An 

anticoagulant is a substance that prevents coagulation; that is, it stops blood from clotting. A group of

pharmaceuticals called anticoagulants can be used in vivo as a medication forthrombotic disorders. Some
chemical compounds are used in medical equipment, such as test tubes, blood transfusion bags,
and renal dialysis equipment.

As medications

Anticoagulants reduce blood clotting. This prevents deep vein thrombosis, pulmonary

embolism, myocardial infarction and stroke.

Coumadins (Vitamin K antagonists)

These oral anticoagulants are a class of pharmaceuticals that antagonize the effects of vitamin K.
Examples include warfarin. It takes at least 48 to 72 hours for the anticoagulant effect to develop. Where
an immediate effect is required, heparin must be given concomitantly. These anticoagulants are used to
treat patients with deep-vein thrombosis (DVT), pulmonary embolism (PE), atrial fibrillation (AF), and
mechanical prosthetic heart valves.

Adverse effects

Patients aged 80 years or more may be especially susceptible to bleeding complications with a rate of 13
bleeds per 100 person-years.

These oral anticoagulants are used widely as poisons for mammalian pests, especially rodents. (For
details, see rodenticide and warfarin.)

Depletion of vitamin K by coumarin therapy increases risk of arterial calcification and heart valve
calcification, especially if too much vitamin D is present.

Available agents

 Warfarin (Coumadin) This is the main agent used in the U.S. and UK

 Acenocoumarol and phenprocoumon This is used more commonly outside the U.S. and the UK
 Brodifacoum Rat poison, not used medically
 Phenindione
Heparin and derivative substances

Heparin is a biological substance, usually made from pig intestines. It works by activating antithrombin III,

which blocks thrombin from clotting blood. Heparin can be used in vivo (by injection), and also in vitro to
prevent blood or plasma clotting in or on medical devices. Vacutainer brand test tubes containing heparin
are usually colored green.

Low molecular weight heparin

Low molecular weight heparin is a more highly processed product that is useful as it does not require
monitoring of the APTT coagulation parameter (it has more predictable plasma levels) and has fewer side
effects.

Synthetic pentasaccharide inhibitors of factor Xa

 Fondaparinux is a synthetic sugar composed of the five sugars (pentasaccharide) in heparin that
bind to antithrombin. It is a smaller molecule than low molecular weight heparin.
 Idraparinux

Major pharmaceutical Heparin recall due to contamination

In March 2008 major recalls of Heparin were announced by pharmaceuticals due to a suspected and
unknown contamination of the raw Heparin stock imported from China. The contaminant was later found
to be a non-naturally occurring compound called oversulfated chondroitin sulfate. The U.S. Food and
Drug Administration was quoted as stating that at least 19 deaths were believed linked to a raw Heparin
ingredient imported from the People's Republic of China, and that they had also received 785 reports of
serious injuries associated with the drug’s use. According to the New York Times: 'Problems with heparin
reported to the agency include difficulty breathing, nausea, vomiting, excessive sweating and rapidly
falling blood pressure that in some cases led to life-threatening shock'.

Direct thrombin inhibitors

Another type of anticoagulant is the direct thrombin inhibitor. Current members of this class
include argatroban, lepirudin, bivalirudin, and dabigatran. An oral direct thrombin
inhibitor,ximelagatran (Exanta) was denied approval by the Food and Drug Administration (FDA) in
September 2004 and was pulled from the market entirely in February 2006 after reports of severe liver
damage and heart attacks.
Other types of anticoagulants

Many other anticoagulants exist, for use in Research & Development, and more or less uses as drug
candidates or diagnostics

 Batroxobin, a toxin from a snake venom that clots platelet-rich plasma without

affecting platelets functions (lyses fibrinogen).
 Hementin is an anticoagulant protease from the salivary glands of Haementeria ghilianii

Food supplements

Food supplements with blood thinning effect include Nattokinase and Lumbrokinase

General indications

Therapeutic uses of anticoagulants include atrial fibrillation, pulmonary embolism (PE), deep vein

thrombosis (DVT), or venous thromboembolism (VTE), congestive heart failure, stroke,myocardial
infarction, genetic or acquired hypercoagulability

Anticoagulants outside the body

Laboratory instruments, test tubes, blood transfusion bags, and medical and surgical equipment will get
clogged up and become nonoperational if blood is allowed to clot. Chemicals can be added to stop blood
clotting. Apart from heparin, most of these chemicals work by binding calcium ions, preventing
the coagulation proteins from using them.

 EDTA is denoted by mauve or purple caps on Vacutainer brand test tubes. This chemical strongly
and irreversibly binds calcium. It is in a powdered form.
 Citrate is usually in blue Vacutainer tube. It is in liquid form in the tube and is used for coagulation
tests, as well as in blood transfusion bags. It gets rid of the calcium, but not as strongly as EDTA.
Correct proportion of this anticoagulant to blood is crucial because of the dilution. It can be in the form
of sodium citrate or ACD.
 Oxalate has a mechanism similar to that of citrate. It is the anticoagulant used in fluoride (grey
top) tubes.
An antihemorrhagic (antihaemorrhagic) agent is a substance that
promotes hemostasis (stops bleeding). It may also be known as a hemostatic (also
spelled haemostatic) agent.

Styptics (also spelled stiptics) are a specific type of antihemorrhagic agent that work by

contracting tissue to seal injured blood vessels. Styptic pencils contain astringents.

Antihemorrhagic agents used in medicine have various mechanisms of action:

 Systemic drugs work by inhibiting fibrinolysis or promoting coagulation.

 Locally-acting hemostatic agents work by causing vasoconstriction or promoting platelet
aggregation.

Systemic

There are several classes of antihemorrhagic drugs used in medicine. These

include antifibrinolytics, vitamin K, fibrinogen, and blood coagulation factors.

Local

Topical hemostatic agents have been gaining popularity for use in emergency bleeding control, especially
in military medicine. They are available in two forms - as a granular powder poured on wounds, or
embedded in a dressing.

Organic

Microfibrillar collagen

Microfibrillar collagen hemostat (MCH) is a topical agent composed of resorbable microfibrillar collagen. It

attracts platelets and allows for the formation of a blood clot when it comes into contact with blood. Unlike
the hemostatic clamp, no mechanical action is involved. The surgeon presses the MCH against a
bleeding site, and the collagen attracts and helps with the clotting process to eventually stop bleeding.

The practical application for MCH is different from that of the hemostatic clamp. It is not possible, for
example, to stop a severed artery from gushing blood by using a patch of MCH and wait for the clotting
process. The blood vessel must be mechanically clamped and repaired.

Chitosan

Chitosan hemostats are topical agents composed of chitosan and its salts. Chitosan bonds with platelets
and red blood cells to form a gel-like clot which seals a bleeding vessel. Unlike other hemostat
technologies its action does not require the normal hemostatic pathway and therefore continues to
function even when anticoagulants like heparin are present.
Chitosan is used in some emergency hemostats which are designed to stop traumatic life-threatening
bleeding. Their use is well established in many military and trauma units.

[edit]Chemical

Hemostatic chemicals use Chitosan in commercial products such as roll gauzes, and granular
powders. Zeolite, for example is used in QuikClot, a dressing.

Styptics

Styptic pencil

A styptic or hemostatic pencil (not to be confused with a caustic pencil) is a short stick of medication,
usually anhydrous aluminum sulfate,potassium alum (both are types of alum) or titanium dioxide which is
used for stanching blood by causing blood vessels to contract at the site of the wound. Before safety
razors were invented, it was an essential part of a shaving kit and was used to seal cuts caused by
impropershaving. Some people continue to use styptic pencils for minor skin wounds from safety or
electric razors.

A similar substance, styptic powder, is used to stop bleeding from nails that are clipped too closely. This
powder is generally used on animals, such as dogs, cats, rabbits, and birds, where the vein is found in
the center of the nail.
Thrombolysis is the breakdown (lysis) of blood clots by pharmacological means. It is colloquially referred
to as clot busting for this reason. It works by stimulating fibrinolysis byplasmin through infusion of analogs
of tissue plasminogen activator (tPA), the protein that normally activates plasmin.

Agents

Thrombolysis suggests the use of thrombolytic drugs, which are either derived
from Streptomyces species, or, more recently, using recombinant biotechnology whereby tPA is
manufactured by bacteria, resulting in a recombinant tissue plasminogen activator or rtPA.

Some commonly used thrombolytics are:

 streptokinase
 urokinase
 Recombinant tissue plasminogen activators
 alteplase (rtPA)
 reteplase
 tenecteplase
Principles

Formation of blood clots lies at the basis of a number of serious diseases (see below). By breaking down
the clot, the disease process can be arrested, or the complications reduced. While
other anticoagulants (such as heparin) decrease the "growth" of a clot, thrombolytic agents
actively reduce the size of the clot.

Most thrombolytic agents work by activating the enzyme plasminogen, which clears the cross-
linked fibrin mesh (the backbone of a clot). This makes the clot soluble and subject to
further proteolysis by other enzymes, and restores blood flow over occluded blood vessels.

Uses

Diseases where thrombolysis is used:

 Myocardial infarction
 Stroke (ischemic stroke)
 Massive pulmonary embolism
 Acute limb ischaemia

Apart from streptokinase, all thrombolytic drugs are administered together with heparin (unfractionated
or low molecular weight heparin), usually for 24–48 hours.
Thrombolysis is usually intravenous. It may also be used during an angiogram (intra-arterial
thrombolysis), e.g. when patients present with stroke beyond three hours.

In some settings such as the United States of America, emergency medical technicians may administer

thrombolytics for heart attacks in prehospital settings, by on-line medical direction. In countries with more
extensive and independent qualifications, prehospital thrombolysis (fibrinolysis) may be initiated by
the emergency care practitioner. Emergency Care Practitioners exist, in among other countries, in South
Africa, United Kingdom, and New Zealand. Prehospital thrombolysis is always the result of a risk benefit
calculation of the heart attack, thrombolysis risks, and PPCI availability. As such, the prehospital
practitioner will often consult with the receiving cardiologist as to treatment decisions─ many cardiologists
have personal preferences to available treatment options.

Contraindications

There are absolute and relative contraindications to thrombolytic therapy.

Absolute

Previous intracranial bleeding at any time, stroke in less than 3months,closed head or facial trauma within
3 months,suspected aortic dissection ,ischemic stroke within 3 months(except in ischemic stroke within
3hours time), active bleeding diathesis, uncontrolled high blood pressure (>180 systolic or >100
diastolic),known structural cerebral vascular lesion viz av malformations.

Streptokinase is contraindicated in patients who have been previously treated with streptokinase, as there
is a risk of anaphylaxis, a life-threatening allergic reaction, due to the production of antibodies against the
enzyme.

Relative

Current anticoagulant use, invasive or surgical procedure in the last 2 weeks, prolonged cardiopulmonary
resuscitation (CPR) defined as more than 10 minutes, known bleeding diathesis, pregnancy, hemorrhagic
or diabetic retinopathies, active peptic ulcer, and controlled severe hypertension.