective 3Objective 3

List agents that affect coagulation by List agents that affect coagulation by category.category. Presented under the discussion of each categoryPresented under the discussion of each category Make drug cards for eachMake drug cards for each

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Objective 4Objective 4

Identify the category of various agents that Identify the category of various agents that effect coagulation.effect coagulation. Each category will be presented with discussion.Each category will be presented with discussion.

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Objective 5Objective 5

State the purpose of each category of State the purpose of each category of medications that effect coagulation.medications that effect coagulation. Presented during discussion Presented during discussion

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Objective 6Objective 6

Describe the action of medications that affect Describe the action of medications that affect coagulation.coagulation. Presented during discussion of each agent.Presented during discussion of each agent.

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Objective 7Objective 7

List uses, routes of administration, side effects, List uses, routes of administration, side effects, and contraindications for agents that affect and contraindications for agents that affect coagulation.coagulation.

– Presented during discussion of each agent.Presented during discussion of each agent.

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Note: all categories/agentsNote: all categories/agents

These categories and agents do one of two These categories and agents do one of two things:things: Assist natural clotting orAssist natural clotting or Prevent natural clottingPrevent natural clotting

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CoagulantsCoagulants

Category: (objective 4)Category: (objective 4) HemostaticsHemostatics

Purpose: (objective 5)Purpose: (objective 5) Promote, accelerate, or make possible blood Promote, accelerate, or make possible blood

clottingclotting

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Coagulants:Coagulants: HemostaticsHemostatics

Agents: (objective 3)Agents: (objective 3) Absorbable gelatinAbsorbable gelatin

Action: (objective 6)Action: (objective 6) Primarily mechanical, with pressure to Primarily mechanical, with pressure to

promote clot formationpromote clot formation

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Objective 7. Absorbable GelatinObjective 7. Absorbable Gelatin

UsesUses General surgery, otologic, orthopedic, General surgery, otologic, orthopedic,

neurosurgery neurosurgery Administration routesAdministration routes

Topical onlyTopical only

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Objective 7. Absorbable GelatinObjective 7. Absorbable Gelatin

Side effectsSide effects N/AN/A

ContraindicationsContraindications Presence of infectionPresence of infection

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Coagulants:Coagulants: HemostaticsHemostatics

Agents: (objective 3)Agents: (objective 3) Microfibrillar collagenMicrofibrillar collagen

• Avitene; Instat MCHAvitene; Instat MCH

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Coagulants:Coagulants: HemostaticsHemostatics

Microfibrillar collagenMicrofibrillar collagen Action: (objective 6)Action: (objective 6)

Attracts platelets; triggers platelet aggregationAttracts platelets; triggers platelet aggregation

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Objective 7. Microfibrillar CollagenObjective 7. Microfibrillar Collagen

UsesUses General surgery, otologic, orthopedic, General surgery, otologic, orthopedic,

neurosurgery neurosurgery Administration routesAdministration routes

Topical onlyTopical only

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Objective 7. Microfibrillar CollagenObjective 7. Microfibrillar Collagen

Side effectsSide effects N/AN/A

ContraindicationsContraindications presence of infectionpresence of infection

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CoagulantsCoagulants: : HemostaticsHemostatics

Agents: (objective 3)Agents: (objective 3) Oxidized celluloseOxidized cellulose

• Surgicel, OxycelSurgicel, Oxycel

Action: (objective 6)Action: (objective 6) Serves as a nucleus for clottingServes as a nucleus for clotting

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Objective 7. Oxidized CelluloseObjective 7. Oxidized Cellulose

UsesUses Neurosurgery, otorhinolaryngologyNeurosurgery, otorhinolaryngology

Administration routesAdministration routes Topical onlyTopical only

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Objective 7. Oxidized CelluloseObjective 7. Oxidized Cellulose

Side effectsSide effects N/AN/A

ContraindicationsContraindications Presence of infectionPresence of infection

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Coagulants:Coagulants: HemostaticsHemostatics

Agents: (Objective 3)Agents: (Objective 3) Absorbable collagen spongeAbsorbable collagen sponge

• Hemopad, Helistat, CollastatHemopad, Helistat, Collastat

Action: (Objective 6)Action: (Objective 6) Promotes platelet aggregationPromotes platelet aggregation

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Objective 7. Absorbable Collagen SpongeObjective 7. Absorbable Collagen Sponge

UsesUses General surgeryGeneral surgery

Administration routesAdministration routes Topical onlyTopical only

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Objective 7. Absorbable Collagen Objective 7. Absorbable Collagen SpongeSponge

Side effectsSide effects N/AN/A

ContraindicationsContraindications Not used on bone when using cementNot used on bone when using cement

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Objective 7. Absorbable Collagen Objective 7. Absorbable Collagen SpongeSponge

Agent: SuperstatAgent: Superstat Contains calciumContains calcium

Action: Action: Activates body’s coagulation mechanismActivates body’s coagulation mechanism

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Objective 7. Absorbable Collagen Objective 7. Absorbable Collagen SpongeSponge

UsesUses General surgeryGeneral surgery

RouteRoute TopicalTopical

Side effectsSide effects N/AN/A

ContraindicationsContraindications NeurosurgeryNeurosurgery

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Coagulants:Coagulants: HemostaticsHemostatics

Agents: (Objective 3)Agents: (Objective 3) ThrombinThrombin

Action: (Objective 6)Action: (Objective 6) Catalyzing the conversion of fibrinogen to fibrinCatalyzing the conversion of fibrinogen to fibrin

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Objective 7. ThrombinObjective 7. Thrombin

UsesUses General surgeryGeneral surgery

Administration routesAdministration routes Topical Topical ONLYONLY Can cause systemic clotting if injected!Can cause systemic clotting if injected!

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Objective 7. ThrombinObjective 7. Thrombin

Side effectsSide effects N/AN/A

Contraindications – hypersensitivityContraindications – hypersensitivity

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Coagulants:Coagulants: HemostaticsHemostatics

Agents: (objective 3)Agents: (objective 3) Bone waxBone wax

Action: (objective 6)Action: (objective 6) Mechanical only, physical plugMechanical only, physical plug

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Objective 7. Bone WaxObjective 7. Bone Wax

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Objective 7. Bone WaxObjective 7. Bone Wax

UsesUses Orthopedics, neurosurgeryOrthopedics, neurosurgery

Administration routesAdministration routes TopicalTopical

Side effects Side effects N/AN/A

ContraindicationsContraindications HypersensitivityHypersensitivity

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Coagulants:Coagulants: HemostaticsHemostatics

Agents: (Objective 3)Agents: (Objective 3) Chemical HemostaticsChemical Hemostatics

• Tannic acidTannic acid

• Silver nitrateSilver nitrate

Action: (Objective 6)Action: (Objective 6) CauterizationCauterization

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Objective 7. Chemical HemostaticsObjective 7. Chemical Hemostatics

UsesUses Tannic acid (in combination)Tannic acid (in combination)

• TonsillectomyTonsillectomy

Silver nitrateSilver nitrate• Remove wartsRemove warts

Admin routeAdmin route TopicalTopical

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Objective 7. Chemical HemostaticsObjective 7. Chemical Hemostatics

Side effectsSide effects N/AN/A

ContraindicationsContraindications Not for use near eyesNot for use near eyes

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Coagulants:Coagulants: HemostaticsHemostatics

Agents: (Objective 3)Agents: (Objective 3) Chemical HemostaticsChemical Hemostatics

• Monsel’s solutionMonsel’s solution

Action: (Objective 6)Action: (Objective 6) CauterizationCauterization

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Objective 7. Monsel’s SolutionObjective 7. Monsel’s Solution

UsesUses Hemostasis for cervical cone biopsyHemostasis for cervical cone biopsy

Admin routeAdmin route TopicalTopical

Side effects Side effects N/AN/A

ContraindicationsContraindications N/AN/A

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Objective 7. Chemical HemostaticsObjective 7. Chemical Hemostatics

CAUTION:CAUTION: Do NOT confuse Monsel’s Do NOT confuse Monsel’s solution with Lugol’s solution, which is a solution with Lugol’s solution, which is a staining agentstaining agent

Both are iodine-based and brown in colorBoth are iodine-based and brown in color Both may be on back table for cervical Both may be on back table for cervical

conizationconization

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CoagulantsCoagulants

Category: (Objective 4)Category: (Objective 4) Systemic coagulantsSystemic coagulants

Purpose: (Objective 5)Purpose: (Objective 5) Replace deficiencies in natural clotting mechanismReplace deficiencies in natural clotting mechanism

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Coagulants:Coagulants: SystemicSystemic

Agents: (Objective 3)Agents: (Objective 3) Calcium saltsCalcium salts

Action: (Objective 6)Action: (Objective 6) Promotes clotting in all 3 stages of cascadePromotes clotting in all 3 stages of cascade

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Objective 7. Calcium saltsObjective 7. Calcium salts

UsesUses Replace deficiencyReplace deficiency Preoperative or intraoperativePreoperative or intraoperative

Administration routesAdministration routes Surgery — IVSurgery — IV Medical — oral or IMMedical — oral or IM

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Objective 7. Calcium saltsObjective 7. Calcium salts

Side effectsSide effects N/AN/A

ContraindicationsContraindications MH susceptible patientsMH susceptible patients

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Coagulants:Coagulants: SystemicSystemic

Agents: (Objective 3)Agents: (Objective 3) Vitamin KVitamin K

Action: (Objective 6)Action: (Objective 6) synthesis of prothrombin by liversynthesis of prothrombin by liver

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Objective 7. Vitamin KObjective 7. Vitamin K

Uses: replace deficiencyUses: replace deficiency PreoperativePreoperative

Administration routesAdministration routes SubcutaneousSubcutaneous RARE: IVRARE: IV

Side effects Side effects N/AN/A

ContraindicationsContraindications N/AN/A

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Coagulants:Coagulants: SystemicSystemic

Agents: (Objective 3)Agents: (Objective 3) Coagulation factorsCoagulation factors VIII (AHF) & IX complexVIII (AHF) & IX complex

Action: (Objective 6)Action: (Objective 6) Vital links in cascade Vital links in cascade

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Objective 7. Coagulation factorsObjective 7. Coagulation factors

Uses: replace deficiencyUses: replace deficiency PreoperativePreoperative

Administration routesAdministration routes IVIV

Side effectsSide effects N/AN/A

ContraindicationsContraindications N/AN/A

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AnticoagulantsAnticoagulants

Category: (Objective 4)Category: (Objective 4) Parenteral anticoagulantsParenteral anticoagulants

Purpose: (Objective 5)Purpose: (Objective 5) Prevent or interfere with clottingPrevent or interfere with clotting

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Anticoagulants: ParenteralAnticoagulants: Parenteral

Agents: (Objective 3)Agents: (Objective 3) HeparinHeparin

Action: (Objective 6)Action: (Objective 6) Inhibits factor X and thrombinInhibits factor X and thrombin Inhibits platelet aggregationInhibits platelet aggregation

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Objective 7. HeparinObjective 7. Heparin

UsesUses All vascular and cardiac surgeryAll vascular and cardiac surgery

Administration routesAdministration routes IV, subq IV, subq Topical (at surgical site)Topical (at surgical site)

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Objective 7. HeparinObjective 7. Heparin

Side effectsSide effects risk hemorrhagerisk hemorrhage ThrombocytopeniaThrombocytopenia

ContraindicationsContraindications Existing thrombocytopeniaExisting thrombocytopenia

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Objective 7. HeparinObjective 7. Heparin

Note: heparin strengths must be labeledNote: heparin strengths must be labeled

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Anticoagulants: ParenteralAnticoagulants: Parenteral

Agents: (Objective 3)Agents: (Objective 3) Enoxaparin (Lovenox)Enoxaparin (Lovenox) A LMW form of heparinA LMW form of heparin

Action: (Objective 6)Action: (Objective 6) Inhibits factor X and thrombinInhibits factor X and thrombin Inhibits platelet aggregationInhibits platelet aggregation

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Objective 7. LovenoxObjective 7. Lovenox

UsesUses Prevent DVT following hip or knee replacementPrevent DVT following hip or knee replacement Medical, not surgical useMedical, not surgical use

Administration routesAdministration routes Subcutaneous Subcutaneous

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Objective 7. LovenoxObjective 7. Lovenox

Side effectsSide effects Local irritation, painLocal irritation, pain Fever, nauseaFever, nausea

ContraindicationsContraindications Active major bleedingActive major bleeding HypersensitivityHypersensitivity

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AnticoagulantsAnticoagulants

Category: (Objective 4)Category: (Objective 4) Oral anticoagulantsOral anticoagulants

Purpose: (Objective 5)Purpose: (Objective 5) Long-term management of thromboembolic Long-term management of thromboembolic

diseasedisease• PE, DVT, CVAPE, DVT, CVA

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Anticoagulants: OralAnticoagulants: Oral

Agents: (Objective 3)Agents: (Objective 3) Warfarin (Coumadin)Warfarin (Coumadin)

Action: (Objective 6)Action: (Objective 6) Inhibits vitamin K activity in liverInhibits vitamin K activity in liver

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Objective 7. WarfarinObjective 7. Warfarin

UsesUses Long-term management of Long-term management of

• DVT, PE, CVADVT, PE, CVA

Administration routesAdministration routes OralOral

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Objective 7. WarfarinObjective 7. Warfarin

Side effectsSide effects Epistaxis, hematuria, bleeding gumsEpistaxis, hematuria, bleeding gums

ContraindicationsContraindications Do not use concurrently with aspirinDo not use concurrently with aspirin

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Objective 7. Warfarin and AspirinObjective 7. Warfarin and Aspirin

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Anticoagulants: OralAnticoagulants: Oral

Agents: (Objective 3)Agents: (Objective 3) AspirinAspirin

Action: (Objective 6)Action: (Objective 6) Inhibits platelet aggregationInhibits platelet aggregation

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Objective 7. aspirinObjective 7. aspirin

Uses (pertaining to clotting)Uses (pertaining to clotting) Post-MI, post-TIA: prevent additional clot Post-MI, post-TIA: prevent additional clot

formationformation Administration routesAdministration routes

OralOral

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Objective 7. AspirinObjective 7. Aspirin

Side effectsSide effects Normal bleeding time may be doubledNormal bleeding time may be doubled

ContraindicationsContraindications Not for use concurrent with warfarin therapyNot for use concurrent with warfarin therapy

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AnticoagulantsAnticoagulants

Category: (Objective 4)Category: (Objective 4) ThrombolyticsThrombolytics

Purpose: (Objective 5)Purpose: (Objective 5) Break down existing blood clotsBreak down existing blood clots

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Anticoagulants: ThrombolyticsAnticoagulants: Thrombolytics

Agents: (Objective 3)Agents: (Objective 3) Streptokinase, urokinase, antistreplaseStreptokinase, urokinase, antistreplase

Action: (Objective 6)Action: (Objective 6) Activate plasminogenActivate plasminogen

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Objective 7. ThrombolyticsObjective 7. Thrombolytics

UsesUses Acute MI w/coronary artery thrombosisAcute MI w/coronary artery thrombosis Treatment of DVT, PETreatment of DVT, PE

Administration routesAdministration routes IVIV

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Objective 7. ThrombolyticsObjective 7. Thrombolytics

Side effectsSide effects Hemorrhage, skin rash, itching, nausea, headacheHemorrhage, skin rash, itching, nausea, headache

ContraindicationsContraindications HypersensitivityHypersensitivity

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Anticoagulants: ThrombolyticsAnticoagulants: Thrombolytics

Agents: (Objective 3)Agents: (Objective 3) Alteplase (Activase)Alteplase (Activase)

Action: (Objective 6)Action: (Objective 6) Human enzyme; tissue-type plasminogen activator Human enzyme; tissue-type plasminogen activator

(tPA)(tPA)

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Objective 7. AlteplaseObjective 7. Alteplase

UsesUses Acute MI w/coronary artery thrombosisAcute MI w/coronary artery thrombosis Treatment of DVT, PE, CVATreatment of DVT, PE, CVA

Administration routeAdministration route IVIV

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Objective 7. AlteplaseObjective 7. Alteplase

Side effectsSide effects Fewer due to human origin of enzymeFewer due to human origin of enzyme

ContraindicationsContraindications N/AN/A

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Objective 8Objective 8

Describe the impact of preoperative oral Describe the impact of preoperative oral anticoagulant therapy on the surgical patient.anticoagulant therapy on the surgical patient.

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Objective 8Objective 8

Bleeding times will be prolonged.Bleeding times will be prolonged. Meticulous hemostasis is necessaryMeticulous hemostasis is necessary Have additional hemostatic aids availableHave additional hemostatic aids available

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Objective 9Objective 9

List examples of surgical procedures in which List examples of surgical procedures in which agents that affect coagulation may be agents that affect coagulation may be administered.administered.

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Objective 9Objective 9

General surgeryGeneral surgery Cholecystectomy (liver bed)Cholecystectomy (liver bed) Liver resection/traumaLiver resection/trauma Spleen or kidney repairSpleen or kidney repair

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Objective 9Objective 9

OrthopedicsOrthopedics Total hip/knee arthroplastyTotal hip/knee arthroplasty Spinal fusionSpinal fusion

NeurosurgeryNeurosurgery CraniotomyCraniotomy Spinal surgerySpinal surgery

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Objective 9Objective 9

Peripheral vascularPeripheral vascular AAAAAA Carotid endarterectomyCarotid endarterectomy Femoral embolectomyFemoral embolectomy Venous access proceduresVenous access procedures Dialysis graft insertionDialysis graft insertion

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Objective 9Objective 9

CardiovascularCardiovascular CABGCABG Valve replacement/repairValve replacement/repair

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Objective 10Objective 10

Compare and contrast administration route, Compare and contrast administration route, onset of action, antagonist, and purpose of onset of action, antagonist, and purpose of parenteral and oral anticoagulants.parenteral and oral anticoagulants.

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Objective 10Objective 10

Compare and contrastCompare and contrast Ask yourself:Ask yourself:

How are these alike?How are these alike? How are they different?How are they different?

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Objective 10: Objective 10:

Administration routeAdministration route DifferentDifferent Parenteral anticoagulantsParenteral anticoagulants

IV, subq, topicalIV, subq, topical Oral anticoagulantsOral anticoagulants

Oral onlyOral only

Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.

Objective 10 Objective 10

Onset of action: DifferentOnset of action: Different Parenteral anticoagulantsParenteral anticoagulants

Heparin = 5 minutesHeparin = 5 minutes Oral anticoagulantsOral anticoagulants

Warfarin = 12-72 hoursWarfarin = 12-72 hours

Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.

Objective 10 Objective 10

Antagonist Antagonist DifferentDifferent Parenteral anticoagulantsParenteral anticoagulants

Protamine sulfateProtamine sulfate Oral anticoagulantsOral anticoagulants

Vitamin K (for warfarin)Vitamin K (for warfarin)

Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.

Objective 10 Objective 10

Purpose: Similar purpose but different indicationsPurpose: Similar purpose but different indications Both prevent clotsBoth prevent clots Parenteral anticoagulantsParenteral anticoagulants

Short-term treatment/surgeryShort-term treatment/surgery Oral anticoagulantsOral anticoagulants

Long-term managementLong-term management